Management of the pancreatic stump following pancreaticoduodenectomy

32 Consecutive Cases of Whipple's Operation with Single-Layer End to Side Dunking Pancreatojejunostomy Without Any Pancreatic Fistula: Our Institutional Experience

The aim of this paper is to study the outcome of single-layer end to side dunking pancreatojejunostomy technique in 32 patients of malignant pancreatic disease undergoing Whipple's surgery in a tertiary care oncology centre in India. From January 2013 to January 2016, 32 consecutive patients who underwent pancreatoduodenectomy for malignant diseases were analysed retrospectively. All the patients underwent standard Whipple's operation. Pancreatojejunostomy was established in a single-layer end to side dunking manner with PDS 4-0. Various patient data, i.e. preoperative symptoms and demography, intra-operative time, blood loss and need of blood transfusion, postoperative hospital stay and complications, were noted. Mean operative time was 3.5 h approximately. Mean blood loss was 328 ml approx (range 150-600 ml). Postoperative delayed gastric emptying was observed in 8 (25%) patients. Three (9.4%) patients developed superficial surgical site infection. Mean hospital stay was 16.5 days (range 13-20 days). There were no pancreatic leak or fistula and no perioperative mortality. It is a feasible technique. It achieved zero leak rates, zero mortality and minimal morbidity without compromising any oncologic principles.

Different types of pancreatico-enteric anastomosis

The pancreatico-enteric anastomosis has widely been regarded as the 'Achilles heel' of the modern day, single-stage, pancreatoduodenectomy (PD). A review of the literature was carried out to address the evolution of the pancreatico-enteric anastomosis following PD, the spectrum of anastomoses performed around the world, and finally present the current evidence in support of each anastomosis. Pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are the most common forms of pancreatico-enteric reconstruction following PD. There is no difference in postoperative pancreatic fistula (POPF) rates between PG and PJ, as well as individual variations, except in a high-risk anastomosis where performance of a PJ may be preferred. The routine use of glue, trans-anastomotic stents or omental wrapping is of no proven benefit. Externalised trans-anastomotic stents may have a role in mitigating the risk of a clinically relevant POPF in high-risk anastomoses. Pancreatico-enteric anastomosis is an important component of reconstruction following PD even though it is fraught with the risk of development of a POPF. Adherence to the tenets of anastomotic reconstruction and performance of a safe and reproducible anastomosis with a low clinically-relevant POPF rate remain the mainstay of achieving the best outcomes. Appropriate selection and opportune use of fistula mitigation strategies may help provide optimal outcomes when faced with the need to perform a high-risk pancreatico-enteric anastomosis.

Total closure of pancreatic section for end-to-side pancreaticojejunostomy decreases incidence of pancreatic fistula in pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a serious complication and results in prolonged hospitalization and high mortality. The present study aimed to evaluate the safety and effectiveness of total closure of pancreatic section for end-to-side pancreaticojejunostomy in pancreaticoduodenectomy (PD).

METHODS

This was a prospective randomized clinical trial comparing the outcomes of PD between patients who underwent total closure of pancreatic section for end-to-side pancreaticojejunostomy (Group A) vs those who underwent conventional pancreaticojejunostomy (Group B). The primary endpoint was the incidence of pancreatic fistula. Secondary endpoints were morbidity and mortality rates.

RESULTS

One hundred twenty-three patients were included in this study. The POPF rate was significantly lower in Group A than that in Group B (4.8% vs 16.7%, P<0.05). About 38.3% patients in Group B developed one or more complications; this rate was 14.3% in Group A (P<0.01). The wound/abdominal infection rate was also much higher in Group B than that in Group A (20.0% vs 6.3%, P<0.05). Furthermore, the average hospital stays of the two groups were 18 days in Group A, and 24 days in Group B, respectively (P<0.001). However, there was no difference in the probability of mortality, biliary leakage, delayed gastric emptying, and pulmonary infection between the two groups.

CONCLUSION

Total closure of pancreatic section for end-to-side pancreaticojejunostomy is a safe and effective method for pancreaticojejunostomy in PD.

Pancreatoduodenectomy for trauma: applying novel reconstruction techniques

This single center study evaluated the technical modifications and outcome of reconstruction after pancreaticoduodenectomy for trauma. Prospectively recorded data including reconstructive techniques used in patients who underwent a pancreatoduodenectomy (PD) for trauma were analyzed. Twenty patients underwent a PD. Six had an initial damage control procedure. Thirteen had a pylorus-preserving PD and 7 a standard Whipple resection because injury to the pylorus precluded a pylorus-preserving resection. Twelve patients had a pancreatojejunostomy and 8 a pancreatogastrostomy, 3 of whom had a duodenojejunal hepaticojejunal sequence of anastomoses to allow endoscopic biliary stent retrieval. Three patients died postoperatively of multi-organ failure. All 17 survivors had postoperative complications: 5 patients developed pancreatic fistula, 2 had gastric outlet obstruction, 2 had bile leaks, 2 had duodenal anastomotic leaks, all of which resolved with conservative treatment. Pancreatic and biliary reconstructions performed under adverse conditions after a trauma PD required a variety of technical modifications. The pylorus does not have to be sacrificed and posterior gastric implantation is a safe option for an edematous pancreas.

Laparoscopic central pancreatectomy: Our technique and long-term results in 14 patients

INTRODUCTION

Conventional pancreatic resections may be unnecessary for benign tumours or for tumours of low malignant potential located in the neck and body of pancreas. Such extensive resections can place the patient at increased risk of developing postoperative exocrine and endocrine insufficiency. Central pancreatectomy is a plausible surgical option for the management of tumours located in these locations. Laparoscopic approach seems appropriate for such small tumours situated deep in the retroperitoneum.

