A novel radiopaque biodegradable stent for pancreatobiliary applications--the first human phase I trial in the pancreas

BACKGROUND/AIMS

During the recent years we have developed and experimentally tested a biodegradable stent for pancreatobiliary applications. Such stents may be used in benign strictures or when securing the flow of bile, pancreatic juice or a fluid collection after endoscopic or surgical procedures. The lack of suitable devices has so far prohibited clinical endoscopic or percutaneous tests whereas surgical application has become possible. Recently we described a modified binding (purse string) pancreaticojejunostomy, where a biodegradable stent is introduced to secure the lumen opening when tightening the bowel over the pancreas with a purse string. Although routine use of any stent in pancreaticojejunostomy has been under debate, we used this setting to run for the first phase I human clinical trial with a biodegradable stent in a pancreatobiliary application.

METHODS

After 29 pancreaticoduodenectomies, a braided gamma sterilized radiopaque 96L/4D polylactide stent was introduced into the duct of pancreas remnant, which was then sunk into the Roux-Y jejunal limb. Complications, stent disappearance and late anastomotic patency (MRI) were monitored.

RESULTS

Hospital mortality was zero. One patient developed Grade C fistula (overall fistula rate 3%). She also developed Grade C hemorrhage and Grade C delayed gastric emptying (DGE). One other patient developed Grade B hemorrhage (overall hemorrhage rate 7%) and B DGE. Three other patients developed clinically significant Grade B-C DGE (5/29=17%). In addition, 10 other patients were not on solid food only on post-operative day 8, and were classified as Grade A DGE (34%). Most of these patients were eating normally and could be discharged from hospital by day 10. Nine out of 26 patients (35%) with negative preoperative trypsinogen test, developed post-operative trypsinogen release suggesting pancreatitis. Within 12 months four patients died and one quitted the study. The stents disappeared in median 3 months. MRI interpretation of the anastomosis failed in one patient having ascites. Of the 23 patients, 13 (57%) had the anastomosis well open, three (13%) had some narrowing, while seven (30%) had the anastomosis obstructed.

CONCLUSION

Compared with our previous experiences obtained in pancreaticoduodenectomy, a biodegradable stent is well tolerated in the human pancreatic duct, encouraging further development for future applications and tests in randomized trials.

Reconstruction by Pancreaticogastrostomy versus Pancreaticojejunostomy following Pancreaticoduodenectomy: A Meta-Analysis of Randomized Controlled Trials

Objectives. The aim of our study was to evaluate and compare the results of pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). Methods. Published data of randomized clinical trials (RCTs) comparing the clinically relevant outcomes of PG versus PJ after PD were analyzed. Two reviewers assessed the quality of each trial and collected data independently. The Cochrane Collaboration's RevMan 5.0 software was used for statistical analysis. Proportions were combined, and the odds ratio (OR) with its 95% CI was used as the effect size estimate. Results. Four RCTs published in 1995 or later were included in this meta-analysis, in which 276 patients underwent PG and 277 patients underwent PJ followed PD. In the combined results of PG versus PJ, a significant difference in the morbidity of intra-abdominal complications (OR, 0.34; 95% CI, 0.23–0.49; P < 0.00001) was found, but no significant difference could be found for pancreatic fistula (OR, 0.69; 95% CI, 0.42–1.12 , P = 0.13) mortality (OR, 1.09; 95% CI, 0.42–2.83; P = 0.87), recovery with no complications (OR, 1.26; 95% CI, 0.90–1.78; P = 0.18), biliary fistula (OR, 0.55; 95% CI, 0.22–1.35; P = 0.19), or in delayed gastric emptying (OR, 0.55; 95% CI, 0.33–1.01; P = 0.06). Conclusions. Current RCTs suggest that PG is better than PJ for pancreatic reconstruction after PD.

The methods of reconstruction of pancreatic digestive continuity after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials

BACKGROUND

Pancreatic fistula (PF) is an important factor responsible for the considerable morbidity associated with pancreaticoduodenectomy (PD). There have been many techniques proposed for the reconstruction of pancreatic digestive continuity to prevent fistula formation but which is best is still highly debated. We carried out a systematic review and meta-analysis to determine the effectiveness of methods of anastomosis after PD.

METHODS

A full literature search was conducted in the Cochrane Controlled Trials Register Databases, Medline, and other resources irrespective of language. Randomized controlled trials (RCTs) were considered for inclusion. Analyses were carried out using RevMan software.

