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Lyu Y, Li T, Wang B, Cheng Y, Zhao S. Selection of pancreaticojejunostomy technique after pancreaticoduodenectomy: duct-to-mucosa anastomosis is not better than invagination anastomosis: A meta-analysis. Medicine (Baltimore) 2018; 97:e12621. [PMID: 30290634 PMCID: PMC6200508 DOI: 10.1097/md.0000000000012621] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND One of the most clinically significant current discussions is the optimal pancreaticojejunostomy (PJ) technique for pancreaticoduodenectomy (PD). We performed a meta-analysis to compare duct-to-mucosa and invagination techniques for pancreatic anastomosis after PD. METHODS A systematic search of PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to June 1, 2018 was performed. Randomized controlled trials (RCTs) comparing duct-to-mucosa versus invagination PJ were included. Statistical analysis was performed using RevMan 5.3 software. RESULTS Eight RCTs involving 1099 patients were included in the meta-analysis. The rate of postoperative pancreatic fistula (POPF) was not significantly different between the duct-to-mucosa PJ (110/547, 20.10%) and invagination PJ (98/552, 17.75%) groups in all 8 studies (risk ratio, 1.13; 95% CI, 0.89-1.44; P = .31). The subgroup analysis using the International Study Group on Pancreatic Fistula criteria showed no significant difference in POPF between duct-to-mucosa PJ (97/372, 26.08%) and invagination PJ (78/377, 20.68%). No significant difference in clinically relevant POPF (CR-POPF) was found between the 2 groups (55/372 vs 40/377, P = .38). Additionally, no significant differences in delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, operation time, or length of stay were found between the 2 groups. The overall morbidity and mortality rates were not significantly different between the 2 groups. CONCLUSION The duct-to-mucosa technique seems no better than the invagination technique for pancreatic anastomosis after PD in terms of POPF, CR-POPF, and other main complications. Further studies on this topic are therefore recommended.
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Affiliation(s)
| | - Ting Li
- Department of Personnel Office, Dongyang People's Hospital, Dongyang, Zhejiang Province, China
| | - Bin Wang
- Department of Hepatobiliary Surgery
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Lee YN, Kim WY. Comparison of Blumgart versus conventional duct-to-mucosa anastomosis for pancreaticojejunostomy after pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2018; 22:253-260. [PMID: 30215047 PMCID: PMC6125278 DOI: 10.14701/ahbps.2018.22.3.253] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/25/2018] [Accepted: 04/26/2018] [Indexed: 12/14/2022] Open
Abstract
Backgrounds/Aims Pancreatic leakage is a major cause of postoperative death and morbidity after pancreaticoduodenectomy (PD). A recent study introduced Blumgart anastomosis (BA), which minimizes severe complications after PD. This study compares BA with conventional anastomosis (CA) for pancreaticojejunostomy (PJ) after PD at a single institution. Methods A total of 87 patients who underwent PD at our hospital between January 2003 and October 2015 were enrolled in this study. The patients were divided into two groups according to the anastomosis type. Of them, 44 patients underwent anastomosis using CA (group A, conventional duct-to-mucosa anastomosis) and 43 underwent anastomosis using BA (group B, Blumgart anastomosis). Results There was a significant difference in duration of the operation between groups A and B (473.1±102.0 versus 386.4±58.5 min, p<0.001) and intraoperative transfusion (2.2±2.7 versus 0.7±1.5 units, p<0.001). There was no significant difference between groups A and B in incidence of postoperative pancreatic fistula (POPF) (43.2% versus 27.9%, p=0.137) ,postoperative hemorrhage (PPH) (13.7% versus 7.0%, p=0.209), delayed gastric emptying (DGE) (29.5% versus 9.3%, p=0.063), surgical and non-surgical complications (60.5% versus 59.1%, p=0.896), length of ICU stay (9.0±6.3 versus 7.4±7.2 days, p=0.099), or length of postoperative hospital stay (37.7±16.7 versus 41.6±15.1 days, p=0.118). Conclusions The results of this study suggest that BA-type PJ is not inferior to CA-type PJ in terms of postoperative complications.
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Affiliation(s)
- Yu-Ni Lee
- Department of Surgery, Presbyterian Medical Center, Jeonju, Korea
| | - Woo-Young Kim
- Department of Surgery, Presbyterian Medical Center, Jeonju, Korea
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Wang W, Zhang Z, Gu C, Liu Q, Liang Z, He W, Chen J, Lai J. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: A network meta-analysis of randomized control trials. Int J Surg 2018; 57:111-116. [PMID: 29777880 DOI: 10.1016/j.ijsu.2018.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 03/03/2018] [Accepted: 04/02/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND A number of pancreatic anastomosis methods for pancreaticoduodenectomy including pancreaticogastrostomy(PG), duct-to-mucosa pancreaticojejunostomy(duct-to-mucosa PJ), invagination pancreaticojejunostomy(invagination PJ) and binding pancreaticojejunostomy(BPJ), but the optimal choice remains unclear. We performed a network meta-analysis to synthesize direct and indirect evidence to identify the optimal choice for pancreatic anastomosis after pancreaticoduodenectomy METHODS: We searched the Embase, PubMed and Cochrane library databases for randomized control trials. The relative risk (RR) and its 95% confidence interval (CI) were calculated. The primary outcome is postoperative pancreatic fistula (POPF). RESULT In total, 16 RCT studies, including a total of 2396 patients, met our criteria. The results showed that PG is not superior to invagination PJ (RR 0.70 95%CI: 0.35-1.39) and duct-to-mucosa PJ (RR 0.58 95%CI: 0.30-1.10) according to the ISGPS definition. Furthermore PG cannot reduce the POPF rates than invagination PJ (RR 0.51 95%CI: 0.2-1.21) and duct-to-mucosa PJ (RR 0.46 95%CI: 0.16-1.14) according to the soft pancreatic texture. BPJ might reduce the incidence of POPF than duct-to-mucosa PJ (RR 0.00 95%CI: 0.00-0.04), invagination PJ (RR 0.00 95%CI: 0.00-0.03), PG (RR 0.00 95%CI: 0.00-0.03), but the results have major limitations with only one RCT reported BPJ and different definition of POPF. CONCLUSION There are no significant differences among BPJ, duct-to-mucosa PJ, invagination PJ and PG in the prevention of POPF, overall morbidity, mortality and DGE. However, further randomized controlled trials should be undertaken to ascertain these findings, especially for BPJ.
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Affiliation(s)
- Weidong Wang
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Zhaohui Zhang
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China
| | - Chichang Gu
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Qingbo Liu
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China
| | - Zhiqiang Liang
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Wei He
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Jianping Chen
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Jiaming Lai
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China.
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Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis. Oncotarget 2018; 8:46449-46460. [PMID: 28521286 PMCID: PMC5542280 DOI: 10.18632/oncotarget.17503] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 04/11/2017] [Indexed: 12/12/2022] Open
Abstract
Objective We aimed to compare the two most commonly used pancreatico-jejunostomy reconstruction techniques—duct-to-mucosa and invagination. Methods Databases, including MEDLINE, EMBASE, Cochrane Library, and several clinical trial registration centers were searched. Randomized controlled trials that compared duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were included and analyzed. Results In total, seven RCTs were included, involving 850 patients. The difference in postoperative pancreatic fistula rate between the duct-to-mucosa and invagination pancreaticojejunostomy was not significant (RR = 1.03, 95% CI = 0.76-1.39, P = 0.86). There was no significant difference in clinically relevant postoperative pancreatic fistula between the two groups (RR = 0.78, 95% CI = 0.15-3.96, P = 0.77). The overall morbidity, overall mortality, delayed gastric emptying, intra-abdominal collection, reoperation rate, and length of hospital stay between the two groups were not significantly different. Sensitivity analysis showed that the meta-analysis was stable. Further, no significant publication bias was seen. Conclusions Duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were comparable in terms of postoperative pancreatic fistula incidence and other parameters.
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Li B, Xu C, Qiu ZQ, Liu C, Yi B, Luo XJ, Jiang XQ. An end-to-side suspender pancreaticojejunostomy: A new invagination pancreaticojejunostomy. Hepatobiliary Pancreat Dis Int 2018; 17:163-168. [PMID: 29567046 DOI: 10.1016/j.hbpd.2018.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 12/20/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a severe complication of the pancreaticoduodenectomy (PD). Recently, we introduced a method of suspender pancreaticojejunostomy (PJ) to the PD. In this study, we retrospectively analyzed various risk factors for complications after PD. We also introduced and assessed the suspender PJ to demonstrate its advantages. METHODS Data from 335 patients with various periampullary lesions, who underwent the Whipple procedure (classic Whipple procedure or pylorus-preserving) PD by either traditional end-to-side invagination PJ or suspender PJ, were analyzed. The correlation between either perioperative or postoperative complications and corresponding PD approaches was evaluated by univariate analysis. RESULTS A total of 147 patients received the traditional end-to-side invagination PJ, and 188 patients were given the suspender PJ. Overall, 51.9% patients had various complications after PD. The mortality rate was 2.4%. The POPF incidence in patients who received the suspender PJ was 5.3%, which was significantly lower than those who received the traditional end-to-side invagination PJ (18.4%) (P < 0.001). Univariate analysis showed that PJ approach and the pancreas texture were significantly associated with the POPF incidence rate (P < 0.01). POPF was a risk factor for both postoperative abdominal cavity infection (OR = 8.34, 95% CI: 3.99-17.42, P < 0.001) and abdominal cavity hemorrhage (OR = 4.86, 95% CI: 1.92-12.33, P = 0.001). CONCLUSIONS Our study showed that the impact of the pancreas texture was a major risk factor for pancreatic leakage after a PD. The suspender PJ can be easily accomplished and widely applied and can effectively decrease the impact of the pancreas texture on pancreatic fistula after a PD and leads to a lower POPF incidence rate.
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Affiliation(s)
- Bin Li
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Chang Xu
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Zhi-Quan Qiu
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Chen Liu
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Bin Yi
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Xiang-Ji Luo
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Xiao-Qing Jiang
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China.