AIMS

To assess the technical feasibility, safety and long-term results of laparoscopic central pancreatectomy in patients with benign and low malignant potential tumours involving the neck and body of pancreas.

SETTINGS AND DESIGN

This study was an observational study which reports a single-centre experience with laparoscopic central pancreatectomy over a 9-year period.

MATERIALS AND METHODS

14 patients underwent laparoscopic central pancreatectomy from October 2004 to September 2013. These included patients with tumours located in the neck and body of pancreas that were radiologically benign-looking tumours of less than 3 cm in size.

STATISTICAL ANALYSIS USED

The statistical analysis was done using GraphPad Prism software.

RESULTS

The mean age of patients was 48.93 years. The mean operative time was 239.7 min. Mean blood loss was 153.2 ml. Mean postoperative ICU stay was 1.2 days and overall mean hospital stay was 8.07 days. There were no mortalities and no major postoperative complications. Margins were negative in all cases and with a median follow-up of 44 months, there was no recurrence.

CONCLUSIONS

Laparoscopic central pancreatectomy is a feasible procedure with acceptable morbidity. In the long term, there were no recurrences and pancreatic function was well preserved.

Omental flaps reduces complications after pancreaticoduodenectomy

BACKGROUND

Major complications after pancreaticoduodenectomy are usually caused by a leaking pancreaticojejunal anastomosis. Omental flaps around various anastomoses were used to prevent the formation of fistula.

METHODS

We reviewed 147 patients who had undergone pancreaticoduodenectomy between March 2006 and March 2012. The patients were divided into 2 groups according to the application of omental flaps around various anastomoses: group A (101 patients) who underwent omental wrapping procedure; group B (46 patients) who did not undergo the omental wrapping procedure. Perioperative data of the two groups were reviewed to assess the effectiveness of omental flap procedure in the prevention of pancreatic fistula and other complications.

RESULTS

No differences were observed in the clinical characteristics between the 2 groups. The incidences of pancreatic fistula (4.0% vs 17.4%), post-pancreatectomy hemorrhage (0 vs 6.5%), biliary fistula (1.0% vs 13.0%), and delayed gastric emptying (4.0% vs 17.4%) were significantly less frequent in group A. The overall morbidity (18.8% vs 47.8%) and hospital stay (8.3 vs 9.6 days) were also significantly lower in group A than in group B.

CONCLUSIONS

Omental flaps around various anastomoses after pancreaticoduodenectomy can reduce the incidences of pancreatic fistula, biliary fistula, post-pancreatectomy hemorrhage and delayed gastric emptying. This procedure is simple and effective to reduce the overall morbidity after pancreaticoduodenectomy.

Effect of Billroth II or Roux-en-Y Reconstruction for the Gastrojejunostomy After Pancreaticoduodenectomy: Meta-analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

This study aimed to compare Billroth II with Roux-en-Y reconstruction after pancreaticoduodenectomy (PD).

METHODS

A literature search was carried out to identify all randomized controlled trials (RCTs) comparing postoperative complications of Billroth II versus Roux-en-Y reconstruction following PD published from 1 January 1990 to 31 August 2014. Pooled risk ratios (RRs) with 95 % confidence intervals (CIs) were calculated using fixed effects or random effects models

RESULTS

In total, three RCTs with 470 patients were included. Using International Study Group of Pancreatic Surgery (ISGPS) definitions, incidences of delayed gastric emptying (DGE) [grades B and C (3.9 versus 12.9 %; RR 0.30, 95 % CI 0.11-0.79; P = 0.01), DGE grade C (0.7 versus 9.6 %; RR 0.11, 95 % CI 0.02-0.61; P = 0.01)] were significantly lower in the Billroth II group than in the Roux-en-Y group, as was the length of hospital stay (weighted mean difference -4.72, 95 % CI -8.91, -0.53; P = 0.03).

CONCLUSIONS

Meta-analysis revealed that the incidence of DGE (grades B and C) after PD can be decreased by using Billroth II rather than Roux-en-Y reconstruction.

Research gaps in pancreatic cancer research and comparative effectiveness research methodologies

Despite advances in cancer care, pancreatic adenocarcinoma remains one of the most lethal tumors. Most patients with pancreatic cancer are diagnosed with late stage disease, and approximately 6 % of patients are alive 5 years after diagnosis. Of the 10-20 % of patients who are candidates for resection and multi-modality therapy, most will succumb to the disease with 5-year survival rates only reaching approximately 25 % (Lim et al. in Annals of surgery 237(1):74-85, 2003 [1]; Trede et al. in Annals of surgery 211(4):447-458, 1990 [2]; Crist et al. in Annals of surgery 206(3):358-365, 1987 [3]). Clearly, there is a need to improve the management of this disease. To identify gaps in research and formulate strategies to address these issues, we designed a framework to encompass the scope of research for pancreatic cancer. In this chapter, we will examine each topic heading within this framework for gaps in knowledge and present research strategies focusing on diverse comparative effectiveness research (CER) methodologies to address the identified gaps.

Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction - An alternative surgical technique for central pancreatic mass resection

Context:

Central pancreatectomy has gained popularity in the past decade as treatment of choice for low malignant potential tumor in the midpancreas due to its ability to achieve optimal preservation of pancreatic parenchyma. Simultaneously, advancement in minimally invasive approach has contributed to numerous novel surgical techniques with significantly lower morbidity and mortality. With the purpose of improving patient outcomes, we describe a laparoscopic assisted central pancreatectomy with pancreaticogastrostomy as an alternative method to the previously described open central pancreatectomy with roux-en-y pancreaticojejunostomy reconstruction.