RESULTS

In all, ten RCTs that included a total of 1,408 patients were included. The meta-analysis showed that the PF, postoperative complications, biliary fistula, mortality, reoperation, and length of hospital stay were not statistically different between the pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) groups. The PF, postoperative complications, mortality, and reoperation were not statistically different between the duct-to-mucosa PJ and PJ groups. Binding PJ significantly decreased the PF and postoperative complications compared with conventional PJ. The PF, postoperative complications, and mortality were not statistically different between ligation of the pancreatic duct without anastomosis versus PJ.

CONCLUSION

No pancreatic reconstruction technique after PD was found to be applicable to all kinds of pancreatic remnants in our systematic review and meta-analysis. Some new approaches such as binding PJ and modified PG will be considered for study in the future.

Endoscopic ampullectomy: techniques and outcomes

Advances in endoscopic ampullectomy continue to mitigate concerns regarding incomplete removal of ampullary neoplasias, postprocedure complications, and insufficient treatment of tumors with undetected malignant foci or intraductal invasion. Advanced T staging of these lesions with endoscopic ultrasound and intraductal ultrasound, while useful tools for selection of candidates for snare polypectomy, should be limited to lesions either greater than 3 cm, bearing the macroscopic appearance of malignancy or unamenable to endoscopic therapy. Intraductal ultrasound has demonstrated T-staging accuracy superior to endoscopic ultrasound. One prospective study of prophylactic pancreatic stent placement and a number of retrospective studies have reported reduced complication rates. Recent studies continue to propose follow-up endoscopic retrograde cholangiopancreatography at 3-month intervals after ampullectomy to evaluate for recurrence and ablate residual tissue, with the interval increased to 6 to 12 months for 5 years on obtaining negative biopsies for adenomatous tissue. The development of thermal ablation, notably argon plasma coagulation, for fulguration of residual unresectable tumor, biductal sphincterotomy and prophylactic pancreatic pancreatic stent placement, and advanced diagnostic imaging mitigate the concerns leveled against endoscopic ampullectomy. In experienced hands, endoscopic papillectomy of noninvasive, benign ampullary lesions is a safe, technically feasible, and effective alternative to surgical resection. This study will focus on diagnosis and staging of ampullary adenomas and reviews indications for, and outcomes and complications of, endoscopic papillectomy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Combined invagination and duct-to-mucosa techniques with modifications: a new method of pancreaticojejunal anastomosis

BACKGROUND

Soft pancreatic texture and a small main pancreatic duct are thought to be the most significant risk factors for the occurrence of pancreatic fistula (PF), a common and serious complication after pancreaticoduodenectomy (PD). This is in part due to the technical difficulties of pancreaticojejunostomy (PJ) posed by a soft gland with a normal-sized duct. To deal with this problem, we developed a new anastomotic technique which combines the two most widely used techniques, namely, the invagination technique and the duct-to-mucosa technique, with a modification of the suture route and insertion of a temporary stent tube.

METHODS

Between January 2003 and December 2009, ninety-two consecutive patients underwent PD in which the new PJ technique was used. Charts and follow-up data of these patients were reviewed for operative details, early postoperative events, and outcomes at 6 months after the operation. PF was defined by the International Study Group on Pancreatic Fistula (ISGPF) guidelines and graded (A, B or C) according to the clinical procedures and outcome.

RESULTS

In this group of 92 patients, there was only 1 early death from acute renal failure. PF was observed in 11 patients (12.0%), 8 in grade A, 1 in grade B, and 2 in grade C. For the 2 patients in grade C, PF was surgically managed. There were no early or late deaths attributable to PF. Six months after the operation, all of the patients were free of PJ-related symptoms except for 2, who were found to have steatorrhea.

CONCLUSIONS

Our modified technique is simple and safe in PD. Present data suggest that this technique produces excellent early and medium-term results.

Binding pancreaticoenteric anastomosis: from binding pancreaticojejunostomy to binding pancreaticogastrostomy

Potential mechanisms of occurrence of pancreatic leakage mainly include leakage from the needle hole and from the seam at the adjacent stitch, anastomotic blood supply, tension at the anastomosis, poor anastomotic healing, etc. Binding pancreaticojejunostomy (BPJ) is a safe and effective technique that avoids the primary complication of pancreatic anastomosis leakage. There are two problems with BPJ: a high discrepancy in the size of pancreas stump and the jejunal lumen; sutures on to the pancreas for fixation might cause exudation of pancreatic juice into the abdominal cavity. In order to avoid these two problems, binding pancreaticogastrostomy (BPG) is designed and successfully performed clinically with encouraging results. BPG is good for accommodating a large pancreas stump, and the binding technique is very helpful in minimizing the leak rate of pancreaticogastrostomy.