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Mesh-reinforced pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective study of 126 patients. World J Surg Oncol 2018; 16:68. [PMID: 29587784 PMCID: PMC5870079 DOI: 10.1186/s12957-018-1365-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/15/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Pancreatic fistula is a major cause of morbidity and mortality after pancreaticoduodenectomy. The aim of this study is to compare the safety and efficacy of a newly developed technique, namely mesh-reinforced pancreaticojejunostomy, in comparison with the conventional use of pancreaticojejunostomy after undergoing a pancreaticoduodenectomy. METHODS Data was collected from regarding 126 consecutive patients, who underwent the mesh-reinforced pancreaticojejunostomy or conventional pancreaticojejunostomy, after standard pancreaticoduodenectomy by one group of surgeons, between the time period of 2005 and 2016. This data was collected retrospectively. Surgical parameters and perioperative outcomes were compared between these two groups. RESULTS A total of 65 patients received mesh-reinforced pancreaticojejunostomy and 61 underwent conventional pancreaticojejunostomy. There were no substantial differences in surgical parameters, mortality, biliary leakage, delayed gastric emptying, gastrojejunostomy leakage, intra-abdominal fluid collection, postpancreatectomy hemorrhage, reoperation, and the total hospital costs between the two groups. Pancreatic fistula rate (15 versus 34%; p = 0.013), overall surgical morbidity (25 versus 43%; p = 0.032), and length of hospital stay (18 ± 9 versus 23 ± 12 days; p = 0.016) were significantly reduced after mesh-reinforced pancreaticojejunostomy. Multivariate analysis of the postoperative pancreatic fistula revealed that the independent factors that were highly associated with pancreatic fistula were a soft pancreatic texture and the type of conventional pancreaticojejunostomy. CONCLUSIONS This retrospective single-center study showed that mesh-reinforced pancreaticojejunostomy appears to be a safe technique for pancreaticojejunostomy. It may reduce pancreatic fistula rate and surgical complications after pancreaticoduodenectomy. TRIAL REGISTRATION This research is waivered from trial registration because it is a retrospective analysis of medical records.
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Kojima T, Niguma T, Watanabe N, Sakata T, Mimura T. Modified Blumgart anastomosis with the "complete packing method" reduces the incidence of pancreatic fistula and complications after resection of the head of the pancreas. Am J Surg 2018; 216:941-948. [PMID: 29606278 DOI: 10.1016/j.amjsurg.2018.03.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/05/2018] [Accepted: 03/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) and its complications remain problems. This study evaluated combination treatment with modified Blumgart anastomosis and an original infection control method (complete packing method) following pancreatic head resection. METHODS This study included 374 consecutive patients who underwent pancreatic head resection: 103 patients underwent Cattell-Warren anastomosis (CWA); 170 patients underwent modified Kakita anastomosis (KA); and 101 patients underwent modified Blumgart anastomosis with the complete packing method (BAC). The outcomes of the KA and BAC groups were compared statistically. RESULTS The POPF rate was significantly lower in the BAC group than in the KA group (28.8% vs 2.97%; p < 0.01). The overall postoperative complication rate, including SSI and postoperative hemorrhage, was significantly lower in the BAC group. CONCLUSIONS The combination of modified Blumgart anastomosis and the complete packing method is a simple and useful method for reducing the incidence of POPF and postoperative complications.
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Affiliation(s)
- Toru Kojima
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama 700-8511, Japan.
| | - Takefumi Niguma
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama 700-8511, Japan
| | - Nobuyuki Watanabe
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama 700-8511, Japan
| | - Taizo Sakata
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama 700-8511, Japan
| | - Tetsushige Mimura
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama 700-8511, Japan
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Polyester Preserves the Highest Breaking Point After Prolonged Incubation in Pancreatic Juice. J Gastrointest Surg 2018; 22:444-450. [PMID: 28861698 DOI: 10.1007/s11605-017-3558-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 08/18/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of suture materials on the development of pancreatic fistula after pancreaticoduodenectomy remains unclear. Thus, their choice among pancreatic surgeons is still mostly experience-based. Aim of the present study is to assess what is the best suture material to be used for pancreaticojejunostomy. MATERIALS AND METHODS The force needed to reach the breaking point of five widely used suture materials (polypropylene, polyester, polydioxanone, silk, and polyglactin 910) has been determined through a digital precision dynamometer at baseline and after 5 and 20 days of incubation in pancreatic juice, bile, or a mixture of both. RESULTS Regardless of the condition, polyglactin 910 has retained only 10% of its baseline force. Silk has maintained almost 90% of its initial force showing a very low baseline value of force. In pancreatic juice, polypropylene has lost less force compared to polyester (0.25 vs. 0.93 N; p = 0.03) and polydioxanone (0.25 vs. 3.67 N; p = 0.04). Polyester and polydioxanone have showed similar values of force. However, polydioxanone has lost a significant amount of force in pancreatic juice when compared to polyester (0.93 vs. 3.67 N; p = 0.03). Polyester has showed the highest value of force needed to reach the breaking point after 20 days of incubation in pancreatic juice. CONCLUSIONS After incubation in pancreaticobiliary secretions, polyglactin 910 loses almost all its force. Polypropylene preserves its characteristic, but polydioxanone and polyester show absolute higher breaking points, with polyester retaining the highest value of force needed to reach its breaking point after incubation in pancreatic juice.
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Xu J, Ji SR, Zhang B, Ni QX, Yu XJ. Strategies for pancreatic anastomosis after pancreaticoduodenectomy: What really matters? Hepatobiliary Pancreat Dis Int 2018; 17:22-26. [PMID: 29428099 DOI: 10.1016/j.hbpd.2018.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/28/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The postoperative pancreatic fistula rate remains approximately 10-20% even in institutions treating a high-volume of pancreatic cases. The best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate. DATA SOURCES Studies were identified by searching PubMed for studies published between January 1934 (when pancreaticogastrostomy was technically feasible) and December 2016. The following search terms were used: "duct-to-mucosa", "invagination", "pancreaticojejunostomy", "pancreaticogastrostomy," and "pancreaticoduodenectomy". The search was limited to English publications. RESULTS Many technical methods have been developed and optimized to restore pancreaticoenteric continuity, including pancreaticojejunostomy, pancreaticogastrostomy, and stented drainage of the pancreatic duct, among other modifications. Researchers have also attempted to decrease the postoperative pancreatic fistula after pancreaticoduodenectomy by using fibrin glue and somatostatin analogues. However, no significant decrease in postoperative pancreatic fistula has been observed in most of these studies, and only an external pancreatic duct stent has been found to decrease the leakage rate of pancreatic anastomosis after pancreaticojejunostomy. CONCLUSION Pancreatic surgeons should choose a suitable technique according to the characteristics of individual cases.
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Affiliation(s)
- Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Shun-Rong Ji
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Bo Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Quan-Xing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Xian-Jun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China.
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Wang X, Bai Y, Cui M, Zhang Q, Zhang W, Fang F, Song T. Modified Blumgart anastomosis without pancreatic duct-to-jejunum mucosa anastomosis for pancreatoduodenectomy: a feasible and safe novel technique. Cancer Biol Med 2018; 15:79-87. [PMID: 29545971 PMCID: PMC5842338 DOI: 10.20892/j.issn.2095-3941.2017.0153] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective This study proposed a modified Blumgart anastomosis (m-BA) that uses a firm ligation of the main pancreatic duct with a supporting tube to replace the pancreatic duct-to-jejunum mucosa anastomosis, with the aim of simplifying the complicated steps of the conventional BA (c-BA). Thus, we observe if a difference in the risk of postoperative pancreatic fistula (POPF) exists between the two methods. Methods The m-BA anastomosis method has been used since 2010. From October 2011 to October 2015, 147 patients who underwent pancreatoduodenectomy (PD) using BA in Tianjin Medical University Cancer Institute and Hospital were enrolled in this study. According to the type of pancreatojejunostomy (PJ), 50 patients underwent m-BA and 97 received c-BA. The two patient cohorts were compared prospectively to some extent but not randomized, and the evaluated variables were operation time, the incidence rate of POPF, and other perioperative complications. Results The operation time showed no significant difference (P > 0.05) between the two groups, but the time of duct-to-mucosa anastomosis in the m-BA group was much shorter than that in the c-BA group ( P < 0.001). The incidence rate of clinically relevant POPF was 12.0% (6/50) in the modified group and 10.3% (10/97) in the conventional group ( P > 0.05), which means that the modified anastomosis method did not cause additional pancreatic leakage. The mean length of postoperative hospital stay of the m-BA group was 23 days, and that of the c-BA group was 22 days ( P > 0.05). Conclusions Compared with the conventional BA, we suggest that the modified BA is a feasible, safe, and effective operation method for P J of PD with no sacrifice of surgical quality. In the multivariate analysis, we also found that body mass index (≥ 25 kg/m2) increased the risk of POPF.