Case Report:

A 39 year old man presented to our clinic with a 2.5 cm neuroendocrine tumor at the neck of the pancreas. Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction was successfully performed. Operative time was 210 minutes with blood loss of 200 ml. Postoperative course was uneventful except for a minimal pancreatic leak which was controlled by an intraoperatively placed closed suction drain. At 2 week follow up, patient was asymptomatic with well preserved pancreatic endo and exocrine functions. Permanent pathology findings showed a well differentiated neuroendocrine tumor with negative margins and nodes.

Conclusions:

Laparoscopic assisted central pancreatectomy with pancreaticogastrostomy reconstruction is feasible and safe for a centrally located tumor. Laparoscopic assisted technique facilitates application of minimally invasive approach by increasing surgical feasibility in typically complex pancreatic operations.

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.

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.

Pancreatic duct holder for facilitating duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy

Duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy may be technically difficult, particularly in cases in which the remnant pancreas is soft with a small main pancreatic duct. We devised a pancreatic duct holder for duct-to-mucosa pancreatojejunostomy. The holder has a cone-shaped tip. A one-third circle of the tip is cut away, which makes a slit. As the tip is inserted gently into the pancreatic duct, the duct can be adequately expanded. The holder provides a good surgical field for anastomosis. A slit of the tip allows needle insertion. The holder facilitates stitches of the jejunum also. Twelve patients underwent pancreatoduodenectomy, followed by duct-to-mucosa pancreatojejunostomy using the holder. The holder allowed 8 or more stitches in duct-to-mucosa anastomosis, even in patients with a small pancreatic duct. No patients developed prolonged pancreatic leakage or pancreatic fistula postoperatively. In conclusion, the pancreatic duct holder is a simple and useful tool for facilitating duct-to-mucosa pancreatojejunostomy.

Prevention and management of pancreatic fistula

Despite significant improvements in the safety and efficacy of pancreatic surgery, post-operative pancreatic fistulae remain an unsolved dilemma. These occur when the transected pancreatic gland, pancreatic-enteric anastomosis, or both, leak rendering the patient at significant risk. They are especially important today since indications for resection (IPMN, carcinoma) continue to increase. This review considers definitions and classifications of pancreatic fistulae, risk factors, preventative approaches and offers management strategies for when they do occur. Key citations from the past seventeen years have been scrutinized, and together with personal experience, provide the basis for this review.

Usefulness of performing a pancreaticojejunostomy with an internal stent after a pancreatoduodenectomy

PURPOSE

In pancreaticojejunostomy (PJ), the occurrence of an injury during the removal of a stented tube is sometimes related to pancreatitis or late-onset stenosis of the pancreatic duct. In this study, we compare the outcomes of a PJ with an external stent versus an internal stent in a randomized study.

METHODS

We compared the complications including pancreatic fistula, mortality, and postoperative hospital stay of 43 patients who had PJ with an external stent (group E) or PJ with an internal stent (group I) after a pancreaticoduodenectomy (PD).

RESULTS

Pancreatic fistula occurred in 8 patients (36.4%) in group E, while it only was seen in 7 patients (33.3%) in group I. Pancreatitis was recognized in 3 patients in group E, while there was no patient in whom an obstruction due to an internal stent was suspected.

CONCLUSION

Pancreaticojejunostomy with an internal stent is therefore considered to be an effective treatment alternative after PD, with an acceptable morbidity and no mortality.

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.

Experimental study on operative methods of pancreaticojejunostomy with reference to anastomotic patency and postoperative pancreatic exocrine function

AIM: To assess the patency of pancreaticoenterostomy and pancreatic exocrine function after three surgical methods.

METHODS: A pig model of pancreatic ductal dilation was made by ligating the main pancreatic duct. After 4 wk ligation, a total of 36 piglets were divided randomly into four groups. The piglets in the control group underwent laparotomy only; the others were treated by three anastomoses: (1) end-to-end pancreaticojejunostomy invagination (EEPJ); (2) end-to-side duct-to-mucosa sutured anastomosis (ESPJ); or (3) binding pancreaticojejunostomy (BPJ). Anastomotic patency was assessed after 8 wk by body weight gain, intrapancreatic ductal pressure, pancreatic exocrine function secretin test, pancreatography, and macroscopic and histologic features of the anastomotic site.

RESULTS: The EEPJ group had significantly slower weight gain than the ESPJ and BPJ groups on postoperative weeks 6 and 8 (P < 0.05). The animals in both the ESPJ and BPJ groups had a similar body weight gain. Intrapancreatic ductal pressure was similar in ESPJ and BPJ. However, pressure in EEPJ was significantly higher than that in ESPJ and BPJ (P < 0.05). All three functional parameters, the secretory volume, the flow rate of pancreatic juice, and bicarbonate concentration, were significantly higher in ESPJ and BPJ as compared to EEPJ (P < 0.05). However, the three parameters were similar in ESPJ and BPJ. Pancreatography performed after EEPJ revealed dilation and meandering of the main pancreatic duct, and the anastomotic site exhibited a variable degree of occlusion, and even blockage. Pancreatography of ESPJ and BPJ, however, showed normal ductal patency. Histopathology showed that the intestinal mucosa had fused with that of the pancreatic duct, with a gradual and continuous change from one to the other. For EEPJ, the portion of the pancreatic stump protruding into the jejunal lumen was largely replaced by cicatricial fibrous tissue.

CONCLUSION: A mucosa-to-mucosa pancreaticojejunostomy is the best choice for anastomotic patency when compared with EEPJ. BPJ can effectively maintain anastomotic patency and preserve pancreatic exocrine function as well as ESPJ.

Management of pancreatic trauma

BACKGROUND

Pancreatic injury can pose a formidable challenge to the surgeon, and failure to manage it correctly may have devastating consequences for the patient. Management options for pancreatic trauma are reviewed and technical issues highlighted.