Current state of surgical management of pancreatic cancer

Pancreatic cancer is still associated with a poor prognosis and remains—as the fourth leading cause of cancer related mortality—a therapeutic challenge. Overall long-term survival is about 1–5%, and in only 10–20% of pancreatic cancer patients is potentially curative surgery possible, increasing five-year survival rates to approximately 20–25%. Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care. Standardized resections can be carried out with low morbidity and mortality below 5% in high volume institutions. Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes. The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.

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

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

Binding versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a case-matched study

BACKGROUND

Postoperative morbidity of pancreaticoduodenectomy remains high and is mainly related to postoperative pancreatic fistula. Peng et al. (J Gastrointest Surg 2003;7:898-900; Am J Surg 2002;183:283-285; Ann Surg 2007;245:692-298) recently described binding pancreaticojejunostomy and reported a zero percent rate of pancreatic fistula. The aim of this study was to compare postoperative outcome of binding pancreaticojejunostomy and conventional pancreaticojejunostomy after pancreaticoduodenectomy.

METHODS

Between June 2006 and June 2008, a case-control study was conducted, including all patients with binding pancreaticojejunostomy after pancreaticoduodenectomy. These patients were matched with similar patients with conventional pancreaticojejunostomy. Matching criteria were as follows: age, body mass index, pancreatic texture, and pancreatic main duct size. Postoperative mortality and morbidity were analyzed. Postoperative pancreatic fistula was defined according to the International Study Group of Pancreatic Surgery.

RESULTS

Twenty-two patients with binding pancreaticojejunostomy and 25 with conventional pancreaticojejunostomy were included. There was no difference concerning the rate of postoperative pancreatic fistula, but median delay for healing of postoperative pancreatic fistula was longer in the binding pancreaticojejunostomy group (29 vs. 9 days, p = 0.003). Postpancreatectomy hemorrhage was more frequent in the binding pancreaticojejunostomy group (6/22 vs. 0/25, p = 0.023).

CONCLUSION

Results of this study showed that binding pancreaticojejunostomy after pancreaticoduodenectomy was not associated with lower postoperative pancreatic fistula and moreover seems to increase postpancreatectomy hemorrhage.

Analysis of procedure-related complications after pancreatodoudenectomy

PURPOSE

To analyze the procedure-related complications after pancreaticoduodenctomy (PD) and their risk factors.

METHODS

One hundred twenty-six patients underwent pancreatoduodenectomy for diseases at region of pancreatic head were reviewed retrospectively.

RESULTS

The overall surgical morbidity was 40.5% (51/126). Ten (7.9%) of 51 patients were identified as having pancreatic leakage, others included delayed gastric emptying (8.7%, 11), abdominal infection and abscess (7.9%, 10), abdominal bleeding (5.6%, 7), wound infection (4.8%, 6), wound dehiscence (2.4%, 3), biliary fistula (1.6%, 2) and operative death (1.6%, 2). Other postoperative complications were lung inflammation (3.9%, 5) and newly developed diabetes mellitus (2.3%, 3). Age (>60 years), coexisting diabetes mellitus, small main pancreatic duct (≤0.5 cm), and surgeon's experience (<10 patients within 5 years) were demonstrated to be independent risk factors by both univariate and multivariate analysis (p < 0.01).

CONCLUSIONS

Old patients with coexisting diabetes mellitus and small main pancreatic duct undergo pancreatoduodenectomy by a less experienced surgeon may be at high risk of procedure-related complications.

Caudate lobe hepatocellular carcinoma treated with selective chemoembolization

PURPOSE

To analyze the clinical outcomes of chemoembolization for solitary caudate lobe hepatocellular carcinoma (HCC) found at initial presentation.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board; the requirement for informed patient consent was waived. From July 1998 to June 2009, 40 patients (28 men, 12 women; mean age, 57 years) found to have a single HCC lesion in the caudate lobe at initial presentation were treated with chemoembolization and evaluated for overall survival and progression-free survival. Multivariate analyses for potential clinical and radiologic factors were performed by using the Cox proportional hazard model.