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Affiliation(s)
- Xiaoqing Wang
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Yang Bai
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Mangmang Cui
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Qingxiang Zhang
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Wei Zhang
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Feng Fang
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Tianqiang Song
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
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Egorov VI, Petrov RV. [Simple and reliable pancreatoenteroanastomosis]. Khirurgiia (Mosk) 2017:60-68. [PMID: 29186099 DOI: 10.17116/hirurgia20171160-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- V I Egorov
- Brothers Bakhrushiny City Clinical Hospital, Moscow Department of Healthcare, Moscow, Russia
| | - R V Petrov
- Brothers Bakhrushiny City Clinical Hospital, Moscow Department of Healthcare, Moscow, Russia
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Kang P, Wang Z, Leng K, Zhong X, Wang H, Wan M, Tai S, Cui Y. Binding pancreaticogastrostomy anastomosis in central pancreatectomy: A single center experience. Medicine (Baltimore) 2017; 96:e8354. [PMID: 29137016 PMCID: PMC5690709 DOI: 10.1097/md.0000000000008354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A growing number of central pancreatectomies are performed. However, reconstruction of pancreaticoenteral digestive continuity after central pancreatectomy remains debated. This study evaluates the short-term outcomes of binding pancreaticogastrostomy anastomosis in central pancreatectomy.We have reviewed our experience with 52 patients who underwent binding pancreaticogastrostomy following central pancreatectomy from February 2009 to March 2015. Indication includes 6 noninvasive intraductal papillary mucinous neoplasms, 11 neuroendocrine tumors, 12 solid pseudopapillary tumor, 9 serous cystadenoma, 6 mucinous cystadenoma, and 8 focal pancreatic traumas.The mortality rate was nil while the morbidity rate was 34.6%. Eighteen patients experienced complications including 6 pancreatic fistulas, 2 postpancreatectomy hemorrhages, 4 delayed gastric emptying, 1 hypostatic pneumonia, and 5 pancreatitis. The median postoperative length of hospital stay was 12 days (10 days for patients without fistula). None of the 52 patients were found to have pancreatic endocrine or exocrine insufficiency or recurrence of tumors.Central pancreatectomy with binding pancreaticogastrostomy is a useful and practicable surgical procedure for benign or borderline lesions of the pancreatic neck or proximal body.
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van Rijssen LB, Koerkamp BG, Zwart MJ, Bonsing BA, Bosscha K, van Dam RM, van Eijck CH, Gerhards MF, van der Harst E, de Hingh IH, de Jong KP, Kazemier G, Klaase J, van Laarhoven CJ, Molenaar IQ, Patijn GA, Rupert CG, van Santvoort HC, Scheepers JJ, van der Schelling GP, Busch OR, Besselink MG, Bruno MJ, van Tienhoven GJ, Norduyn A, Berry DP, Tingstedt B, Tseng JF, Wolfgang CL. Nationwide prospective audit of pancreatic surgery: design, accuracy, and outcomes of the Dutch Pancreatic Cancer Audit. HPB (Oxford) 2017; 19:919-926. [PMID: 28754367 DOI: 10.1016/j.hpb.2017.06.010] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/19/2017] [Accepted: 06/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Auditing is an important tool to identify practice variation and 'best practices'. The Dutch Pancreatic Cancer Audit is mandatory in all 18 Dutch centers for pancreatic surgery. METHODS Performance indicators and case-mix factors were identified by a PubMed search for randomized controlled trials (RCT's) and large series in pancreatic surgery. In addition, data dictionaries of two national audits, three institutional databases, and the Dutch national cancer registry were evaluated. Morbidity, mortality, and length of stay were analyzed of all pancreatic resections registered during the first two audit years. Case ascertainment was cross-checked with the Dutch healthcare inspectorate and key-variables validated in all centers. RESULTS Sixteen RCT's and three large series were found. Sixteen indicators and 20 case-mix factors were included in the audit. During 2014-2015, 1785 pancreatic resections were registered including 1345 pancreatoduodenectomies. Overall in-hospital mortality was 3.6%. Following pancreatoduodenectomy, mortality was 4.1%, Clavien-Dindo grade ≥ III morbidity was 29.9%, median (IQR) length of stay 12 (9-18) days, and readmission rate 16.0%. In total 97.2% of >40,000 variables validated were consistent with the medical charts. CONCLUSIONS The Dutch Pancreatic Cancer Audit, with high quality data, reports good outcomes of pancreatic surgery on a national level.
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Affiliation(s)
- L Bengt van Rijssen
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas G Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maurice J Zwart
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Koert P de Jong
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Geert Kazemier
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Joost Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Coen G Rupert
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | | | - Joris J Scheepers
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | | | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Pancreatico-jejunal anastomoses after pancreatoduodenectomy. J Visc Surg 2017; 154:269-277. [PMID: 28688776 DOI: 10.1016/j.jviscsurg.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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65
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Sun YL, Zhao YL, Li WQ, Zhu RT, Wang WJ, Li J, Huang S, Ma XX. Total closure of pancreatic section for end-to-side pancreaticojejunostomy decreases incidence of pancreatic fistula in pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2017; 16:310-314. [PMID: 28603100 DOI: 10.1016/s1499-3872(17)60010-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a serious complication and results in prolonged hospitalization and high mortality. The present study aimed to evaluate the safety and effectiveness of total closure of pancreatic section for end-to-side pancreaticojejunostomy in pancreaticoduodenectomy (PD). METHODS This was a prospective randomized clinical trial comparing the outcomes of PD between patients who underwent total closure of pancreatic section for end-to-side pancreaticojejunostomy (Group A) vs those who underwent conventional pancreaticojejunostomy (Group B). The primary endpoint was the incidence of pancreatic fistula. Secondary endpoints were morbidity and mortality rates. RESULTS One hundred twenty-three patients were included in this study. The POPF rate was significantly lower in Group A than that in Group B (4.8% vs 16.7%, P<0.05). About 38.3% patients in Group B developed one or more complications; this rate was 14.3% in Group A (P<0.01). The wound/abdominal infection rate was also much higher in Group B than that in Group A (20.0% vs 6.3%, P<0.05). Furthermore, the average hospital stays of the two groups were 18 days in Group A, and 24 days in Group B, respectively (P<0.001). However, there was no difference in the probability of mortality, biliary leakage, delayed gastric emptying, and pulmonary infection between the two groups. CONCLUSION Total closure of pancreatic section for end-to-side pancreaticojejunostomy is a safe and effective method for pancreaticojejunostomy in PD.
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Affiliation(s)
- Yu-Ling Sun
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University; Institute of Hepatobiliary and Pancreatic Diseases, Zhengzhou University, Zhengzhou 450052, China.
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Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, Yeo CJ, Fernandez-delCastillo C, Dervenis C, Halloran C, Gouma DJ, Radenkovic D, Asbun HJ, Neoptolemos JP, Izbicki JR, Lillemoe KD, Conlon KC, Fernandez-Cruz L, Montorsi M, Bockhorn M, Adham M, Charnley R, Carter R, Hackert T, Hartwig W, Miao Y, Sarr M, Bassi C, Büchler MW. Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2017; 161:1221-1234. [PMID: 28027816 DOI: 10.1016/j.surg.2016.11.021] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/02/2016] [Accepted: 11/13/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (grades B and C of the ISGPS definition) remains the most troublesome complication after pancreatoduodenectomy. The approach to management of the pancreatic remnant via some form of pancreatico-enteric anastomosis determines the incidence and severity of clinically relevant postoperative pancreatic fistula. Despite numerous trials comparing diverse pancreatico-enteric anastomosis techniques and other adjunctive strategies (pancreatic duct stenting, somatostatin analogues, etc), currently, there is no clear consensus regarding the ideal method of pancreatico-enteric anastomosis. METHODS An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the best contemporary literature concerning pancreatico-enteric anastomosis and worked to develop a position statement on pancreatic anastomosis after pancreatoduodenectomy. RESULTS There is inherent risk assumed by creating a pancreatico-enteric anastomosis based on factors related to the gland (eg, parenchymal texture, disease pathology). None of the technical variations of pancreaticojejunal or pancreaticogastric anastomosis, such as duct-mucosa, invagination method, and binding technique, have been found to be consistently superior to another. Randomized trials and meta-analyses comparing pancreaticogastrostomy versus pancreaticojejunostomy yield conflicting results and are inherently prone to bias due to marked heterogeneity in the studies. The benefit of stenting the pancreatico-enteric anastomosis to decrease clinically relevant postoperative pancreatic fistula is not supported by high-level evidence. While controversial, somatostatin analogues appear to decrease perioperative complications but not mortality, although consistent data across the more than 20 studies addressing this topic are lacking. The Fistula Risk Score is useful for predicting postoperative pancreatic fistula as well as for comparing outcomes of pancreatico-enteric anastomosis across studies. CONCLUSION Currently, no specific technique can eliminate development of clinically relevant postoperative pancreatic fistula. While consistent practice of any standardized technique may decrease the rate of clinically relevant postoperative pancreatic fistula, experienced surgeons can have lower postoperative pancreatic fistula rates performing a variety of techniques depending on the clinical situation. There is no clear evidence on the benefit of internal or external stenting after pancreatico-enteric anastomosis. The use of somatostatin analogues may be important in decreasing morbidity after pancreatoduodenectomy, but it remains controversial. Future studies should focus on novel approaches to decrease the rate of clinically relevant postoperative pancreatic fistula with appropriate risk adjustment.
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Affiliation(s)
- Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
| | - Masillamany Sivasanker
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, Technische Universitat Munchen, Munich, Germany
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Abe Fingerhut
- Department of Digestive Surgery, University Hospital of Graz, Austria
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | | | - Christoper Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Dejan Radenkovic
- First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Horacio J Asbun
- Department of General Surgery, Mayo Clinic, Jacksonville, FL
| | - John P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin C Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Laureano Fernandez-Cruz
- Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Milan, Italy
| | - Max Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hopital Edouard Herriot, HCL, UCBL1, Lyon, France
| | - Richard Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Ross Carter
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Werner Hartwig
- Department of Surgery, Klinikum Großhadern, University of Munich, Munich, Germany
| | - Yi Miao
- Pancreas Center, Nanjing Medical University, Nanjing, P.R. China
| | - Michael Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Claudio Bassi
- Department of Surgery and Oncology, Pancreas Institute, University Hospital Trust of Verona, Verona, Italy
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Pancreatic stump closure after pancreatoduodenectomy in elderly patients: a retrospective clinical study. Aging Clin Exp Res 2017; 29:35-40. [PMID: 27837458 PMCID: PMC5334406 DOI: 10.1007/s40520-016-0657-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/12/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pancreatic fistula (PF) after pancreatoduodenectomy (PD) represents the major source of morbidity. Derivative procedures are preferred by pancreatic surgeons, but the optimal management of remnant pancreatic stump remains controversial. AIMS The purpose of this retrospective study is to evaluate the efficacy and safety of pancreatic stump closure in selected elderly patients (>65 years). METHODS Clinical data of 44 PD undergone mechanical closure of the pancreatic stump performed between 2001 and 2014 in two department of general and oncologic surgery were retrospectively collected. Considering the age, patients were divided into two groups: 21 patients of less than 65 years (Group A) and 23 patients of more than 65 years (Group B). RESULTS A soft pancreatic parenchyma with a not-dilated duct (diameter <3 mm) was reported in all the 44 patients. A grade-A PF, which did not required further treatments, developed in 20 cases (45.4%; 13 in group A and 7 in group B; p < 0.05), grade-B in 5 patients (11.4%; 3 in group A and 2 in group B; statistically not significant) and a grade-C PF was observed only in one patient (2.2%; 1 in group A and 0 in group B). DISCUSSION In selected "high risk" elderly patients (>65 years) with soft pancreatic texture, the closure of the pancreatic stump can be a useful tool in the surgical armamentarium with the aim to reduce the incidence of age-related complications. CONCLUSIONS Prospective randomized controlled trial to better evaluate PF risk factors is needed.
