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Fernández-Cruz L, Sabater L, Fabregat J, Boggi U. Complicaciones después de una pancreaticoduodenectomía. Cir Esp 2012; 90:222-32. [DOI: 10.1016/j.ciresp.2011.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 03/23/2011] [Accepted: 04/04/2011] [Indexed: 12/18/2022]
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Lavu H. Pancreatic remnant reconstruction following pancreaticoduodenectomy and the pancreatic stump-closed pancreaticojejunostomy. J Surg Res 2012; 180:244-5. [PMID: 22472695 DOI: 10.1016/j.jss.2012.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 12/13/2011] [Accepted: 01/03/2012] [Indexed: 11/25/2022]
Affiliation(s)
- Harish Lavu
- Department of Surgery, Thomas Jefferson University, 1025 Walnut Street, College Bldg., Suite 605, Philadelphia, PA 19107, USA.
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Nordback I, Räty S, Laukkarinen J, Järvinen S, Piironen A, Leppiniemi J, Kellomäki M, Sand J. A novel radiopaque biodegradable stent for pancreatobiliary applications--the first human phase I trial in the pancreas. Pancreatology 2012; 12:264-71. [PMID: 22687383 DOI: 10.1016/j.pan.2012.02.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 02/29/2012] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Isto Nordback
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
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155
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Reconstruction by Pancreaticogastrostomy versus Pancreaticojejunostomy following Pancreaticoduodenectomy: A Meta-Analysis of Randomized Controlled Trials. Gastroenterol Res Pract 2012; 2012:627095. [PMID: 22474444 PMCID: PMC3296445 DOI: 10.1155/2012/627095] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 10/13/2011] [Accepted: 11/09/2011] [Indexed: 12/16/2022] Open
Abstract
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.
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Yang SH, Dou KF, Sharma N, Song WJ. The methods of reconstruction of pancreatic digestive continuity after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. World J Surg 2012; 35:2290-7. [PMID: 21800201 DOI: 10.1007/s00268-011-1159-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Sun Hu Yang
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, 17 Changle Western Road, Xi'an, 710032 Shanxi Province, China
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158
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Liu C, Long J, Liu L, Xu J, Zhang B, Yu X, Ni Q. Pancreatic Stump-Closed Pancreaticojejunostomy can be Performed Safely in Normal Soft Pancreas Cases. J Surg Res 2012; 172:e11-7. [DOI: 10.1016/j.jss.2011.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/11/2011] [Accepted: 09/02/2011] [Indexed: 01/08/2023]
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Abstract
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.
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160
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Hong TH, Youn YC, You YK, Kim DG. An easy and secure pancreaticogastrostomy after pancreaticoduodenectomy: transpancreatic suture with a buttress method through an anterior gastrotomy. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81:332-8. [PMID: 22148126 PMCID: PMC3229002 DOI: 10.4174/jkss.2011.81.5.332] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 07/04/2011] [Accepted: 07/28/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this report was to describe a new reconstructive technique of pancreaticogastrostomy and to also discuss this procedure's effectiveness for reducing the incidence of postoperative complications. METHODS We retrospectively analyzed early surgical outcomes in 21 consecutive patients who underwent this novel pancreaticogastrostomy after pancreaticoduodenectomy. Pancreaticogastrostomy was completed with 2 transpancreatic sutures with buttresses on both the upper and lower edges of the implanted pancreas through the retracted anterior gastrotomy. RESULTS Operative mortality was zero and morbidity was 23.8%. A significant pancreatic fistula occurred in 1 patient (4.7%; grade B). CONCLUSION This technique is very easy to perform, less traumatic to the pancreatic stump, can be performed through a mini-laparotomy due to good vision and straight sutures, and it is secure owing to anchoring of the invaginated pancreatic stump to the stomach's posterior wall with buttresses. The results of this pilot study indicate that the technique may provide a favorable outcome and could be an alternative method of pancreatoenteric anastomosis. However, to determine its superiority over the conventional procedures, this operative technique should be evaluated more comprehensively in a larger series.