RESULTS

Selective chemoembolization via the caudate artery was achieved in 34 (85%) patients. Overall survival rates at 1, 2, 3, 4, and 5 years were 92%, 79%, 65%, 56%, and 56%, respectively. Selective chemoembolization of the caudate artery was a critically important factor in longer overall survival (hazard ratio, 0.091; 95% confidence interval [CI]: 0.021, 0.389; P < .001), and portal vein tumor thrombosis (hazard ratio, 31.25; 95% CI: 4.88, 200.1; P < .001) and multiple tumor-feeding vessels (hazard ratio, 6.87; 95% CI: 1.47, 32.1; P = .014) were significant factors in shorter overall survival. Selective chemoembolization of the caudate artery was also a significant factor in longer progression-free survival (hazard ratio, 0.278; 95% CI: 0.10, 0.76; P = .013).

CONCLUSION

Selective chemoembolization via the caudate artery is possible in most patients with caudate lobe HCC and a critical factor in longer overall survival and longer progression-free survival.

Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Pancreatic fistula (PF) after pancreatoduodenectomy (PD) remains a challenging problem. The only commonly accepted risk factor is the soft consistency of the pancreatic remnant.

METHODS

In all, 100 consecutive patients underwent PD. All data, including commonly accepted risk factors for PF and PF defined according to the International Study Group of Pancreatic Fistula, were collected prospectively. On the pancreatic margin, a score of fibrosis and a score of fatty infiltration were assessed by a pathologist blinded to the postoperative course.

RESULTS

PF occurred in 31% of patients. In univariate analysis, male sex, age greater than 58 years, body mass index (BMI) > or =25 kg/m(2), pre-operative high blood pressure, operation for nonintraductal papillary and mucinous neoplasm (IPMN) disease and for ampullary carcinoma, operative time, blood loss, soft consistency of the pancreatic remnant, absence of pancreatic fibrosis, and presence of fatty infiltration of the pancreas were associated with a greater risk of PF. In a multivariate analysis, only BMI > or =25 kg/m(2), absence of pancreatic fibrosis, and presence of fatty pancreas were significant predictors of PF. A score based on the number of risk factors present divided the patient population into 4 subgroups carrying a risk of PF that ranged from 7% (no risk factor) to 78% (3 risk factors) and from 0% to 81%, taking into account only symptomatic PF (grade B and C).

CONCLUSION

The presence of an increased BMI, the presence of fatty pancreas, and the absence of pancreatic fibrosis as risk factors of PF allows a more precise and objective prediction of PF than the consistency of pancreatic remnant alone. A predictive score based on these 3 factors could help to tailor preventive measures.

Peng's binding pancreaticojejunostomy after pancreaticoduodenectomy: a French prospective study

BACKGROUND

Pancreatic fistula (PF) is the single most important complication after pancreaticoduodenectomy. Recently, a 0% rate of PF was reported using a binding pancreaticojejunostomy with intussusception of the pancreatic stump. The aim of this study was to assess the safety of this new binding pancreaticojejunostomy in condition most susceptible to PF, i.e. soft pancreas and non-dilated main pancreatic duct.

METHODS

Forty-five consecutive patients with soft pancreas and non-dilated main pancreatic duct underwent a binding pancreaticojejunostomy. Post-operative PF was defined according to the International Study Group of Pancreatic Fistula.

RESULTS

Four patients (8.9%) developed a PF. In one case, PF developed on post-operative day 3 due to a technical deficiency. In the three other cases, pancreatic fistula developed after the tenth post-operative day; all the patients had local and/or general co-morbidities before PF occurrence.

CONCLUSIONS

Binding pancreaticojejunostomy according to Peng is a safe and secure technique that improves the rate of pancreatic fistula, especially in case of soft texture of the pancreas remnant. However, a 0% rate seems to be hard to achieve because other abdominal and general complications are frequent and can lead to secondary leakage of the pancreatic anastomosis.

The pancreatic stump after pancreatoduodenectomy: the "Achille's heel" revisited

Pancreatic fistula, the most dreaded complication of pancreatoduodenectomy occurs with an incidence ranging from 4-30% in literature reports; the incidence varies considerably according to the definition of fistula used. This literature review describes various methods proposed over the last decade to decrease the incidence and severity of pancreatic fistula including techniques of pancreatico-jejunal and pancreatico-gastric anastomoses, deliberate avoidance of pancreatico-enteric anastomosis, and the prophylactic role of somatostatin analogues.

Prognostic factors in the surgical treatment of caudate lobe hepatocellular carcinoma

AIM: To evaluate the short- and long-term outcomes of liver resection for caudate lobe hepatocellular carcinoma (HCC).

METHODS: We retrospectively analyzed 114 consecutive patients with HCC, originating from the caudate lobe, who underwent resection between January 2001 and January 2007. Univariate and multivariate analyses were performed on several clinicopathologic variables to determine the factors affecting long-term outcome and intrahepatic recurrence.