METHOD

The English-language literature on pancreatic trauma from 1970 to 2006 was reviewed.

RESULTS AND CONCLUSIONS

Most pancreatic injuries are minor and can be treated by external drainage. Injuries involving the body, neck and tail of the pancreas, and with suspicion or direct evidence of pancreatic duct disruption, require distal pancreatectomy. Similar injuries affecting the head of the pancreas are best managed by simple external drainage, even if there is suspected pancreatic duct injury. Pancreaticoduodenectomy should be reserved for extensive injuries to the head of the pancreas, and should be practised as part of damage control. Most complications should initially be treated by a combination of nutrition, percutaneous drainage and endoscopic stenting.

Surgery insight: surgical management of pancreatic cancer

Pancreatic ductal adenocarcinoma is a common malignancy of the gastrointestinal tract. The number of new cases diagnosed and the number of deaths each year are almost identical, demonstrating the particularly dismal prognosis for patients affected by this disease. Despite recent advances in the field of medical and radiation oncology, and the introduction of neoadjuvant and adjuvant regimens, surgery remains the single most important modality for the treatment of pancreatic ductal adenocarcinoma. Surgery for pancreatic cancer is widely viewed as a complex procedure associated with considerable perioperative morbidity and mortality. Many aspects of surgery for pancreatic cancer, such as the extent of resection, the value of vascular resection, the use of laparoscopy, and the importance of treatment at high-volume centers, are currently under debate. This Review describes the current status of surgical treatment for pancreatic ductal adenocarcinoma, and highlights the new developments in this field.

A new technique of polypropylene mesh-reinforced pancreaticojejunostomy

Anastomotic leakage of pancreaticojejunostomy is a common problem and a significant cause of morbidity and mortality after pancreatic resection. An appropriate technique to minimize pancreatic leakage is very important. Recently we have performed a safe and simple mesh-reinforced pancreaticojejunostomy, by which a strip of polypropylene mesh is wrapped around the pancreatic stump in order to secure the end-to-end pancreaticojejunal anastomosis. No leakage developed in all 10 patients who received this procedure.

Guidelines for the Surgical Management of Pancreatic Adenocarcinoma

Pancreaticoduodenectomy remains the most formidable operative procedure for the surgical treatment of gastrointestinal malignancy. Improved outcomes after the Whipple procedure have been attributed to better preoperative patient selection, advances in three-dimensional radiographic imaging, and regionalization of referrals to high-volume, tertiary care centers. Despite these advances, morbidity and mortality after pancreaticoduodenectomy are not insignificant and the overall prognosis following resection for adenocarcinoma of the pancreas remains poor. Improvements in endoscopic decompression of malignant biliary obstruction have decreased the need for palliative bypass operations and have focused current surgical issues on ways to improve clinical outcomes following potentially curative resections. Controversies such as whether or not to perform extended lymph node dissections, and standard versus pylorus-preserving resections have been addressed by randomized, prospective clinical trials. Major venous resections secondary to local tumor extension are now performed without an increase in morbidity or mortality and with survival rates comparable to standard resections. This has led to even more aggressive resections following neoadjuvant therapy for lesions previously considered unresectable and now perhaps better categorized as borderline resectable. The impact of surgical specialization and regionalization of referrals to tertiary care centers is evident in markedly improved perioperative mortality rates. This article will attempt to describe current guidelines for the preoperative, intraoperative, and postoperative management of patients with localized pancreatic adenocarcinoma.

[Results of defunctionalized jejunal loop after pancreaticoduodenectomy]

INTRODUCTION

Anastomotic leak continues to be a common cause of complications after pancreaticoduodenectomy. Numerous surgical techniques have been described to avoid this complication.

OBJECTIVE

We evaluated the use of a defunctionalized jejunal loop for the pancreas after pancreaticoduodenectomy.

MATERIAL AND METHODS

Between 1991 and 2005, the findings in 80 patients were analyzed in this prospective study of the use of a defunctionalized jejunal loop for the pancreas as a reconstructive procedure following pancreaticoduodenectomy. All the patients were operated on by two surgeons. The following clinical variables were recorded: age, sex, diameter of the main pancreatic duct, pancreas texture, operating time, intraoperative blood transfusion, mean length of hospital stay, and operative mortality. Seven complications were defined: anastomotic leakage (biliary and duodenal), pancreatic fistula, abscess, sepsis, bleeding, delayed gastric emptying, and postoperative pancreatitis. Four different definitions were used for pancreatic fistula.

RESULTS

Of the 80 patients, 16 (20%) developed pancreatic fistula according to at least one of the criteria used. Pancreatic fistula was more frequent in patients with a small duct (33.3%), and soft pancreatic texture (29%), and was the cause of 100% of intraabdominal hemorrhages, 80% of abdominal abscesses, and 60% of mortality. The mean length of hospital stay was 20.6 days and the mortality rate was 6.6% (5/80). During follow-up two patients developed pancreatitis.

CONCLUSION

After pancreaticoduodenectomy, reconstruction with a defunctionalized jejunal loop for the pancreas is a safe and effective technique.