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Affiliation(s)
- Tae Ho Hong
- Division of Hepatobiliary-Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea School of Medicine, Seoul, Korea
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161
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Zhu B, Geng L, Ma YG, Zhang YJ, Wu MC. Combined invagination and duct-to-mucosa techniques with modifications: a new method of pancreaticojejunal anastomosis. Hepatobiliary Pancreat Dis Int 2011; 10:422-7. [PMID: 21813393 DOI: 10.1016/s1499-3872(11)60072-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
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.
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Affiliation(s)
- Bin Zhu
- Second Department of Biliary Surgery and Department of Special Treatment, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
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162
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Jiang C, Wang M, Xu Q, Wu X, Yu D, Ding Y. A modified technique for end-to-side pancreaticojejunostomy by purse-string suture. J Surg Oncol 2011; 104:852-6. [PMID: 21713776 DOI: 10.1002/jso.21978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Accepted: 04/22/2011] [Indexed: 12/24/2022]
Affiliation(s)
- Chunping Jiang
- Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical College, Nanjing, China
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Fernández-Cruz L, Belli A, Acosta M, Chavarria EJ, Adelsdorfer W, López-Boado MA, Ferrer J. Which is the best technique for pancreaticoenteric reconstruction after pancreaticoduodenectomy? A critical analysis. Surg Today 2011; 41:761-6. [DOI: 10.1007/s00595-011-4515-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 02/06/2011] [Indexed: 01/26/2023]
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Binding pancreaticoenteric anastomosis: from binding pancreaticojejunostomy to binding pancreaticogastrostomy. Updates Surg 2011; 63:69-74. [PMID: 21442343 DOI: 10.1007/s13304-011-0067-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 03/14/2011] [Indexed: 12/22/2022]
Abstract
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.
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Current state of surgical management of pancreatic cancer. Cancers (Basel) 2011; 3:1253-73. [PMID: 24212660 PMCID: PMC3756412 DOI: 10.3390/cancers3011253] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 02/19/2011] [Accepted: 03/10/2011] [Indexed: 12/12/2022] Open
Abstract
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.
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166
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167
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Ball CG, Howard TJ. Does the type of pancreaticojejunostomy after Whipple alter the leak rate? Adv Surg 2010; 44:131-48. [PMID: 20919519 DOI: 10.1016/j.yasu.2010.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis 46202, USA
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Maggiori L, Sauvanet A, Nagarajan G, Dokmak S, Aussilhou B, Belghiti J. Binding versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a case-matched study. J Gastrointest Surg 2010; 14:1395-400. [PMID: 20577828 DOI: 10.1007/s11605-010-1212-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 04/20/2010] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Léon Maggiori
- Department of Hepato-Biliary and Pancreatic Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital (AP-HP), 100 boulevard du Général Leclerc, 92118, Clichy, France
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Han SL, Zheng XF, Shen X, Liu Z, Li JL, Lan SH, Zhu GB. Analysis of procedure-related complications after pancreatodoudenectomy. Indian J Surg 2010; 72:194-9. [PMID: 23133246 DOI: 10.1007/s12262-010-0050-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 10/04/2009] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Shao-Liang Han
- Department of General Surgery, Wenzhou Medical College, Wenzhou, 325 000 Zhejiang Province, PR China
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170
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Kim HC, Chung JW, Jae HJ, Yoon JH, Lee JH, Kim YJ, Lee HS, Yoon CJ, Park JH. Caudate lobe hepatocellular carcinoma treated with selective chemoembolization. Radiology 2010; 257:278-87. [PMID: 20697120 DOI: 10.1148/radiol.10100105] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Hyo-Cheol Kim
- Department of Radiology, Seoul National University College of Medicine; Institute of Radiation Medicine; Seoul National University Medical Research Center, Seoul, Korea
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Gaujoux S, Cortes A, Couvelard A, Noullet S, Clavel L, Rebours V, Lévy P, Sauvanet A, Ruszniewski P, Belghiti J. Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. Surgery 2010; 148:15-23. [PMID: 20138325 DOI: 10.1016/j.surg.2009.12.005] [Citation(s) in RCA: 264] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 12/07/2009] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Sébastien Gaujoux