RESULTS: Overall mortality and morbidity were 0% and 18%, respectively. After a median follow-up of 31 mo (interquartile range, 11-66 mo), tumor recurrence had occurred in 76 patients (66.7%). The 1-, 3-, and 5-year disease-free survival rates were 65.7%, 38.1%, and 18.4%, respectively. The 1-, 3-, and 5-year overall survival rates were 76.1%, 54.7%, and 31.8%, respectively. Univariate analysis showed that subsegmental location of the tumor (45.7% vs 16.2%, P = 0.01), liver cirrhosis (12.3% vs 47.9%, P = 0.03), surgical margin (18.5% vs 54.6%, P = 0.04), vascular invasion (37.9% vs 23.2%, P = 0.04) and extended caudate resection (42.1% vs 15.4%, P = 0.04) were related to poorer long-term survival. Multivariate analysis showed that only subsegmental location of the tumor, liver cirrhosis and surgical margin were significant independent prognostic factors.

CONCLUSION: Hepatectomy was an effective treatment for HCC in the caudate lobe. The subsegmental location of the tumor, liver cirrhosis and surgical margin affected long-term survival.

The evolution of the surgical treatment of chronic pancreatitis

OBJECTIVE

To establish the current status of surgical therapy for chronic pancreatitis, recent published reports are examined in the context of the historical advances in the field.

BACKGROUND

The basis for decompression (drainage), denervation, and resection strategies for the treatment of pain caused by chronic pancreatitis is reviewed. These divergent approaches have finally coalesced as the head of the pancreas has become apparent as the nidus of chronic inflammation.

METHODS

The recent developments in surgical methods to treat the complications of chronic pancreatitis and the results of recent prospective randomized trials of operative approaches were reviewed to establish the current best practices.

RESULTS

Local resection of the pancreatic head, with or without duct drainage, and duodenum-preserving pancreatic head resection offer outcomes as effective as pancreaticoduodenectomy, with lowered morbidity and mortality. Local resection or excavation of the pancreatic head offers the advantage of lowest cost and morbidity and early prevention of postoperative diabetes. The late incidences of recurrent pain, diabetes, and exocrine insufficiency are equivalent for all 3 surgical approaches.

CONCLUSIONS

Local resection of the pancreatic head appears to offer best outcomes and lowest risk for the management of the pain of chronic pancreatitis.

Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications

BACKGROUND

Pancreatic anastomotic failure has traditionally been a source of significant morbidity and potential mortality after pancreaticoduodenectomy. Both patient-derived and technical factors contribute to pancreatic anastomotic failure. From a technical standpoint, an "ideal" pancreaticojejunal anastomosis would meet the following criteria: applicable to all patients, easy to teach, and associated with a low rate of pancreatic anastomotic failure-related complications. The pancreaticojejunostomy described by one of the authors (LHB) meets the criteria for an "ideal" pancreaticojejunostomy.

STUDY DESIGN

We performed an audit of results of a consecutive series of patients at two institutions who underwent pancreaticojejunostomy using the described technique. Pancreaticojejunostomy after pancreaticoduodenectomy was performed in all cases using a novel two-layer technique consisting of an outer full thickness pancreas-to-seromuscular jejunal anastomosis and an inner duct-to-mucosal anastomosis. Incidences of pancreatic anastomotic failure (measured using the International Study Group of Pancreatic Fistula definition) and perioperative pancreatic anastomotic failure-related complications were analyzed.

RESULTS

One hundred eighty-seven patients underwent pancreaticojejunostomy after pancreaticoduodenectomy using the described technique. Overall mortality was 1.6%. The rate of clinically significant pancreatic anastomotic failure (International Study Group of Pancreatic Fistula grade B or C) was only 6.9%. There was no bleeding, reoperation, or mortality secondary to pancreatic anastomotic failure among patients in this series.

CONCLUSIONS

The novel pancreaticojejunostomy is applicable to all patients in whom the pancreatic duct can be identified, and it is associated with very low rates of significant postoperative morbidity and mortality. These findings support its routine use for pancreaticojejunal reconstruction after pancreaticoduodenectomy.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is endoscopic papillectomy safe for ampullary adenomas with high-grade dysplasia?

OBJECTIVES

This study was designed to provide safe management guidelines for ampullary adenoma by analysis of clinicopathological features.

BACKGROUND

The treatment of ampullary cancer has been established; however, the indications for treatment of ampullary adenoma remain controversial.