Open pancreaticogastrostomy after pancreaticoduodenectomy: a pilot study

Management of the pancreatic stump following pancreaticoduodenectomy (PD) has always been a main source of concern among pancreatic surgeons. The present pilot study describes the reconstructive technique of anterior transgastric pancreaticogastrostomy (PG) after pylorus-preserving PD. Outcome in 50 patients with "soft" residual parenchyma treated with this technique is also reported. The average duration of the intervention was 351 minutes (range, 240-360); only two patients needed intraoperative transfusion with 2 units of blood. The postoperative period involved complications in 15 cases (30%). In particular, four patients developed pancreatic fistulas (8%), which were grade C in three cases (6%) and grade B in one patient (2%). Two patients (4%) presented with enteric fistula from erosion from a drain. Two patients experienced perianastomotic fluid collections associated with delayed gastric emptying (4%) and a clinically silent 5-cm abdominal collection was observed in an additional case. Bleeding of a gastric ulcer was treated in one case and four patients developed bronchopneumonia. None of the complications required a second surgical intervention and there were no deaths. One patient with a symptomatic fluid collection was treated by ultrasound-guided cutaneous drainage. The mean hospitalization time was 11.1 days (range, 8-25 days). The results obtained in this pilot study appear encouraging and merit further analysis in a randomized comparative trial.

Risk factors for pancreatic anastomotic leakage: the significance of preoperative dynamic magnetic resonance imaging of the pancreas as a predictor of leakage

BACKGROUND

The histologic degree of pancreatic fibrosis can be assessed preoperatively by using the time-signal intensity curve (TIC) of the pancreas obtained from dynamic magnetic resonance imaging.

STUDY DESIGN

To identify risk factors for postoperative pancreatic anastomotic leakage and to assess the impact of pancreatic TIC on this complication, 89 patients who underwent a pancreatic head resection with an end-to-side pancreaticojejunostomy between December 1998 and August 2005 were retrospectively reviewed. The pancreatic TIC profiles were classified into 3 types: type I, indicating a normal pancreas without fibrosis; and types II and III indicating fibrotic pancreas.

RESULTS

Pancreaticojejunal anastomotic leakage occurred in 14 patients (16%). In a univariate analysis, pancreatic texture (hard, 3% versus intermediate, 20% versus soft, 23%; p = 0.046), pancreatic duct size (> 3 mm, 8% versus <or= 3 mm, 25%; p = 0.037), and pancreatic TIC (types II, III, 3% versus type I, 25%; p = 0.006) were notably associated with pancreatic anastomotic leakage. In a multivariable analysis, pancreatic TIC (odds ratio [OR], 9.58; 95% CI, 1.1 to 91.7) was the only marked independent predictor of postoperative pancreatic leakage. A subanalysis of 52 patients with type I pancreatic TIC demonstrated hemoglobin A1c (odds ratio, 9.81; 95% CI, 1.2 to 127.9) to be a notable predictor of leakage and pancreatic leakage developed in diabetic patients with a high hemoglobin A1c concentration (> 6.0%) than in those with a normal hemoglobin A1c level.

CONCLUSIONS

Pancreatic TIC from dynamic MRI provides reliable information for predicting risk of pancreatic anastomotic leakage after pancreatic head resection. Especially in patients with type I pancreatic TIC, the presence of uncontrolled diabetes is considered a primary risk factor for postoperative pancreatic leakage.

Pancreatic anastomoses after pancreaticoduodenectomy: do we need further studies?

Pancreatic anastomotic leak is the single most important factor responsible for the considerable morbidity and mortality associated with pancreaticoduodenectomy. Management of the pancreatic remnant is controversially discussed, reflecting the complexity of anastomosing a pancreas of different textures to the digestive tract. A number of studies evaluating diverse options have often provided conflicting conclusions. This information is confusing particularly to those surgeons outside of large-volume centers with broad experience and to general surgeons who perform pancreatic surgery. A PubMed search with the key words pancreaticoduodenectomy, pancreatic anastomosis, pancreaticojejunostomy, pancreaticogastrostomy, and pancreatic fistula was performed. Major series of pancreatic anastomosis published between 1990 and 2002 were studied from diverse centers worldwide. Their results with regard to pancreatic fistula, morbidity, and mortality were documented. Nine series of pancreaticojejunostomy and seven series of pancreaticogastrostomy were evaluated. Eight comparative studies evaluating the two techniques were also analyzed. A single randomized controlled trial was identified among these comparative studies. Equally good results were observed with the two techniques. Other uncommon methods of management of the pancreatic remnant (duct occlusion and ligation) were also evaluated. Pancreaticojejunostomy followed by pancreaticogastrostomy are the most favored techniques. A duct-to-mucosa anastomosis is preferred over other methods. Fistula rates of less than 5%-10% should be the standard irrespective of the technique used. Unlike in the past, mortality can be reduced even in the event of an anastomotic dehiscence, and this aspect is primarily dependent on a meticulous anastomosis based on sound surgical principles rather than the method per se. Based on the information accumulated, adherence to these specific principles could ensure a safe and reliable pancreatic anastomosis with mimimal morbidity and mortality after pancreaticoduodenectomy, even in the hands of general surgeons operating outside high-volume centers.

No Mortality among 100 Consecutive Pancreaticoduodenectomies in a Middle-volume Center

Mortality rate following pancreaticoduodenectomy has markedly decreased in high-volume centers. We achieved zero mortality among 100 pancreaticoduodenectomies in a middle-volume center. The purpose of this study was to review our experience and analyze factors contributing to the zero mortality. Patient backgrounds, intraoperative variables, postoperative complications, and surgical, radiologic, and other medical interventions for the complications were retrospectively analyzed for 100 consecutive pancreaticoduodenectomies for malignant or benign disease. The mean age of the patients was 63 years. Altogether, 59 patients had preoperative co-morbidity, and 35 had a past history of abdominal surgery. The median operating time and blood loss were 525 minutes and 1215 ml, respectively. Postoperative complications occurred in 42 patients. The most frequent complication was pancreatic stump leak (n = 12), but no life-threatening pancreatic anastomotic leak occurred. This may result from the duct invagination anastomosis applied to 67 pancreases with a small duct. Serious complications were seen in six patients; two patients required surgical intervention, but four were successfully treated with the help of interventional radiologists or internists. Radiologic intervention was applied to 13 patients: drainage of an intraabdominal abscess/collection and vascular intervention. In addition to advances in surgical techniques to reduce local complications, particularly pancreatic anastomotic leak, intimate collaboration with experienced interventional radiologists and internists allows zero mortality even in middle-volume centers.