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No mortality or pancreatic fistula after full-thickness suture pancreaticogastrostomy in 39 patients who underwent pancreaticoduodenectomy. Int Surg 2016; 100:275-80. [PMID: 25692430 DOI: 10.9738/intsurg-d-14-00095.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Pancreaticoduodenectomy is considered the standard operation for periampullary tumors. Despite major advances in pancreatic surgery, pancreatic fistula is still an important cause of morbidity and mortality after pancreaticoduodenectomy. Meticulous surgical technique and proper reconstruction of the pancreas are essential to prevent pancreatic fistula. Pancreaticogastrostomy is a safe method for reconstruction of the pancreas after pancreaticoduodenectomy. Regardless of pancreatic texture or duct diameter, the reconstruction is performed by passing full-thickness sutures through both the anterior and posterior sides of the pancreas. In this study, we report 39 cases of reconstruction with pancreaticogastrostomy after pancreaticoduodenectomy without mortality or pancreatic fistula.
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69
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Ammori JB, Choong K, Hardacre JM. Surgical Therapy for Pancreatic and Periampullary Cancer. Surg Clin North Am 2016; 96:1271-1286. [PMID: 27865277 DOI: 10.1016/j.suc.2016.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgery is the key component of treatment for pancreatic and periampullary cancers. Pancreatectomy is complex, and there are numerous perioperative and intraoperative factors that are important for achieving optimal outcomes. This article focuses specifically on key aspects of the surgical management of periampullary and pancreatic cancers.
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Affiliation(s)
- John B Ammori
- Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Kevin Choong
- Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol 2016; 51:1147-54. [PMID: 27216233 PMCID: PMC4975078 DOI: 10.3109/00365521.2016.1169317] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers. METHODS A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF. RESULTS A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained. CONCLUSIONS Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital,
Stavanger,
Norway,Department of Clinical Medicine, University of Bergen,
Bergen,
Norway,CONTACT Kjetil Søreide
Department of Gastrointestinal Surgery, Stavanger University Hospital, POB 8100,
N-4068Stavanger,
Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital,
Oslo,
Norway
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Wu W, Wang X, Wu X, Li M, Weng H, Cao Y, Bao R, Su S, Lu J, Gong W, Shi W, Gu J, Wang X, Liu Y, Quan Z, Peng S. Total mesopancreas excision for pancreatic head cancer: analysis of 120 cases. Chin J Cancer Res 2016; 28:423-8. [PMID: 27647970 PMCID: PMC5018537 DOI: 10.21147/j.issn.1000-9604.2016.04.05] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the feasibility and safety of total mesopancreas excision (TMpE) in the treatment of pancreatic head cancer. METHODS The clinical and pathological data of 120 patients with pancreatic head cancer who had undergone TMpE in our center from May 2010 to January 2014 were retrospectively analyzed. RESULTS The mean operative time was (275.0±50.2) min and the average intra-operative blood loss was (390.0±160.5) mL. Post-operative complications were reported in 45 patients, while no peri-operative death was noted. The specimen margins were measured in three dimensions, and 86 patients (71.6%) achieved R0 resection. CONCLUSIONS TMpE is safe and feasible for pancreatic head cancer and is particularly helpful to increase the R0 resection rate.
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Affiliation(s)
- Wenguang Wu
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xu'an Wang
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiangsong Wu
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Maolan Li
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hao Weng
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yang Cao
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Ruifa Bao
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Sijun Su
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jianhua Lu
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Wei Gong
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Weibin Shi
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jun Gu
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xuefeng Wang
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yingbin Liu
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhiwei Quan
- Department of General Surgery and Laboratory of General Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China; Institute of Biliary Tract Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shuyou Peng
- Department of General Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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Pan SB, Geng W, Zhou DC, Chen JM, Zhao HC, Liu FB, Xie SX, Hou H, Zhao YJ, Xie K, Wang GB, Geng XP. One-layer versus two-layer duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: study protocol for a randomized controlled trial. Trials 2016; 17:407. [PMID: 27530630 PMCID: PMC4988010 DOI: 10.1186/s13063-016-1517-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 07/21/2016] [Indexed: 02/07/2023] Open
Abstract
Background Although various pancreaticojejunal duct-to-mucosa anastomosis methods have been developed to reduce the postoperative risks of pancreaticoduodenectomy, pancreatic fistula remains the most serious complication with a high incident rate. The aim of this study is to compare the safety and effectiveness of one-layer and two-layer duct-to-mucosa pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy. Methods/design In this study, adult patients who sign consent forms will be recruited and scheduled for elective pancreaticoduodenectomy. One hundred and fourteen patients will be included and randomized before pancreaticojejunal reconstruction and after resection of the lesion from the pancreatic or periampullary region. The primary efficacy endpoint is the incident rate of postoperative pancreatic fistula. Statistical analysis will be based on the intention-to-treat population. Patients will be followed up for 3 months by monitoring for complications and other adverse events. Discussion This prospective, single-center, randomized, single-blinded, two-group parallel trial is designed to compare one-layer with two-layer duct-to-mucosa anastomosis for pancreaticojejunal anastomosis during elective pancreaticoduodenectomy. Trial registration Clinical Trials.gov: NCT02511951. Registered on 29 July 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1517-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shu-Bo Pan
- Department of Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, Anhui, 230022, China
| | - Wei Geng
- Department of Liver Surgery, Ren Ji Hospital, School of Medicine Shanghai Jiao Tong University, No. 1630 Dongfang Road, Shanghai, 200127, China
| | - Da-Chen Zhou
- Department of Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, Anhui, 230022, China
| | - Jiang-Ming Chen
- Department of Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, Anhui, 230022, China
| | - Hong-Chuan Zhao
- Department of Surgery, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218#, Shushan District, Hefei, Anhui, 230022, China
| | - Fu-Bao Liu
- Department of Surgery, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218#, Shushan District, Hefei, Anhui, 230022, China
| | - Sheng-Xue Xie
- Department of Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, Anhui, 230022, China
| | - Hui Hou
- Department of Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, Anhui, 230022, China
| | - Yi-Jun Zhao
- Department of Surgery, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218#, Shushan District, Hefei, Anhui, 230022, China
| | - Kun Xie
- Department of Surgery, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218#, Shushan District, Hefei, Anhui, 230022, China
| | - Guo-Bin Wang
- Department of Surgery, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218#, Shushan District, Hefei, Anhui, 230022, China
| | - Xiao-Ping Geng
- Department of Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, Anhui, 230022, China.
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73
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A comparative study on the complications of conventional and end-to-side inserting pancreatojejunostomy after pancreaticoduodenectomy. Surg Today 2016; 47:238-244. [DOI: 10.1007/s00595-016-1364-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/15/2016] [Indexed: 12/19/2022]
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Testini M, Piccinni G, Lissidini G, Gurrado A, Tedeschi M, Franco IF, Di Meo G, Pasculli A, De Luca GM, Ribezzi M, Falconi M. Surgical management of the pancreatic stump following pancreato-duodenectomy. J Visc Surg 2016; 153:193-202. [PMID: 27130693 DOI: 10.1016/j.jviscsurg.2016.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.
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Affiliation(s)
- M Testini
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy.
| | - G Piccinni
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G Lissidini
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - A Gurrado
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Tedeschi
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - I F Franco
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G Di Meo
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - A Pasculli
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G M De Luca
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Ribezzi
- Anesthesiology Unit, Department of Emergency Surgery and Organs Transplantation, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Falconi
- Pancreatic Surgery Unit, San Raffaele Hospital IRCCS, University Vita e Salute, Milan, Italy
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75
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Kennedy EP, Yeo CJ. Dunking pancreaticojejunostomy versus duct-to-mucosa anastomosis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 18:769-74. [PMID: 21845376 DOI: 10.1007/s00534-011-0429-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Following the resectional aspect of pancreaticoduodenectomy, three anastomoses are used to reestablish gastrointestinal continuity. The pancreatic-enteric anastomosis is by far the most problematic, and has been considered by many the Achilles heel of the pancreaticoduodenal resection. Multiple clinical trials have been published focusing on improving outcomes of the pancreatic-enteric anastomosis, including elements such as the use of prophylactic octreotide, the use of sealants, stenting of the pancreatic duct, and surgical technique. There are two widely used methods to accomplish an end-to-side pancreaticojejunostomy (PJ) after pancreaticoduodenectomy: either invagination PJ or duct-to-mucosa PJ. Two prospective randomized trials have evaluated these techniques, the first a trial by Bassi and co-authors, and the second a trial by Berger et al. In this article we will focus on our current technique for both invagination pancreaticojejunostomy and duct-to-mucosa pancreaticojejunostomy, recognizing that careful surgical technique, surgeon experience, and surgical volume are factors that are important in yielding the best outcomes.
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Affiliation(s)
- Eugene P Kennedy
- Department of Surgery, Jefferson Pancreatic, Biliary and Related Cancer Center, Thomas Jefferson University, 1015 Walnut Street, 620 Curtis, Philadelphia, PA 19107, USA
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreatic, Biliary and Related Cancer Center, Thomas Jefferson University, 1015 Walnut Street, 620 Curtis, Philadelphia, PA, 19107, USA.