METHODS

Between July 1997 and July 2008, a total of 33 patients were diagnosed with ampullary adenoma prior to procedures: 20 endoscopic papillectomies (ESP), 5 transduodenal resections (TDR), and 8 pancreatoduodenectomies (PD).

RESULTS

The false-negative rate of biopsy for cancer was 27.5% (8/29). Coexistence of cancer in patients with pre-high-grade dysplasia (HGD) was 50.0% (5/10), whereas it was 15.7% in pre-low-grade dysplasia (LGD). In addition, the rate of recurrence was 80% (8/10) in patients with pre-HGD. The size of tumor by final pathology was 1.27 +/- 0.89 cm in LGD, 1.81 +/- 0.99 cm in HGD, and 1.98 +/- 1.08 cm in cancer group. There was a significant correlation between size of tumor and final pathology (P = 0.036). According to receiver operating characteristic (ROC) curve, criterion to predict HGD/cancer was tumor size larger than 1.5 cm; sensitivity and specificity were 55.6% and 80.0%, respectively, and likelihood ratio was 2.778. However, size of tumor was not associated with preprocedural pathology.

CONCLUSIONS

Ampullary adenoma with preprocedural HGD was highly associated with coexistence of cancer and recurrence. Moreover, most of large tumors were treated by surgical procedures and proved to be cancer. Therefore, we suggest that ampullary adenoma with preprocedural HGD or more than 1.5 cm should not be managed with endoscopic papillectomy due to high associated rates of recurrence.

Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial

BACKGROUND

Pancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy. There have been no large prospective randomized trials evaluating PF rates comparing invagination versus duct to mucosa pancreaticojejunostomy. We tested the hypothesis that a duct to mucosa pancreaticojejunostomy would reduce the PF rate.

STUDY DESIGN

Between August 2006 and May 2008, 197 patients at two institutions underwent pancreaticoduodenectomy by a total of 8 experienced pancreatic surgeons as part of this prospective randomized trial (clinical trial no. NCT00359320). All patients were stratified by pancreatic texture and randomized to either an invagination or a duct to mucosa pancreaticojejunal anastomosis. Recorded variables included pancreatic duct diameter, operative time, blood loss, complications, and pathology. Primary end point was PF rate, as defined by the International Study Group on Pancreatic Fistula. Secondary end points included PF grade, postoperative length of hospital stay, other morbidities, and mortality.

RESULTS

Rate of PF for the entire cohort was 17.8%. There were 23 fistulas (24%) in the duct to mucosa cohort and 12 fistulas (12%) in the invagination cohort (p < 0.05). The greatest risk factor for a PF was pancreas texture: PF developed in only 8 patients (8%) with hard glands, and in 27 patients (27%) with a soft gland. There were two perioperative deaths (both in the duct to mucosa group), with the proximate causes of death being PF, followed by bleeding and sepsis.

CONCLUSIONS

This dual-institution prospective randomized trial reveals considerably fewer fistulas with invagination compared with duct to mucosa pancreaticojejunostomy after pancreaticoduodenectomy. Results confirm increased PF rates in soft as compared with hard glands. Additional studies are needed to define the optimal technique of pancreatic reconstruction after pancreaticoduodenectomy.

Is isolated Roux loop pancreaticojejunostomy superior to conventional reconstruction in pancreaticoduodenectomy?

OBJECTIVES

Pancreatic fistula (PF) predicts mortality and morbidity in patients undergoing pancreaticoduodenectomy (PD). This study aimed to assess whether isolated Roux loop pancreaticojejunostomy (IPJ) is superior to conventional pancreaticojejunostomy (CPJ).

METHODS

Between September 2003 and July 2007, we performed 108 PDs. All patients underwent classical Kausch-Whipple PD with pancreaticojejunostomy (PJ). Patients were divided into two groups based on the type of PJ. Patients in group 1 underwent IPJ and those in group 2 underwent CPJ. A retrospective analysis of prospectively maintained data was performed to compare outcomes in the two groups.

RESULTS

There were 53 patients in group 1 and 55 in group 2. The two groups were comparable in both pre- and intraoperative parameters. The overall incidence of PF was 10.1% (five cases in group 1 vs. six in group 2). The course of clinically significant PF was similar in both groups in terms of fistula behaviour, management and the duration of spontaneous closure. Two patients in each group died. Overall complications, mortality and length of hospital stay were also similar; however, duration of surgery was significantly higher in group 1 vs. group 2 (442 min and 370 min, respectively; P= 0.005).

CONCLUSIONS

Isolated Roux loop pancreaticojejunostomy is not superior to conventional PJ; instead, it increases the duration of surgery.