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Paris, France
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Zhu WH, Li S, Zhang DF, Peng JR, Jin ZT, Li GM, Wang FS, Zhu JY, Leng XS. Risk factors and outcome of pancreatic fistula after consecutive pancreaticoduodenectomy with pancreaticojejunostomy for patients with malignant tumor. Chin J Cancer Res 2010. [DOI: 10.1007/s11670-010-0032-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Pancreaticogastrostomy for high-risk gland after pancreaticoduodenectomy: an eligible choice? World J Surg 2010; 35:224-5; author reply 226. [PMID: 20495976 DOI: 10.1007/s00268-010-0632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Buc E, Flamein R, Golffier C, Dubois A, Nagarajan G, Futier E, Pezet D. Peng's binding pancreaticojejunostomy after pancreaticoduodenectomy: a French prospective study. J Gastrointest Surg 2010; 14:705-10. [PMID: 20054660 DOI: 10.1007/s11605-009-1125-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 11/30/2009] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Emmanuel Buc
- Service de Chirurgie Digestive et Hépatobiliaire, CHU Clermont-Ferrand, Hôtel Dieu-Bd Léon Malfreyt, 63058 Clermont-Ferrand, France.
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175
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Abstract
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.
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Affiliation(s)
- F Paye
- Service de chirurgie digestive, hôpital Saint-Antoine, UPMC Paris-06, 75012 Paris, France.
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176
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Liu P, Yang JM, Niu WY, Kan T, Xie F, Li DQ, Wang Y, Zhou YM. Prognostic factors in the surgical treatment of caudate lobe hepatocellular carcinoma. World J Gastroenterol 2010; 16:1123-8. [PMID: 20205285 PMCID: PMC2835791 DOI: 10.3748/wjg.v16.i9.1123] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To 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.
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Abstract
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.
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Surgical Treatmant of Pancreatic Cancer. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0035-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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179
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Rudloff U, Maker AV, Brennan MF, Allen PJ. Randomized Clinical Trials in Pancreatic Adenocarcinoma. Surg Oncol Clin N Am 2010; 19:115-50. [DOI: 10.1016/j.soc.2009.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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180
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Turrini O, Delpero J. Épiploolastie de couverture des vaisseaux au cours d’une duodénopancréatectomie céphalique : technique modifiée. ACTA ACUST UNITED AC 2009; 146:545-8. [DOI: 10.1016/j.jchir.2009.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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181
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Grobmyer SR, Kooby D, Blumgart LH, Hochwald SN. Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications. J Am Coll Surg 2009; 210:54-9. [PMID: 20123332 DOI: 10.1016/j.jamcollsurg.2009.09.020] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 08/24/2009] [Accepted: 09/09/2009] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Stephen R Grobmyer
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
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183
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Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump. Pancreas 2009; 38:e177-82. [PMID: 19730152 DOI: 10.1097/mpa.0b013e3181b57705] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the impact of the length of the isolated jejunal loop and the type of pancreaticojejunostomy on pancreatic leakage after pancreaticoduodenectomy. METHODS One hundred thirty-two consecutive patients who underwent a pancreaticoduodenectomy were studied according to the length of the isolated jejunal loop (short loop, 20-25 cm vs long loop, 40-50 cm) and the type of pancreaticojejunostomy (invagination vs duct to mucosa). RESULTS The use of the long isolated jejunal loop was associated with a significantly lower pancreatic leakage rate compared with the use of a short isolated jejunal loop (4.34% vs 14.2%, P < 0.05). In addition, the use of duct-to-mucosa technique was associated with significantly lower incidence of postoperative pancreatic fistula compared with the invagination technique (4.2% vs 14.5%, P < 0.05). Finally, patients with a short isolated jejunal loop compared with patients with a long loop had increased morbidity (50.7% vs 27.5%, P < 0.05) and prolonged hospital stay (16.3 +/- 1.9 days vs 10.2 +/- 2.3 days, P < 0.05). Overall mortality rate was 1.5%. CONCLUSIONS The use of a long isolated jejunal loop and a duct-to-mucosa pancreaticojejunostomy is associated with decreased pancreatic leakage rate after pancreaticoduodenectomy.