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76
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Pancreaticojejunostomy versus pancreaticogastrostomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 18:762-8. [PMID: 21912837 DOI: 10.1007/s00534-011-0428-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE In the majority of reports morbidity after pancreaticoduodenectomy remains high and leakage from the pancreatic stump still accounts for the majority of surgical complications. Many technical modifications of the pancreaticoenteric anastomosis to decrease the pancreatic leakage rate have been suggested. METHODS A Medline search for surgical guidelines, prospective randomized controlled trials, systematic meta-analyses, and clinical results was performed with regard to technical aspects of reconstruction, i.e., pancreaticojejunostomy versus pancreaticogastrostomy, after pancreaticoduodenectomy. Here we illustrate the different approaches to reconstruction, with an emphasis on technical aspects and their details. CONCLUSIONS Pancreaticojejunostomy appears to be the most widely performed reconstruction, but pancreaticogastrostomy is a reasonable alternative. However, in the analysis of the clinical results it is important to know which specific pancreaticoenteric anastomosis is considered; for example, end-to-end, dunking, invagination of the pancreatic stump, or duct-to-mucosa. It is hoped that collaborative trials will provide high-level data to allow tailoring of the operative technique, depending on the risk factors for pancreatic leakage in any particular patient.
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77
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Bai X, Zhang X, Lu F, Li G, Gao S, Lou J, Zhang Y, Ma T, Wang J, Chen W, Huang B, Liang T. The implementation of an enhanced recovery after surgery (ERAS) program following pancreatic surgery in an academic medical center of China. Pancreatology 2016; 16:665-70. [PMID: 27090583 DOI: 10.1016/j.pan.2016.03.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 02/16/2016] [Accepted: 03/29/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The experience of implementing enhanced recovery after surgery (ERAS) programs in pancreatic surgery is limited. The aim of this study was to evaluate the feasibility of ERAS program in pancreatic surgery in an academic medical center of China. METHODS Between May 2014 and August 2015, 124 patients managed with an ERAS program following pancreatic surgery (ERAS group), were compared to a historical cohort of 63 patients, treated with traditional perioperative care between August 2013 and April 2014 (no-ERAS group). Postoperative hospital stay (POPH), unplanned reoperation, unplanned readmissions, mortality and complications were compared between the two groups. RESULTS Mean POPH of all patients was significantly reduced (p = 0.007) from 17.1 days (no-ERAS group) to 11.7 days (ERAS group). Especially, mean POPH was reduced significantly in ERAS group of patient with no (7.0 vs. 8.7, p = 0.020) or grade I-II (10.6 vs. 14.4, p = 0.001) complications. There was no difference of complication grades and types between two groups, as well as the rate of mortality, unplanned reoperation and readmission. CONCLUSION The ERAS program is safe and feasible for patients undergoing pancreatic surgery, and it can decrease the postoperative hospital stay.
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Affiliation(s)
- Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyu Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fangyan Lu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ji Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bingfeng Huang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Collaborative Innovation Center for Cancer Medicine, Zhejiang University, Hangzhou, China.
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Abstract
Pancreaticoduodenectomy (PD) represents an important challenge for surgeons due to the complexity of the operation, requirement for technical skills and experience, and postoperative management involving important and life-threatening complications. Despite efforts to reduce mortality in high-volume centers, the morbidity rate is still high (approximately 40-50%). The PD standardization process of surgical aspects and preoperative and postoperative settings is essential to permit pancreatic surgeons to communicate in the same language, compare experiences and results, and to improve the short- and long-term outcomes. The aim of this article is to assess the state of the art practices for important matters of debate for PD (the role of mini invasive approach, the definition and the role of mesopancreas, the extent of lymphadenectomy, the different methods of reconstructions, the prophylactic drainage of the abdominal cavity), and to suggest possible future studies.
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79
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Oda T, Hashimoto S, Miyamoto R, Shimomura O, Fukunaga K, Kohno K, Ohshiro Y, Akashi Y, Enomoto T, Ohkohchi N. The Tight Adaptation at Pancreatic Anastomosis Without Parenchymal Laceration: An Institutional Experience in Introducing and Modifying the New Procedure. World J Surg 2016; 39:2014-22. [PMID: 25894407 DOI: 10.1007/s00268-015-3075-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Among the types of pancreatic anastomosis used after pancreatoduodenectomy (PD), Blumgart type reconstruction has rapidly been distributed for its theoretical reasonableness, including secure tight adaptation of jejunal wall and pancreatic parenchyma without cause of parenchymal laceration. The clinical appropriateness of our modified Blumgart method was demonstrated by comparing to that of Kakita method. METHODS Retrospective analysis of 156 patients underwent elective open PD, reconstructed former 78 patients with the Kakita method, utilizing a full-thickness penetrating suture for tight stump adhesion. The later 78 patients were treated with the modified Blumgart method, which involved clamping the pancreatic parenchymal stump by the jejunal seromuscular layers with horizontal mattress-type penetration sutures. Evaluated variables were the rate of pancreatic fistula (PF) and the length of postoperative hospital stay (POHS). RESULTS The rate of ISGPF grade B+C PF was 29/78 (37.2%) in the Kakita group and 16/78 (20.5%) in the Blumgart group (P=0.033). The median POHS for the Kakita group was 23 days, whereas that for the Blumgart group was 16 days (P<0.001), one of the shortest value among Japanese high-volume centers. There was no perioperative intensive hemorrhage or deaths in either group. CONCLUSION A unique concept of Blumgart pancreatic anastomosis, i.e., utilizing the jejunum as an interstitial cushion to prevent pancreatic laceration at the knot site, has become realistic through a simple "one step" modification. This technique, also providing flexible handling space at main pancreatic duct anastomosis, should contribute to the improved PF prevention and shortening the POHS.
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Affiliation(s)
- Tatsuya Oda
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan,
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80
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Kim EY, Hong TH. Total Laparoscopic Pancreaticoduodenectomy Using a New Technique of Pancreaticojejunostomy with Two Transpancreatic Sutures with Buttresses. J Laparoendosc Adv Surg Tech A 2016; 26:133-9. [DOI: 10.1089/lap.2015.0427] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Eun Young Kim
- Department of Hepato-biliary and Pancreas Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Tae Ho Hong
- Department of Hepato-biliary and Pancreas Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
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81
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Halloran CM, Platt K, Gerard A, Polydoros F, O'Reilly DA, Gomez D, Smith A, Neoptolemos JP, Soonwalla Z, Taylor M, Blazeby JM, Ghaneh P. PANasta Trial; Cattell Warren versus Blumgart techniques of panreatico-jejunostomy following pancreato-duodenectomy: Study protocol for a randomized controlled trial. Trials 2016; 17:30. [PMID: 26772736 PMCID: PMC4714471 DOI: 10.1186/s13063-015-1144-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 12/23/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Failure of the pancreatic remnant anastomosis to heal following pancreato-duodenectomy is a major cause of significant and life-threatening complications, notably a post-operative pancreatic fistula. Recently, non-randomized trials have shown superiority of a most intuitive anastomosis (Blumgart technique), which involves both a duct-to-mucosa and a full-thickness pancreatic "U" stitch, in effect a mattress stitch, over a standard duct-mucosa technique (Cattell-Warren). The aim of this study is to examine if these findings remain within a randomized setting. METHODS/DESIGN The PANasta trial is a randomized, double-blinded multi-center study, whose primary aim is to assess whether a Blumgart pancreatic anastomosis (trial intervention) is superior to a Cattell-Warren pancreatic anastomosis (control intervention), in terms of pancreatic fistula rates. Patients with suspected malignancy of the pancreatic head, in whom a pancreato-duodenectomy is recommended, would be recruited from several UK specialist regional centers. The hypothesis to be tested is that a Blumgart anastomosis will reduce fistula rate from 20 to 10 %. Subjects will be stratified by research site, pancreatic consistency and diameter of pancreatic duct; giving a sample size of 253 per group. The primary outcome measure is fistula rate at the pancreatico-jejunostomy. Secondary outcome measures are: entry into adjuvant therapy, mortality, surgical complications, non-surgical complications, hospital stay, cancer-specific quality of life and health economic assessments. Enrolled patients will undergo pancreatic resection and be randomized immediately prior to pancreatic reconstruction. The operation note will only record "anastomosis constructed as per PANasta trial randomization," thus the other members of the trial team and patient are blinded. An inbuilt internal pilot study will assess the ability to randomize patients, while the construction of an operative manual and review of operative photographs will maintain standardization of techniques. DISCUSSION The PANasta trial will be the first multi-center randomized controlled trial (RCT) comparing two types of duct-to-mucosa pancreatic anastomosis with surgical quality assurance. TRIAL REGISTRATION ISRCTN52263879 . Date of registration 15 January 2015.
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Affiliation(s)
- Christopher M Halloran
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, The Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Kellie Platt
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Abbie Gerard
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Fotis Polydoros
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Derek A O'Reilly
- Department of Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, UK. Derek.O'
| | - Dhanwant Gomez
- Queen's Medical Center, Derby Road, Nottingham, NG7 2UH, UK.
| | - Andrew Smith
- Department of Pancreatic Surgery, Abdominal Medicine and Surgery CSU, St James's University Hospital, 3rd Floor Bexley Wing, Leeds, LS9 7TF, UK.
| | - John P Neoptolemos
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Zahir Soonwalla
- Churchill Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford, OX3 7LJ, UK.
| | - Mark Taylor
- Mater Hospital, Belfast Health and Social care Trust, Crumlin Rd, Belfast, BT12 6AB, UK.
| | - Jane M Blazeby
- Bristol Center for Surgical Research, School of Social and Community Medicine, University of Bristol, BS8 2PS and University Hospitals Bristol NHS Foundation Trust, Bristol, BS2 8HW, UK.
| | - Paula Ghaneh
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
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82
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Hu BY, Leng JJ, Wan T, Zhang WZ. Application of single-layer mucosa-to-mucosa pancreaticojejunal anastomosis in pancreaticoduodenectomy. World J Gastrointest Surg 2015; 7:335-344. [PMID: 26649157 PMCID: PMC4663388 DOI: 10.4240/wjgs.v7.i11.335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the simplicity, reliability, and safety of the application of single-layer mucosa-to-mucosa pancreaticojejunal anastomosis in pancreaticoduodenectomy.