Modified Cattell's pancreaticojejunostomy, buttressing for soft pancreases and an isolated biliopancreatic loop are safety measurements that improve outcome after pancreaticoduodenectomy: a pilot study

BACKGROUND

Pancreatic anastomotic leak is one of the most serious complications following pancreaticoduodenectomy (PD). Various factors have been implicated as contributors to pancreatic anastomotic leaks, the incidence of which has been as high as 28% in some series.

OBJECTIVES

We describe technical modifications to Cattell's technique for pancreaticojejunostomy (PJ), with buttressing of 'soft' pancreases and use of an isolated biliopancreatic loop for reconstruction following a PD.

METHODS

We report our early experience using this technique in 50 patients who underwent PD between May 2002 and June 2006.

RESULTS

There was no mortality in our series. The postoperative morbidity rate was 32% (16/50), with major complications occurring in seven (14%) patients. Pancreatic leak occurred in one patient (2%) and bile leak in one patient (2%). Both patients were managed conservatively.

CONCLUSIONS

Reconstruction after PD using an isolated biliopancreatic loop and modifications to Cattell's technique for PJ, with buttressing of the soft pancreas, can be performed with a low risk of pancreatic anastomotic leakage.

Controversies and appraisals about gastrointestinal reconstruction in pancreatoduodenectomy

Gastrointestinal reconstruction has been considered to be closely related to postoperative morbidity, mortality and quality of life of the patients who undergo pancreatoduodenectomy (PD). For more than half a century, the scholars all around the world have offered numerous operative modifications and new procedures to improve the alimentary reconstruction for PD, but the effect and appraisal of these methods have always been controversial. In recent years many large prospective randomized controlled trials have been reported and the questions above have been re-studied based on the meta-analysis, which enables us to have a correct understanding about these questions for the first time. This article summarized newest research findings, and carried out the synthesis contrast analysis of the main methods of digestive canal reconstruction for PD such as pancreaticojejunostomy (PJ) versus pancreaticogastrostomy (PG), the child type or Roux-en-Y technique, pylorus-preserving pancreatoduodenectomy (PPPD) and the classic Whipple procedure (WPD), duct-to- mucosa anastomosis versus end-to-end invaginated PD, etc. The objective effects of these commonly clinically used procedures are discussed in this paper.

Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy: a prospective randomized study

OBJECTIVE

To compare the results of postoperative morbidity rate of a new pancreatogastrostomy technique, pylorus-preserving pancreaticoduodenectomy (PPPD) with gastric partition (PPPD-GP) with the conventional technique of pancreaticojejunostomy (PJ).

SUMMARY AND BACKGROUND DATA

Pancreatojejunostomy and pancreatogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreatoduodenectomy (PD). All randomized controlled trials failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally results. However, postoperative morbidity remains high. The best technique in pancreatic anastomosis is still debated.

METHOD

Described here is a new technique, PPPD-GP; in this technique the gastroepiploic arcade is preserved. Gastric partition was performed using 2 endo-Gia staplers along the greater curvature of the stomach, 3 cm from the border. This gastric segment, 10 to 12 cm in length is placed in close proximity to the cut edge of the pancreatic stump. An end-to-side, duct-to-mucosa anastomosis (with pancreatic duct stent) is constructed. One hundred eight patients undergoing PPPD for benign and malignant diseases of the pancreatic head and the periampullary region were randomized to receive PG (PPPD-GP) or end-to-side PJ (PPPD-PJ).

RESULTS

The two treatment groups showed no differences in preoperative parameters and intraoperative factors. The overall postoperative complications were 23% after PPPD-GP and 44% after PPPD-PJ (P < 0.01). The incidence of pancreatic fistula was 4% after PPPD-GP and 18% after PPPD-PJ (P < 0.01). The mean + SD hospital stay was 12 +/- 2 days after PPPD-GP and 16 +/- 3 days after PPPD-PJ.

CONCLUSIONS

This study shows that PPPD-GP can be performed safely and is associated with less complication than PPPD-PJ. The advantage of this technique over other PG techniques is that the anastomosis is outside the area of the stomach where the contents empty into the jejunum, but pancreatic juice drains directly into the stomach.

Risk factors affecting pancreatic fistulas after pancreaticoduodenectomy

AIM: To analyze the risk factors of pancreatic leakage after pancreaticoduodenectomy.

METHODS: We retrospectively reviewed 172 consecutive patients who had undergone pancreatico-duodenectomy at Inha University Hospital between April 1996 and March 2006. We analyzed the pancreatic fistula rate according to the clinical characteristics, the pathologic and laboratory findings, and the anastomotic methods.