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184
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Anatomy-Specific Pancreatic Stump Management to Reduce the Risk of Pancreatic Fistula After Pancreatic Head Resection. World J Surg 2009; 33:2166-76. [DOI: 10.1007/s00268-009-0179-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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185
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Kleespies A, Rentsch M, Seeliger H, Albertsmeier M, Jauch KW, Bruns CJ. Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection. Br J Surg 2009; 96:741-50. [PMID: 19526614 DOI: 10.1002/bjs.6634] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Leakage from the pancreaticojejunostomy is the major cause of septic complications after partial pancreaticoduodenectomy. This study evaluated a new transpancreatic U-suture technique (Blumgart anastomosis, BA), which aims to avoid shear forces during knot-tying. METHODS Using a before-after study design, BA was compared with a modified Cattell-Warren anastomosis (CWA). Two patient cohorts (CWA, 90; BA, 92), which were similar with respect to primary diagnosis, age, sex and American Society of Anesthesiologists score, were compared retrospectively. Dependent variables were surgical and overall morbidity and mortality after partial pancreaticoduodenectomy. RESULTS Duration of operation (354 versus 328 min for CWA versus BA; P = 0.002), pancreatic leakage rate (13 versus 4 per cent; P = 0.032), postoperative haemorrhage (11 versus 3 per cent; P = 0.040), total surgical complications (31 versus 15 per cent; P = 0.011), general complications (36 versus 17 per cent; P = 0.005) and length of intensive care unit stay (median 5.4 versus 2.8 days; P = 0.015) were significantly reduced after BA. These effects were not related merely to an improvement over time. CONCLUSION BA appears to be a fast, simple and safe technique for pancreaticojejunostomy. It might reduce leakage rates and surgical complications after partial pancreaticoduodenectomy.
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Affiliation(s)
- A Kleespies
- Department of Surgery, Klinikum Grosshadern, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
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186
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Kim JH, Kim JH, Han JH, Yoo BM, Kim MW, Kim WH. Is endoscopic papillectomy safe for ampullary adenomas with high-grade dysplasia? Ann Surg Oncol 2009; 16:2547-54. [PMID: 19568817 DOI: 10.1245/s10434-009-0509-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 04/16/2009] [Accepted: 04/16/2009] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Ji Hun Kim
- Departments of Surgery, School of Medicine, Ajou University, Suwon, Korea
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187
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Berger AC, Howard TJ, Kennedy EP, Sauter PK, Bower-Cherry M, Dutkevitch S, Hyslop T, Schmidt CM, Rosato EL, Lavu H, Nakeeb A, Pitt HA, Lillemoe KD, Yeo CJ. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg 2009; 208:738-47; discussion 747-9. [PMID: 19476827 DOI: 10.1016/j.jamcollsurg.2008.12.031] [Citation(s) in RCA: 279] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Accepted: 01/12/2009] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Adam C Berger
- Department of Surgery, Thomas Jefferson University, Jefferson Pancreas, Biliary and Related Cancer Center, Philadelphia, PA 19107, USA.