METHODS: A retrospective analysis was performed on the data of patients who received pancreaticoduodenectomy completed by the same surgical group between January 2011 and April 2014 in the General Hospital of the People’s Liberation Army. In total, 51 cases received single-layer mucosa-to-mucosa pancreaticojejunal anastomosis and 51 cases received double-layer pancreaticojejunal anastomosis. The diagnoses of pancreatic fistula and clinically relevant pancreatic fistula after pancreaticoduodenectomy were judged strictly by the International Study Group on pancreatic fistula definition. The preoperative and intraoperative data of these two groups were compared. χ2 test and Fisher’s exact test were used to analyze the incidences of pancreatic fistula, peritoneal catheterization, abdominal infection and overall complications between the single-layer anastomosis group and double-layer anastomosis group. Rank sum test were used to analyze the difference in operation time, pancreaticojejunal anastomosis time, postoperative hospitalization time, total hospitalization time and hospitalization expenses between the single-layer anastomosis group and double-layer anastomosis group.
RESULTS: Patients with grade A pancreatic fistula accounted for 15.69% (8/51) vs 15.69% (8/51) (P = 1.0000), and patients with grades B and C pancreatic fistula accounted for 9.80% (5/51) vs 52.94% (27/51) (P = 0.0000) in the single-layer and double-layer anastomosis groups. Although there was no significant difference in the percentage of patients with grade A pancreatic fistula, there was a significant difference in the percentage of patients with grades B and C pancreatic fistula between the two groups. The operation time (220.059 ± 60.602 min vs 379.412 ± 90.761 min, P = 0.000), pancreaticojejunal anastomosis time (17.922 ± 5.145 min vs 31.333 ± 7.776 min, P = 0.000), postoperative hospitalization time (18.588 ± 5.285 d vs 26.373 ± 15.815 d, P = 0.003), total hospitalization time (25.627 ± 6.551 d vs 33.706 ± 15.899 d, P = 0.002), hospitalization expenses (116787.667 ± 31900.927 yuan vs 162788.608 ± 129732.500 yuan, P = 0.001), as well as the incidences of pancreatic fistula [13/51 (25.49%) vs 35/51 (68.63%), P = 0.0000], peritoneal catheterization [0/51 (0%) vs 6/51 (11.76%), P = 0.0354], abdominal infection [1/51 (1.96%) vs 11/51 (21.57%), P = 0.0021], and overall complications [21/51 (41.18%) vs 37/51 (72.55%), P = 0.0014] in the single-layer anastomosis group were all lower than those in the double-layer anastomosis group.
CONCLUSION: Single-layer mucosa-to-mucosa pancreaticojejunal anastomosis appears to be a simple, reliable, and safe method. Use of this method could reduce the postoperative incidence of complications.
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Xu J, Zhang B, Shi S, Qin Y, Ji S, Xu W, Liu J, Liu L, Liu C, Long J, Ni Q, Yu X. Papillary-like main pancreatic duct invaginated pancreaticojejunostomy versus duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized trial. Surgery 2015; 158:1211-8. [DOI: 10.1016/j.surg.2015.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 03/29/2015] [Accepted: 04/09/2015] [Indexed: 12/11/2022]
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Bai X, Zhang Q, Gao S, Lou J, Li G, Zhang Y, Ma T, Zhang Y, Xu Y, Liang T. Duct-to-Mucosa vs Invagination for Pancreaticojejunostomy after Pancreaticoduodenectomy: A Prospective, Randomized Controlled Trial from a Single Surgeon. J Am Coll Surg 2015; 222:10-8. [PMID: 26577499 DOI: 10.1016/j.jamcollsurg.2015.10.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/12/2015] [Accepted: 10/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic fistula (PF) is the most common significant complication after pancreaticoduodenectomy. Invagination and duct-to-mucosa anastomoses are anastomotic techniques that are commonly performed after pancreaticoduodenectomy. There are conflicting data on invagination vs duct-to-mucosa anastomoses about which is superior for minimizing the risk of PF. In addition, all previous studies involved multiple operating surgeons and failed to control for variation in surgeon expertise. STUDY DESIGN This was a randomized controlled study comparing the outcomes of PD between patients who underwent invagination vs those who had duct-to-mucosa anastomoses. All 132 patients were operated on between October 2012 and March 2015 by a single surgeon experienced in both procedures. Pancreatic fistula was the main end point. RESULTS Overall and clinically relevant rates of PF rate were 29.5% and 10.6%, respectively. Overall PF rates in the patients treated with invagination vs duct-to-mucosa anastomoses were 30.9% vs 28.5% (p = 0.729), respectively and the corresponding clinically relevant PF rates were 17.6% vs 3.1%, respectively (p = 0.004). Although the overall complication rates were similar in the 2 groups, severe complications were significantly more frequent in the patients treated with invagination (p = 0.013). Duct-to-mucosa anastomosis was also associated with shorter postoperative hospital stay (13 vs 15 days; p = 0.021). There was one perioperative death. Independent variables for the risk of PF were the diameter of the pancreatic duct (greater risk with smaller diameter), the underlying pathology, and male sex. CONCLUSIONS Both methods yield similar overall rates for PF, but the rate of clinically relevant PF is lower in patients treated with duct-to-mucosa anastomosis. Additional single-surgeon studies or multi-institution randomized trials controlling for comparable expertise in both procedures should be conducted to confirm these results.
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Affiliation(s)
- Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qi Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yibo Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuanliang Xu
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Collaborative Innovation Center for Cancer Medicine, Zhejiang University, Guangzhou, China.
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Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand? Indian J Surg 2015; 77:409-25. [PMID: 26722205 DOI: 10.1007/s12262-015-1366-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic resection has become a feasible treatment of pancreatic neoplasms, and with improvements in surgical techniques and perioperative management, mortality associated with pancreatic surgery has decreased considerably. Despite this improvement, a high rate of complications is still associated with these procedures. Among these complications, delayed gastric emptying (DGE) and postoperative pancreatic fistula (POPF) have a substantial impact on patient outcomes and burden our healthcare system. Technical modifications and postoperative approaches have been proposed to reduce rates of both POPF and DGE in patients undergoing pancreatectomy; however, to date, their rates have remained unchanged. In the present study, we summarize the findings of the most significant studies that have investigated these complications. In particular, several studies focused on technical modifications including extent of dissection, stent placement, nature of anastomosis, type of reconstruction, and application of biological or non-biological agents to site of anastomosis. Moreover, postoperatively, drain placement, duration of drain usage, postoperative feeding, and use of pharmacological agents were studied to reduce rates of POPF and DGE. In this review, we summarize the most relevant literature on this fundamental aspect of pancreatic surgery. Despite studies identifying the potential benefit of technical modifications and postoperative approaches, these findings remain controversial and suggest need for further extensive investigation. Most importantly, we recommend that all surgeons performing these procedures base their practice on the most updated and highest available level of evidence.
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Ji Z, Meng G, Huang D, Yue X, Wang B. NMFBFS: A NMF-Based Feature Selection Method in Identifying Pivotal Clinical Symptoms of Hepatocellular Carcinoma. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:846942. [PMID: 26579207 PMCID: PMC4633688 DOI: 10.1155/2015/846942] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/20/2015] [Accepted: 07/02/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a highly aggressive malignancy. Traditional Chinese Medicine (TCM), with the characteristics of syndrome differentiation, plays an important role in the comprehensive treatment of HCC. This study aims to develop a nonnegative matrix factorization- (NMF-) based feature selection approach (NMFBFS) to identify potential clinical symptoms for HCC patient stratification. METHODS The NMFBFS approach consisted of three major steps. Firstly, statistics-based preliminary feature screening was designed to detect and remove irrelevant symptoms. Secondly, NMF was employed to infer redundant symptoms. Based on NMF-derived basis matrix, we defined a novel similarity measurement of intersymptoms. Finally, we converted each group of redundant symptoms to a new single feature so that the dimension was further reduced. RESULTS Based on a clinical dataset consisting of 407 patient samples of HCC with 57 symptoms, NMFBFS approach detected 8 irrelevant symptoms and then identified 16 redundant symptoms within 6 groups. Finally, an optimal feature subset with 39 clinical features was generated after compressing the redundant symptoms by groups. The validation of classification performance shows that these 39 features obviously improve the prediction accuracy of HCC patients. CONCLUSIONS Compared with other methods, NMFBFS has obvious advantages in identifying important clinical features of HCC.
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Affiliation(s)
- Zhiwei Ji
- Machine Learning & Systems Biology Lab, School of Electronics and Information Engineering, Tongji University, 4800 Caoan Road, Shanghai 201804, China
- School of Information Engineering, Zhejiang A&F University, 88 Huancheng North Road, Linan 311300, China
| | - Guanmin Meng
- Department of Clinical Laboratory, Tongde Hospital of Zhejiang Province, 234th Gucui Road, Hangzhou 310012, China
| | - Deshuang Huang
- Machine Learning & Systems Biology Lab, School of Electronics and Information Engineering, Tongji University, 4800 Caoan Road, Shanghai 201804, China
| | - Xiaoqiang Yue
- Department of Traditional Chinese Medicine, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai 200003, China
| | - Bing Wang
- Machine Learning & Systems Biology Lab, School of Electronics and Information Engineering, Tongji University, 4800 Caoan Road, Shanghai 201804, China
- The Advanced Research Institute of Intelligent Sensing Network, Tongji University, 4800 Caoan Road, Shanghai 201804, China
- The Key Laboratory of Embedded System and Service Computing, Tongji University, 4800 Caoan Road, Shanghai 201804, China
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87
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Mitra A, D'Souza A, Goel M, Shrikhande SV. Surgery for Pancreatic and Periampullary Carcinoma. Indian J Surg 2015; 77:371-80. [PMID: 26722199 DOI: 10.1007/s12262-015-1358-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
Surgical resection for pancreatic and periampullary cancer has evolved over several decades. The postoperative mortality for these resections has declined to less than 5 %. However, morbidity associated with these resections is still considerable. Various technical modifications like pylorus preservation, reconstruction techniques and methods to perform pancreaticoenteric anastomosis have been suggested to improve postoperative outcomes after pancreaticoduodenectomy. Surgical modifications to improve oncological clearance and decrease fistula rates after distal pancreatic resections have also been suggested. Dilemma still exists whether interventions like pancreatic duct stents, octreotide and drains help to improve postoperative outcomes. The role of extended lymph node dissection and extended resections for pancreatic and periampullary cancer is still controversial, as is the management of borderline resectable pancreatic cancer. In this review, we discuss the literature pertaining to various surgical aspects of pancreatic and periampullary carcinoma.