RESULTS: The incidence of developing pancreatic fistulas in patients older than 60 years of age was 21.7% (25/115), while the incidence was 8.8% (5/57) for younger patients; the difference was significant (P = 0.03). Patients with a dilated pancreatic duct had a lower rate of post-operative pancreatic fistulas than patients with a non-dilated duct (P = 0.001). Other factors, including clinical features, anastomotic methods, and pathologic diagnosis, did not show any statistical difference.

CONCLUSION: Our study demonstrated that pancreatic fistulas are related to age and a dilated pancreatic duct. The surgeon must take these risk factors into consideration when performing a pancre-aticoduodenectomy.

Decreasing the pancreatic leak rate after pancreaticoduodenectomy

Although pancreaticoduodenectomy has become a safe and effective procedure for benign and malignant pancreatic diseases in recent years, leakage of pancreaticoenteric anastomosis still remains a major cause of morbidity and even mortality. Various methods have been used to prevent pancreatic fistula with either pharmacologic or technical approaches. Based on meta-analysis of results from European and American trials, prophylactic use of octreotide to inhibit pancreatic secretion cannot be recommended for routine use in pancreaticoduodenectomy. Further randomized trials are required to clarify the role of selective use of octreotide in patients at high risk for pancreatic leakage. Technical improvement by surgeons is probably the most important approach to reduce pancreatic anastomotic leakage rate. Various technical modifications for pancreaticoenteric anastomosis have been suggested; some have been tested in randomized controlled trials, but data from randomized trials are generally scarce. Use of PG instead of PJ anastomosis, internal stenting of PJ anastomosis, pancreatic duct occlusion, and fibrin glue have not been shown to be effective in reducing pancreatic leakage rate after pancreaticoduodenectomy. One randomized trial recently showed significant reduction of pancreatic leakage rate using an external diverting stent after PJ anastomosis, and another randomized trial showed significant reduction in PJ anastomosis leakage using the binding PJ anastomosis technique. Nonetheless, further high-quality randomized controlled trials are needed to evaluate the benefit of these technical modifications in decreasing the pancreatic leakage rate after pancreaticoduodenectomy.

Polypropylene mesh-reinforced pancreaticojejunostomy for periampullar neoplasm

AIM

To evaluate the effect of polypropylene mesh-reinforced pancreatojejunostomy on pancreatic leakage.

METHODS

Seventeen consecutive patients with paraampullar malignancy received polyprolene mesh-reinforced pancreatodudeonectomy and the Child's method was used to rebuild the alimentary tract.

RESULTS

The mean time of polyprolene mesh-reinforced pancreatojejunostomy was 22 min. Anastomosis could endure 30-500 cm H(2)O pressure during operation. All patients recovered without pancreatic leakage.

CONCLUSION

Polyprolene mesh-reinforced pancreato-jejunostomy is a feasible and reliable procedure to prevent pancreatic leakage.

An easier method for performing a pancreaticojejunostomy for the soft pancreas using a fast-absorbable suture

AIM: To clarify the usefulness of a new method for performing a pancreaticojejunostomy by using a fast-absorbable suture material irradiated polyglactin 910, and a temporary stent tube for a narrow pancreatic duct with a soft pancreatic texture.

METHODS: Among 63 consecutive patients with soft pancreas undergoing a pancreaticoduodenectomy from 2003 to 2006, 35 patients were treated with a new reconstructive method. Briefly, after the pancreatic transaction, a stent tube was inserted into the lumen of the pancreatic duct and ligated with it by a fast-absorbable suture. Another tip of the stent tube was introduced into the intestinal lumen at the jejunal limb, where a purse-string suture was made by another fast-absorbable suture to roughly fix the tube. The pancreaticojejunostomy was completed by ligating two fast-absorbable sutures to approximate the ductal end and the jejunal mucosa, and by adding a rough anastomosis between the pancreatic parenchyma and the seromuscular layer of the jejunum. The initial surgical results with this method were retrospectively compared with those of the 28 patients treated with conventional duct-to-mucosa anastomosis.

RESULTS: The incidences of postoperative morbidity including pancreatic fistula were comparable between the two groups (new; 3%-17% vs conventional; 7%-14% according to the definitions). There was no mortality and re-admission. Late complications were also rarely seen.

CONCLUSION: A pancreaticojejunostomy using an irradiated polyglactin 910 suture material and a temporary stent is easy to perform and is feasible even in cases with a narrow pancreatic duct and a normal soft pancreas.