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188
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Perwaiz A, Singhal D, Singh A, Chaudhary A. Is isolated Roux loop pancreaticojejunostomy superior to conventional reconstruction in pancreaticoduodenectomy? HPB (Oxford) 2009; 11:326-31. [PMID: 19718360 PMCID: PMC2727086 DOI: 10.1111/j.1477-2574.2009.00051.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Accepted: 02/16/2009] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Azhar Perwaiz
- Department of Surgical Gastroenterology, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India
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189
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Pancreatogastrostomy with an elastic purse-string suture around the gastric orifice after pancreatoduodenectomy. Surg Today 2009; 39:548-51. [DOI: 10.1007/s00595-008-3908-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Accepted: 08/07/2008] [Indexed: 12/27/2022]
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Abu Hilal M, Malik HZ, Hamilton-Burke W, Verbeke C, Menon KV. Modified Cattell's pancreaticojejunostomy, buttressing for soft pancreases and an isolated biliopancreatic loop are safety measurements that improve outcome after pancreaticoduodenectomy: a pilot study. HPB (Oxford) 2009; 11:154-60. [PMID: 19590641 PMCID: PMC2697882 DOI: 10.1111/j.1477-2574.2009.00028.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Accepted: 11/30/2008] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Mohammed Abu Hilal
- Department of Hepatopancreatobiliary Surgery, St. James's University Hospital, Leeds, UK
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191
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Li HX. Controversies and appraisals about gastrointestinal reconstruction in pancreatoduodenectomy. Shijie Huaren Xiaohua Zazhi 2009; 17:476-481. [DOI: 10.11569/wcjd.v17.i5.476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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192
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Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy: a prospective randomized study. Ann Surg 2009; 248:930-8. [PMID: 19092337 DOI: 10.1097/sla.0b013e31818fefc7] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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193
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Choe YM, Lee KY, Oh CA, Lee JB, Choi SK, Hur YS, Kim SJ, Cho YU, Ahn SI, Hong KC, Shin SH, Kim KR. Risk factors affecting pancreatic fistulas after pancreaticoduodenectomy. World J Gastroenterol 2008; 14:6970-4. [PMID: 19058333 PMCID: PMC2773861 DOI: 10.3748/wjg.14.6970] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To 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.
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194
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Poon RTP, Fan ST. Decreasing the pancreatic leak rate after pancreaticoduodenectomy. Adv Surg 2008; 42:33-48. [PMID: 18953808 DOI: 10.1016/j.yasu.2008.03.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Ronnie T P Poon
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China.
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Chen HW, Lai ECH, Su SY, Cai YF, Zhen ZJ, Lau WY. Modified Technique of Pancreaticojejunal Anastomosis with Invagination Following Pancreaticoduodenectomy: A Cohort Study. World J Surg 2008; 32:2695-700. [DOI: 10.1007/s00268-008-9760-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gouma DJ, Busch OR, van Gulik TM. Treatment of Pancreatic Adenocarcinoma: A European Perspective. Surg Oncol Clin N Am 2008; 17:569-86, ix. [DOI: 10.1016/j.soc.2008.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Huang DY, Wang XF, Zhou W, Xin Y, Mou YP, Cai XJ. Polypropylene mesh-reinforced pancreaticojejunostomy for periampullar neoplasm. World J Gastroenterol 2008; 13:6072-5. [PMID: 18023102 PMCID: PMC4250893 DOI: 10.3748/wjg.v13.45.6072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Di-Yu Huang
- Depatment of Surgery, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Institute of Microinvasive Surgery of Zhejiang University, 3 East Qingchun Road, Hangzhou 310016, Zhejiang Province, China
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Hakamada K, Narumi S, Toyoki Y, Nara M, Ishido K, Miura T, Kubo N, Sasaki M. An easier method for performing a pancreaticojejunostomy for the soft pancreas using a fast-absorbable suture. World J Gastroenterol 2008; 14:1091-6. [PMID: 18286692 PMCID: PMC2689413 DOI: 10.3748/wjg.14.1091] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To 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.
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