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Affiliation(s)
- Abhishek Mitra
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Ashwin D'Souza
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Mahesh Goel
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Shailesh V Shrikhande
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
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Hua J, He Z, Qian D, Meng H, Zhou B, Song Z. Duct-to-Mucosa Versus Invagination Pancreaticojejunostomy Following Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis. J Gastrointest Surg 2015; 19:1900-9. [PMID: 26264363 DOI: 10.1007/s11605-015-2913-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/03/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most common complications after pancreaticoduodenectomy (PD). The ideal choice of pancreaticojejunostomy (PJ) anastomosis remains a matter of debate. METHODS A meta-analysis of randomized controlled trials (RCTs) comparing duct-to-mucosa with invagination PJ following PD was performed. Pooled odds ratio (OR) with 95 % confidence intervals (CI) were calculated using fixed-effects or random-effects models. RESULTS In total, five RCTs involving 654 patients were included. Meta-analysis revealed no significant difference in POPF rate between the duct-to-mucosa and invagination PJ techniques (OR = 1.23, 95 % CI = 0.78-1.93; P = 0.38). Two of five trials applied the POPF definition proposed by the International Study Group of Pancreatic Surgery (ISGPS). Using this definition, the incidence of clinically relevant POPF was lower in patients undergoing invagination PJ than in those undergoing duct-to-mucosa PJ (OR = 2.94, 95 % CI = 1.31-6.60; P = 0.009). There was no significant difference in terms of delayed gastric emptying, intra-abdominal collection, overall morbidity and mortality, reoperation rate, and length of hospital stay between the two groups. CONCLUSION Invagination PJ is not superior to duct-to-mucosa PJ in terms of POPF and other complications but appears to reduce clinically relevant POPF. Further well-designed RCTs that use ISGPS definition are still required before strong evidence-based recommendations can be formulated.
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Affiliation(s)
- Jie Hua
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Zhigang He
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Daohai Qian
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Hongbo Meng
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Bo Zhou
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Zhenshun Song
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China.
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89
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Pancreatic fistula following pancreatoduodenectomy. Evaluation of different surgical approaches in the management of pancreatic stump. Literature review. Int J Surg 2015; 21 Suppl 1:S4-9. [DOI: 10.1016/j.ijsu.2015.04.088] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 03/23/2015] [Accepted: 04/10/2015] [Indexed: 02/08/2023]
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90
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Gurusamy K, Toon C, Virendrakumar B, Morris S, Davidson B. Feasibility of Comparing the Results of Pancreatic Resections between Surgeons: A Systematic Review and Meta-Analysis of Pancreatic Resections. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2015; 2015:896875. [PMID: 26351405 PMCID: PMC4553327 DOI: 10.1155/2015/896875] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/15/2015] [Indexed: 02/06/2023]
Abstract
Background. Indicators of operative outcomes could be used to identify underperforming surgeons for support and training. The feasibility of identifying HPB surgeons with poor operative performance ("outliers") based on the results of pancreatic resections is not known. Methods. A systematic review of Medline, Embase, and the Cochrane library was performed to identify studies on pancreatic resection including at least 100 patients and published between 2004 and 2014. Proportions that lay outside the upper 95% and 99.8% confidence intervals based on results of the systematic reviews were considered as "outliers." Results. In total, 30 studies reporting on 10712 patients were eligible for inclusion in this review. The average short-term mortality after pancreatic resections was 3.1% and proportion of patients with procedure-related complications was 47.0%. None of the classification systems assessed the long-term impact of the complications on patients. The surgeon-specific mortality should be 5 times the average mortality before he or she can be identified as an outlier with 0.1% false positive rate if he or she performs 50 surgeries a year. Conclusions. A valid risk prognostic model and a classification system of surgical complications are necessary before meaningful comparisons of the operative performance between pancreatic surgeons can be made.
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Affiliation(s)
- Kurinchi Gurusamy
- Department of Surgery, UCL Medical School, Royal Free Campus, London NW3 2PF, UK
| | - Clare Toon
- Public Health Research Unit, West Sussex County Council, County Hall Campus, West Sussex PO19 1QT, UK
| | - Bhavisha Virendrakumar
- Evidence Synthesis, Sightsavers, 35 Perrymount Road, Haywards Heath, West Sussex RH16 3BW, UK
| | - Steve Morris
- Department of Applied Health Research, UCL, London WC1E 7HB, UK
| | - Brian Davidson
- Department of Surgery, UCL Medical School, Royal Free Campus, London NW3 2PF, UK
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91
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Binding pancreaticogastrostomy in laparoscopic central pancreatectomy: a novel technique in laparoscopic pancreatic surgery. Surg Endosc 2015; 30:715-720. [PMID: 26123326 DOI: 10.1007/s00464-015-4265-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/08/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Even though more and more cases of laparoscopic central pancreatectomy (LCP) are reported (Machado et al. in Surg Laparosc Endosc Percutan Tech 23(6):486-490, 2013; Hong et al. in World J Surg Oncol 10:223, 2012; Gonzalez et al. in JOP 14(3):273-276, 2013, Zhang et al. in J Laparoendosc Adv Surg Tech A 23(11):912-918, 2013; Sucandy et al. in N Am J Med Sci 2(9):438-441, 2010; Sa Cunha et al. in Surgery 142(3):405-409, 2007), the management for pancreatic stumps remains the most technically challenging part which is the same as in pancreatoduodenectomy (PD), making it the bottleneck for laparoscopic pancreatic surgery. In open surgery, various pancreatic reconstruction techniques designed for either pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) have been attempted to reduce the postoperative pancreatic fistula (POPF), including the binding anastomosis, invented by our team, i.e., binding PG (BPG) and binding PJ, which have been proved to be effective to reduce the POPF (Hong et al. 2012; Peng et al. in Ann Surg 245(5):692-698, 2007; Peng et al. in Updates Surg 63(2):69-74, 2011). However, despite of this, few reports are seen addressing such technique for laparoscopic surgery even though laparoscopic pancreatic surgery is more performed. After a previous successful laparoscopic BPG in a case of laparoscopic CP (LCP; Hong et al. 2012) and more than 50 cases of open PD and CP (Peng et al. 2011), we further performed laparoscopic BPG in 10 consecutive cases of LCP with satisfactory outcomes. OBJECTIVE To explore the feasibility and efficacy of LCP with BPG. METHODS Between October 2011 and July 2014, LCP with laparoscopic BPG was performed in ten consecutive patients with lesions of benign or low malignancy at the pancreatic neck. Operative and pathological data, complications, hospital stay and details on the surgical techniques were introduced. RESULTS The operations were successfully performed in all the ten cases, with no conversions. The tumor size ranged from 2.0-3.0 to 2.5-3.0 cm, average (2.50 ± 0.35) to (2.66 ± 0.35) cm, and the diameter of pancreatic duct was (1.6-2.1) mm, average (1.71 ± 0.17) mm. Operation time was 170-250 (198.50 ± 25.82) min, and blood loss was 20-300 (125 ± 107.31) mL. Three cases had grade A pancreatic fistula (PF), and one case had delayed gastric emptying, which were all managed with conservative treatment. Upper GI bleeding occurred in one case which was cured with second operation, time for the recovery of bowl movement was 3-5 (4.2 ± 0.8) days, the time for semifluid dieting was 6-10 (8.2 ± 1.5) days, and the hospital stay was 8-20 (12.8 ± 4.63) days. The postoperative fast blood sugar was (6.3 ± 1.6) mmol/L with the normal diet, which was not significantly different from the preoperative data (5.3 ± 0.5) mmol/L (P > 0.05). The postoperative pathology was as follows: five cases of cystic serous adenoma, one case of intraductal papillary mucinous neoplasm, two cases of neuroendocrine tumor, and two cases of solid pseudopapillary tumor of pancreas. All the patients were followed up for 7-40 months, no recurrence happened, and no new incidence of diabetes or insufficiency of pancreatic exocrine function occurred. CONCLUSIONS LCP with BPG is feasible and safe; the advantages lie in its minimal invasiveness, the efficacy for avoiding PF, and the preservation of the pancreatic endocrine and exocrine function insufficiency, making it an ideal procedure for the benign or low-malignant lesions at the pancreatic neck.