Incidence and management of pancreatic leakage after pancreatoduodenectomy

BACKGROUND

Optimal management of severe pancreatic leakage after pancreatoduodenectomy can reduce morbidity and mortality. Completion pancreatectomy may be adequate but leads to endocrine insufficiency. This study evaluated an alternative management strategy for pancreatic leakage.

METHODS

Outcome after disconnection of the jejunal limb, resection of the pancreatic body and preservation of a small pancreatic remnant, performed between 1997 and 2002, was compared with that after completion pancreatectomy performed between 1992 and 1996.

RESULTS

Pancreatoduodenectomy was performed in 459 consecutive patients. Pancreatic leakage occurred in 41 patients (8.9 per cent); its incidence did not change over the study period. Non-surgical drainage procedures were performed in 14 patients, of whom one died, and surgical drainage in eight patients, of whom two died. Completion pancreatectomy was performed in nine patients with no deaths. A pancreatic remnant was preserved in ten patients, of whom three died. A remnant tail had to be resected in two patients and three patients still developed endocrine insufficiency ('brittle' diabetes).

CONCLUSION

The incidence of pancreatic leakage did not change over the study interval. Preservation of a small pancreatic tail was associated with higher morbidity and mortality rates than those of completion pancreatectomy.

Complications with Reconstruction Procedures in Pylorus-preserving Pancreaticoduodenectomy

This study was conducted retrospectively to examine the efficacy of Traverso reconstruction compared with Billroth I reconstruction after pylorus-preserving pancreaticoduodenectomy, in the prevention of several complications. Pylorus-preserving pancreaticoduodenectomy is an aggressive surgery, and insufficiency of the pancreaticoenterostomy plays an important role in the postoperative progression. However, reports examining the correlation between pancreatic fistula and the type of reconstruction after pylorus-preserving pancreaticoduodenectomy have been limited. Sixty-four patients who underwent pylorus-preserving pancreaticoduodenectomy (33 reconstructed by the Traverso technique and 31 reconstructed by the Billroth I technique) were entered into this study to investigate whether the complications were related to the type of reconstruction procedure employed. Insufficiency of the pancreaticojejunostomy, including major leakage and pancreatic fistula, occurred in 18.2% of the reconstructions by Billroth I and 0% of the reconstructions by Traverso (p < 0.05). In addition, jejunal obstruction by recurrent tumor in the remnant pancreas was observed in 3 patients reconstructed by Billroth I, and required palliative bypass surgery. Reconstruction by the Traverso procedure after pylorus-preserving pancreaticoduodenectomy is a safe surgical method and has an advantage for advanced pancreatic cancer, which has high risk of jejunal obstruction by recurrent tumor in the remnant pancreas.

The Evaluation of Duct-to-mucosal Pancreaticojejunostomy in pancreaticoduodenectomy

This study was conducted to examine the efficacy of duct-to-mucosal pancreaticojejunostomy compared with external stented pancreaticojejunostomy in prevention of several complications, retrospectively. Seventy-six patients with pancreatic head resection (59 male; median age, 60.1 years) underwent pancreaticoduodenectomy at the Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan, between January 1, 1994, and March 31, 2002. In early postoperative status, the incidence of pancreatic fistula by duct-to-mucosal anastomosis (n = 45) was similar to that by external stent (n = 31); soft pancreas is a risk factor of pancreatic fistula compared with hard pancreas (p < 0.05). During the late postoperative period, however, no patients with duct-to-mucosal anastomosis showed pancreatic duct dilatation by computed tomography (CT). At the same time, 58.8% of patients with external stent followed by CT showed pancreatic duct dilatation (p < 0.01). The duct-to-mucosal anastomosis was more effective pancreaticojejunostomy than the external stent in terms of prevention of pancreatic duct dilatation, and it should be the surgical procedure of choice in pancreaticoduodenectomy.

Management of bleeding and leakage after pancreatic surgery

Pancreatic surgery has advanced considerably during the past decades. Recent studies report reduced morbidity rates and virtually no mortality after resection. However, postoperative complications are still a formidable menace. In this chapter we discuss the management of postoperative bleeding and leakages which are considered the most feared complications, and discuss the advent of minimal invasive methods for management of these complications. Patients who develop postoperative bleeding almost always present with septic complications and a sentinel bleed before onset of bleeding. These patients should undergo early diagnostic angiography followed by embolisation. If this does control the bleeding an emergency laparotomy should be performed as last resort. Patients who develop pancreatic leakage are generally managed conservatively by means of percutaneous drainage. Aggressive surgery should be performed at the first sign of severe sepsis. The condition of the pancreatic remant found during reoperation dictates the type of surgical intervention best performed.

Pancreaticogastrostomy: a novel application after central pancreatectomy

BACKGROUND

Limited middle segment pancreatectomy, or central pancreatectomy, has been described for sparing normal pancreatic tissue during resection of benign neoplasms of the pancreatic neck. Anatomic reconstruction after central pancreatectomy has been reported in other series with creation of a Roux-en-Y loop of jejunum for a mucosa-to-mucosa pancreaticojejunostomy.

STUDY DESIGN

Hospital charts and outpatient records were reviewed for 12 consecutive patients undergoing central pancreatectomy from August 1999 to November 2002.

RESULTS

We performed central pancreatectomy with pancreaticogastrostomy in 12 patients: 5 with serous cystadenomas, 6 with mucinous cystadenomas, and 1 with neuroendocrine tumor. All tumors were located in the body or neck of the pancreas, measuring a mean +/- standard deviation (SD) of 2.5 +/- 1.2 cm. Median postoperative hospital stay was 6.5 days (range 5 to 15 days). There were no intraoperative complications. Perioperative complications included two urinary tract infections and one readmission for acute pancreatitis. There were no pancreatic leaks or fistulas in this series. Two of the 12 patients experienced endocrine insufficiency with elevated glycosylated hemoglobin levels during outpatient followup. None of the 12 patients experienced exocrine insufficiency.

CONCLUSIONS

Central pancreatectomy with pancreaticogastrostomy reconstruction is safe and technically advantageous over Roux-en-Y pancreaticojejunostomy, and should be considered a safe reconstruction technique after central pancreatectomy for benign disease.

Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial

BACKGROUND

Anastomotic failure is still a significant problem that affects the outcome of pancreaticoduodenectomy. There have been many techniques proposed for the reconstruction of pancreatic digestive continuity, but there have been few prospective and randomized studies that compare their efficacy.

METHODS

In the current work, 144 patients who underwent a pancreaticoduodenectomy with soft residual tissue were assigned randomly to receive either a duct-to-mucosa anastomosis (group A) or a 1-layer end-to-side pancreaticojejunostomy (group B).

RESULTS

The 2 treatment groups were found not to have any differences in regards to vital statistics, underlying disease, or operative techniques. The postoperative course was complicated in 54% of the 144 patients, with a comprehensive incidence of abdominal complications in 36% (group A, 35%; group B, 38%; P=not significant). The principal complication was pancreatic fistulas, which occurred in 14% of patients (group A, 13%; group B, 15%; P=not significant). Two patients (2%) required reoperation; the postoperative mortality rate was 1%.

CONCLUSION

The 2 methods that were studied revealed no significant difference the rate of complications.

Binding pancreaticojejunostomy: 150 consecutive cases without leakage

The objective of this study was to verify the safety of a new technique termed "binding pancreaticojejunostomy" in a prospective cohort study. Pancreaticojejunal anastomostic leakage is a major cause of morbidity and mortality after pancreaticoduodenectomy. To prevent the development of pancreatic fistulas, we designed a special technique that we termed binding pancreaticojejunostomy. Binding pancreaticojejunostomy entails binding 3 cm of the serosamuscular sheath of the jejunum to the intussuscepted pancreatic stump. From January 1996 to May 2001, a total of 150 consecutive patients were treated with this type of pancreaticojejunostomy, including typical pancreaticoduodenectomy in 120, hepatopancreaticoduodenectomy in 17, pylorus-preserving pancreaticoduodenectomy in 10, and duodenal-preserving resection of the head of the pancreas in three. None of the patients developed pancreatic fistulas. The overall morbidity was 31.3%. The following complications occurred: gastrointestinal bleeding in six, pulmonary infection in 12, wound infection in 20, delayed gastric emptying in three, incision dehiscence in four, and hepatic insufficiency in two. The mean postoperative hospital stay was 19.8 +/- 5 days. Binding pancreaticojejunostomy is a safe, simple, and effective technique.

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Pancreatic trauma in the adult: current knowledge in diagnosis and management

BACKGROUND/AIMS

Although pancreatic trauma, isolated or not, is uncommon, it carries significant morbidity and mortality because of the delay in recognition and consequent treatment.

METHODS

The current knowledge of pancreatic injury, concerning the incidence, mechanism of induction, diagnosis, treatment, complications and outcome, is herein presented based on a literature review and our limited experience.

RESULTS

The diagnosis of pancreatic trauma entails a high index of suspicion because neither clinical nor laboratory evaluation provide pathognomonic elements. Patients with penetrating injuries are usually evaluated during laparotomy, while those with a blunt trauma can be managed conservatively, provided they are in a stable condition, there is no pancreatic duct involvement and care is intensive. At laparotomy, minor pancreatic injuries are best managed by drainage. Distal pancreatectomy is best suited for distal pancreatic trauma with ductal involvement. For severe trauma, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, duodenal diversion operations and Whipple's procedure are all indicated according to the preoperative evaluation and intraoperative findings. Independent of the procedure to be performed, drainage is mandatory.

CONCLUSION

Because pancreatic injury is rare, most general surgeons lack experience and ability to deal with such injured patients. Therefore, an experienced and skilled surgeon should govern the management of pancreatic trauma in order to minimize the incidence of morbidity and mortality.

Relationship between grade of fibrosis in pancreatic stump and postoperative pancreatic exocrine activity after pancreaticoduodenectomy: with special reference to insufficiency of pancreaticointestinal anastomosis

BACKGROUND

Pancreaticoduodenectomy (PD) has become a standard operation for malignant and benign periampullary diseases. Although the operative mortality of PD has decreased to less than 4% in hospitals with many cases of PD, the leakage of pancreaticointestinal anastomosis (PIA) still carries a substantial risk of lethal outcome. The aim of this study was to evaluate the local factors that affect the incidence of PIA leakage by evaluation of exocrine function and fibrosis in the pancreatic remnant following PD.

METHOD

Twenty-eight patients (17 pancreatic disease, 8 bile duct cancers and 3 ampullary cancers) underwent PD with complete extracorporeal pancreatic juice drainage. The cut-end of the pancreatic remnant was histologically studied for its grade of fibrosis in comparison with the exocrine activity of the pancreatic remnant (EAPR) calculated by the value of the product of volume of drained pancreatic juice and its amylase activity. The influences of those factors and other clinicopathologic data on PIA outcome were evaluated.