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92
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Wei J, Liu X, Wu J, Xu W, Zhou J, Lu Z, Chen J, Guo F, Gao W, Li Q, Jiang K, Dai C, Miao Y. Modified One-layer Duct-to-mucosa Pancreaticojejunostomy Reduces Pancreatic Fistula After Pancreaticoduodenectomy. Int Surg 2015; 103:10.9738/INTSURG-D-15-00094.1. [PMID: 26037262 DOI: 10.9738/intsurg-d-15-00094.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) is a major source of morbidity after pancreaticoduodenectomy (PD). The purpose of this retrospective study comparing one-layer pancreaticojejunostomy (PJ) with two-layer PJ after PD was to evaluate whether the one-layer duct-to-mucosa PJ after PD can reduce the incidence of POPF.A total of 194 consecutive patients who underwent PD by one surgeon (Y. Miao) from January 2011 to February 2014 were included in this study. Among those patients, 104 underwent one-layer PJ (one-layer group) and 90 patients underwent two-layer PJ (two-layer group), respectively. Preoperative clinicopathologic features, intraoperative parameters, postoperative morbidity with focus on POPF, were compared between the two groups.The overall incidence of POPF was 19.6% (38/194), and clinically relevant grade B/C POPF rates were 8.6% (16/194) and 3.1% (6/194), respectively. There were no differences in patients' demographics and operation related factors between the two groups. However, the incidence of POPF in the one-layer group was significantly lower than in two-layer group (13.5% [14/104 patients] and 26.7% [24/90 patients] respectively; p=0.021). The median postoperative hospital stay was also significantly lower in the one-layer group compared to the two-layer group (13 days vs. 15 days, p=0.035). One patient in two-layer group died due to postoperative hemorrhage.One-layer duct-to-mucosa pancreaticojejunostomy is a simple and easy technique for pancreaticojejunal anastomosis after PD, and can reduce the POPF rate in comparison to the two-layer technique.
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Affiliation(s)
- Jishu Wei
- b The first Affiliated Hospital of Nanjing Medical University
| | - Xinchun Liu
- c The first Affiliated Hospital of Nanjing Medical University
| | | | | | | | | | | | | | | | | | | | | | - Yi Miao
- f The first hospital affiliated of, Nanjing, Jiangsu, China
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93
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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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94
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Pancreaticogastrostomy as an Ideal Drainage Procedure After Pancreaticoduodenectomy: Can We Draw a Conclusion? Ann Surg 2015; 263:e66. [PMID: 25906413 DOI: 10.1097/sla.0000000000001091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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95
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A comparison of two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy. Gastroenterol Res Pract 2015; 2015:894292. [PMID: 25852753 PMCID: PMC4380088 DOI: 10.1155/2015/894292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 03/03/2015] [Indexed: 12/20/2022] Open
Abstract
Background. The aim of the study was to compare two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy. Methods. For effective prevention of the development of pancreatic leakage, we modified invagination technique that we term the "serous touch." We analysed the diameter of the main pancreatic duct, the texture of the remnant pancreas, the method of the reconstruction, pancreatic external drainage, anastomotic procedure time, histopathological examination, and postoperative complications. Results. Fifty-two patients underwent pancreatoduodenectomy with pancreatojejunostomy using "serous touch" technique (ST group) and 52 classic pancreatojejunostomy (C group). In the ST group one patient (1.9%) was diagnosed as grade B pancreatic fistula, and no patient experienced fistula grade A or C. In the C group 6 patients (11.5%) were diagnosed as fistula grade A, 1 (1.9%) patient as fistula grade B, and 1 (1.9%) patient as fistula grade C. There was a significant statistical difference in incidents of pancreatic fistula (P < 0.05) and no statistical difference in other postoperative complications or mortality in comparison group. Anastomosis time was statistically shorter in the ST group. Conclusions. "Serous touch" technique appeared to be easy, safe, associated with fewer incidences of pancreatic fistulas, and less time consuming in comparison with classical pancreatojejunostomy.
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96
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Risk factors and medico-economic effect of pancreatic fistula after pancreaticoduodenectomy. Gastroenterol Res Pract 2015; 2015:917689. [PMID: 25788941 PMCID: PMC4350616 DOI: 10.1155/2015/917689] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 01/20/2015] [Indexed: 12/26/2022] Open
Abstract
The study aimed to uncover the risk factors for the new defined pancreatic fistula (PF) and clinical related PF (CR-PF) after pancreaticoduodenectomy (PD) surgery and to evaluate the medico-economic effect of patients. A total of 412 patients were classified into two groups according to different criteria, PF and NOPF according to PF occurrence: CR-PF (grades B and C) and NOCR-PF (grade A) based on PF severity. A total of 28 factors were evaluated by univariate and multivariate logistic regression test. Hospital charges and stays of these patients were assessed. The results showed that more hospital stages and charges are needed for patients in PF and CR-PF groups than in NOPF and NOCR-PF groups (P < 0.05). The excessive drinking, soft remnant pancreas, preoperative albumin, and intraoperative blood transfusion are risk factors affecting both PF and CR-PF incidence. More professional surgeons can effectively reduce the PF and CR-PF incidence. Patients with PF and CR-PF need more hospital costs and stages than that in NOPF and NOCR-PF groups. It is critical that surgeons know the risk factors related to PF and CR-PF so as to take corresponding therapeutic regimens for each patient.
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97
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El Nakeeb A, El Hemaly M, Askr W, Abd Ellatif M, Hamed H, Elghawalby A, Attia M, Abdallah T, Abd ElWahab M. Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized study. Int J Surg 2015; 16:1-6. [PMID: 25682724 DOI: 10.1016/j.ijsu.2015.02.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD. METHODS Consecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions. RESULTS One hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively. CONCLUSION Invagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. CLINICAL TRIALS. GOV ID NCT02142517.
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Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt.
| | - Mohamed El Hemaly
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | - Waleed Askr
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | | | - Hosam Hamed
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | - Ahmed Elghawalby
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | - Mohamed Attia
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | - Tallat Abdallah
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
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98
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Kim EY, You YK, Kim DG, Hong TH. A simple pancreaticojejunostomy technique for hard pancreases using only two transpancreatic sutures with buttresses: a comparison with the previous pancreaticogastrostomy and dunking methods. Ann Surg Treat Res 2015; 90:64-71. [PMID: 26878013 PMCID: PMC4751147 DOI: 10.4174/astr.2016.90.2.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/28/2015] [Accepted: 10/06/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE In this study, we introduced a novel technique, the pancreaticojejunostomy (PJ), which uses only two transpancreatic sutures with buttresses (PJt), and compared the surgical outcomes with previously used methods, especially for hard pancreases. METHODS A total of 101 patients who underwent pancreaticoduodenectomy with hard pancreases were enrolled and divided into 3 groups according to the method of pancreaticoenteric anastomosis: 30 patients (29.7%) underwent the conventional dunking method (Du), 31 patients (30.7%) underwent pancreaticogastrostomy using transpancreatic sutures (PGt) and 40 patients (39.6%) underwent PJ using transpancreatic sutures (PJt). The surgical outcomes were compared according to the type of anastomosis to analyze the feasibility and ease of each technique. RESULTS The overall operative time was shorter in the PJt group (325.1 ± 63.8 minutes) than in the PGt group (367.3 ± 70.5 minutes) or the Du group (412.0 ± 38.2 minutes, P < 0.001). In terms of pancreaticoenteric anastomosis time, it was also shorter in the PJt group (10.3 ± 3.5 minutes) than in the Du group (20.7 ± 0.7 minutes) or the PGt group (16.8 ± 5.4 minutes, P = 0.005). Significant postoperative pancreatic fistula (POPF) developed in 2 cases (6.7%) in the Du group, whereas there were no POPF cases in the PGt or PJt groups (P = 0.086). Overall postoperative morbidities occurred in 31 cases (30.7%), and there were no significant differences among the 3 groups (P = 0.692). CONCLUSION The novel PJ technique, which uses only two transpancreatic sutures with buttresses, is a very simple, easy and secure method for hard pancreases and can be performed in a shorter amount of time compared with conventional methods.
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Affiliation(s)
- Eun Young Kim
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoung You
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Goo Kim
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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99
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Robot-assisted laparoscopic partial caudate lobe resection for hepatocellular carcinoma in cirrhotic liver. Surg Laparosc Endosc Percutan Tech 2015; 24:e88-91. [PMID: 24887545 DOI: 10.1097/sle.0b013e31829ce820] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To evaluate the technical feasibility and safety of robot-assisted laparoscopic partial caudate lobe resection using the robotic surgical system. MATERIALS AND METHODS This is a report of the use of robot-assisted laparoscopic partial caudate lobe resection on 2 patients with hepatocellular carcinoma. RESULTS Robot-assisted laparoscopic partial caudate lobe resection was completed successfully in these 2 patients. The operating time was 137 and 150 minutes, respectively. The blood loss was 137 and 150 mL, respectively. They were able to tolerate liquids on the second postoperative day. Both patients recovered from the operation. They were discharged 4 and 5 days after the operation, respectively. The resected margins of both specimens were tumor free (R0 resections). CONCLUSIONS Robot-assisted laparoscopic partial caudate lobe resection is a feasible and safe procedure. Our results demonstrate the advantages of robotic system on short-term outcomes and suggest the extended indication of minimally invasive hepatectomy even in the technically challenging anatomic area.
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100
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Kang CM, Lee SH, Chung MJ, Hwang HK, Lee WJ. Laparoscopic pancreatic reconstruction technique following laparoscopic pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:202-10. [PMID: 25546026 DOI: 10.1002/jhbp.193] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the advance of laparoscopic experiences and techniques, it is carefully regarded that laparoscopic pancreaticoduodenectomy (lap-PD) is feasible and safe in managing perimapullary pancreatic pathology. Especially, laparoscopic management of remnant pancreas can be a critical step toward completeness of minimally invasive PD. According to available published reports, there is a wide range of technical differences in choosing surgical options in managing remnant pancreas after lap-PD. For the evidence-based surgical approach, it would be ideal to test potential techniques by randomized controlled trials, but, currently, it is thought to be very difficult to expect those clinical trials to be successful because there are still a lack of expert surgeons with sound surgical techniques and experience. In addition, lap-PD is so complicated and technically demanding that many surgeons are still questioning whether this surgical approach could be standardized and popular like laparoscopic cholecystectomy. In general, surgical options are usually chosen based on following question: (1) Is it simple? (2) Is it easy and feasible? (3) Is it secure and safe? (4) Is there any supporting scientific evidence? It would be interesting to estimate which surgical technique would be appropriate in managing remnant pancreas under these considerations. It is hoped that a well standardized multicenter-based randomized control study would be successful to test this fundamental issues based on sound surgical techniques and scientific background.
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Affiliation(s)
- Chang Moo Kang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Ludlow Faculty Research Building #203, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea; Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Institute of Gastroenterology, Severance Hospital, Seoul, Korea
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