RESULTS

The histological grade of fibrosis in the pancreatic stump was inversely correlated with EAPR (rs=0.5848, p=0.0011). Three patients had major leakages and 6 had minor leakages of PIA; all the patients with leakages had biliary or ampullary diseases, but not pancreatic diseases. The incidence of leakage of PIA was significantly higher in the patients with high values of EAPR (p<0.05). None with EAPR less than 10(7) had PIA leakage. The incidence of PIA leakage in low-grade fibrosis of the pancreatic stump was significantly higher than that in high-grade fibrosis (p<0.05). Other clinicopathologic data did not influence the incidence of leakage of PIA.

CONCLUSIONS

The degree of fibrosis in the pancreatic stump is significantly related to the EAPR and affects the development of PIA insufficiency as a local factor.

Binding pancreaticojejunostomy is a new technique to minimize leakage

Pancreaticoduodenectomy (Whipple procedure) has been the standard treatment for periampullary and pancreatic carcinoma. A leak or fistula from the pancreatic anastomosis is the leading cause of morbidity and mortality after pancreaticoduodenectomy. In order to effectively prevent the development of pancreatic fistulae, we designed a special technique called binding pancreaticojejunostomy, by which 3 cm of the serosa-muscular sheath of the jejunum was bound to the pancreatic remnant. We have performed this procedure in 105 consecutive patients; none of the cases developed pancreatic fistula. It is a safe, simple, and efficient technique.

Pancreaticojejunostomy with invagination of spatulated pancreatic stump into a jejunal pouch

BACKGROUND

Pancreaticoenteric anastomosis after pancreatic resection is of major concern as anastomotic leak continues to be common. There is no unanimity for the preferred technique and overall incidence of pancreatic leak is reported to be 2% to 14%.

METHODS

A new safe method of anastomosing pancreatic stump to a jejunal pouch is described. A 15-cm length of the jejunal end is detubularized and reconfigurated into a U-shaped patch. The pancreatic stump is mobilized for about 3 cm and the duct is spatulated posteriorly and anastomosed to a cut in convex margins of the patch. This is converted into a pouch invaginating the spatulated pancreaticojejunal anastomosis.

RESULTS

Eleven cases of periampullary malignancy after pancreaticoduodenectomy have been operated on with no pancreatic leak.

CONCLUSIONS

Even a bulky pancreas can be invaginated into the pouch. The resulting anastomosis is completely intraluminal. Spatulated mucosa to mucosa anastomosis should reduce the chances of late stenosis.

Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy

BACKGROUND

Leakage at the pancreaticoenteric anastomosis remains a common and serious complication after pancreaticoduodenectomy. Over the past decade, various measures directed towards prevention of pancreatic leakage have been studied. This article reviews the available data on the efficacy of these measures.

DATA SOURCES

The Medline database from 1990 to 2000 was searched for studies on the prevention of pancreatic anastomotic leakage, and the bibliographies of the articles were reviewed for additional references.

RESULTS

A meta-analysis of the results of prophylactic octreotide in preventing pancreatic fistula after pancreaticoduodenectomy from data available in three randomized controlled studies yielded an odds ratio of 1.08 (95% confidence interval 0.64 to 1.84). Pending further trials to clarify its role, the routine use of octreotide in pancreaticoduodenectomy cannot be recommended. Retrospective or nonrandomized prospective studies suggested that technical modifications such as duct-to-mucosa anastomosis, pancreaticogastrostomy and external pancreatic duct stenting may reduce the leakage rate, but there is a paucity of randomized trials. A randomized trial comparing pancreaticogastrostomy and pancreaticojejunostomy did not reveal a significant difference in the leakage rate.

CONCLUSIONS

Further randomized controlled studies are required to determine the optimum technique of pancreaticoenteric anastomosis after pancreaticoduodenectomy.

Determinants of pancreaticoenteric anastomotic leak following pancreaticoduodenectomy

BACKGROUND

The purpose of the present paper was to study the incidence, presentation and management of pancreaticoenteric anastomotic (PEA) leak following pancreaticoduodenectomy (PD) and to identify risk factors associated with PEA leak.

METHODS

One hundred and twenty patients underwent PD for benign and malignant pancreatic and periampullary lesions from 1989 to 1998. Prospectively collected data were analysed for incidence and outcome of PEA leak. Four clinical, three laboratory parameters, preoperative biliary drainage (PBD), perioperative octreotide use, nine intraoperative parameters, site of tumour and stage of malignant tumours were analysed by univariate and multivariate logistic regression analysis to identify factors influencing PEA leak.

RESULTS

Pancreatic leak developed in 15 (12.5%) patients. Nine patients (60%) had a PEA leak that manifested as controlled leak through the drain. All were managed conservatively and the leak stopped after a mean duration of 17 days (range: 6-32 days). Six (40%) patients had associated intra-abdominal complications, and three (50%) died in the postoperative period. Pancreatic fistula healed in the three remaining patients after a mean duration of 18 days (range: 15-25 days). Diabetes (P = 0.02; odds ratio (OR) = 4.60; 95% confidence interval (CI): 1.23-17.18), PBD (P = 0.03; OR = 4.82; 95% CI: 1.21-19.24), sequence of reconstruction (bilioenteric anastomosis as first anastomosis; P = 0.01; OR = 6.25; 95% CI: 1.45-26.83) and duration of surgery > 8 h (P = 0.01; OR: 5.61; 95% CI: 1.54-20.39) were associated with a significantly higher incidence of PEA leak.

CONCLUSION

Pancreaticoenteric anastomotic leak occurred in 12% of patients undergoing PD for pancreatic and periampullary tumours. The majority of these were uncomplicated and healed with conservative treatment. Complicated leaks were associated with high mortality. Diabetes mellitus, PBD, prolonged surgery and the sequence of reconstruction were risk factors associated with an increased incidence of PEA leak.