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Duan P, Sun L, Kou K, Li XR, Zhang P. Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2023:S1499-3872(23)00204-7. [PMID: 37980179 DOI: 10.1016/j.hbpd.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 10/31/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE. DATA SOURCES Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles. RESULTS In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE. CONCLUSIONS Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.
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Affiliation(s)
- Peng Duan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Lu Sun
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Kai Kou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Xin-Rui Li
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, China
| | - Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China.
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The impact of gastrojejunostomy orientation on delayed gastric emptying after pancreaticoduodenectomy: a single center comparative analysis. HPB (Oxford) 2022; 24:654-663. [PMID: 34654621 DOI: 10.1016/j.hpb.2021.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/14/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) represents the most frequent complication after pancreaticoduodenectomy (PD). Aim of this study was to evaluate the impact of gastrojejunostomy (GJ)orientation on DGE incidence after PD. METHODS One-hundred and twenty-one consecutive PDs were included in the analysis and divided in the horizontal (H-GJ group) and vertical GJ anastomosis groups (V-GJ group). Postoperative data and the value of the flow angle between the efferent jejunal limb and the stomach of the GJ anastomosis at the upper gastrointestinal series were registered. RESULTS Seventy-five patients (62%)underwent H-GJ, while 46 patients (38%)underwent V-GJ. The incidence of DGE was significantly lower in the V-GJ group as compared to the H-GJ group (23.9%vs45.3%; p = 0.02). V-GJ was also associated to a less severe DGE manifestation (p = 0.006). The flow angle was significantly lower in case of V-GJ as compared to H-GJ (24.5°vs37°; p = 0.002). At the multivariate analysis, ASA score≥3 (p = 0.02), H-GJ (p = 0.03), flow angle>30°(p = 0.004) and Clavien-Dindo≥3 (p = 0.03) were recognized as independent prognostic factors for DGE. These same factors were independent prognostic features also for a more severe DGE manifestation. CONCLUSION VGJ and the more acute flow angle appear to be associated to a lower incidence rate and severity of DGE. This modified technique should be considered by surgeons in order to reduce postoperative DGE occurrence.
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Werba G, Sparks AD, Lin PP, Johnson LB, Vaziri K. The PrEDICT-DGE score as a simple preoperative screening tool identifies patients at increased risk for delayed gastric emptying after pancreaticoduodenectomy. HPB (Oxford) 2022; 24:30-39. [PMID: 34274231 DOI: 10.1016/j.hpb.2021.06.417] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/17/2021] [Accepted: 06/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Morbidity after Pancreaticoduodenectomy (PD) has remained unchanged over the past decade. Delayed Gastric Emptying (DGE) is a major contributor with significant impact on healthcare-costs, quality of life and, for malignancies, even survival. We sought to develop a scoring system to aid in easy preoperative identification of patients at risk for DGE. METHODS The ACS-NSQIP dataset from 2014 to 2018 was queried for patients undergoing PD with Whipple or pylorus preserving reconstruction. 15,154 patients were analyzed using multivariable logistic regression to identify risk factors for DGE, which were incorporated into a prediction model. Subgroup analysis of patients without SSI or fistula (primary DGE) was performed. RESULTS We identified 9 factors independently associated with DGE to compile the PrEDICT-DGE score: Procedures (Concurrent adhesiolysis, feeding jejunostomy, vascular reconstruction with vein graft), Elderly (Age>70), Ductal stent (Lack of biliary stent), Invagination (Pancreatic reconstruction technique), COPD, Tobacco use, Disease, systemic (ASA>2), Gender (Male) and Erythrocytes (preoperative RBC-transfusion). PrEDICT-DGE scoring strongly correlated with actual DGE rates (R2 = 0.95) and predicted patients at low, intermediate, and high risk. Subgroup analysis of patients with primary DGE, retained all predictive factors, except for age>70 (p = 0.07) and ASA(p = 0.30). CONCLUSION PrEDICT-DGE scoring accurately identifies patients at high risk for DGE and can help guide perioperative management.
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Affiliation(s)
- Gregor Werba
- Department of Surgery, George Washington University, Washington, DC, USA.
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Paul P Lin
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Lynt B Johnson
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University, Washington, DC, USA
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Tewari M, Swain JR, Mahendran R. Update on Management Periampullary/Pancreatic Head Cancer. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02053-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Fukui T, Noda H, Watanabe F, Kato T, Endo Y, Aizawa H, Kakizawa N, Iseki M, Rikiyama T. Drain output volume after pancreaticoduodenectomy is a useful warning sign for postoperative complications. BMC Surg 2021; 21:279. [PMID: 34082725 PMCID: PMC8176603 DOI: 10.1186/s12893-021-01285-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 06/01/2021] [Indexed: 01/04/2023] Open
Abstract
Introduction The drain output volume (DOV) after pancreaticoduodenectomy (PD) is an easily assessable indicator in clinical settings. We explored the utility of the DOV as a possible warning sign of complications after PD. Methods A total of 404 patients undergoing PD were considered for inclusion. The predictability of the DOV for overall morbidity, major complications, intraabdominal infection (IAI), clinically relevant (CR) postoperative pancreatic fistula (POPF), CR delayed gastric emptying (DGE), CR chyle leak (CL), and CR post-pancreatectomy hemorrhaging (PPH) was evaluated. Results One hundred (24.8%) patients developed major complications, and 131 (32.4%) developed IAI. Regarding CR post-pancreatectomy complications, 75 (18.6%) patients developed CR-POPF, 23 (5.7%) developed CR-DGE, 20 (5.0%) developed CR-CL, and 28 (6.9%) developed CR-PPH. The median DOV on postoperative day (POD) 1 and POD 3 was 266 and 234.5 ml, respectively. A low DOV on POD 1 was an independent predictor of CR-POPF, and a high DOV on POD 3 was an independent predictor of CR-CL. A receiver operating characteristics (ROC) analysis revealed that the DOV on POD 1 had a negative predictive value (area under the curve [AUC] 0.655, sensitivity 65.0%, specificity 65.3%, 95% confidence interval [CI]: 0.587–0.724), with a calculated optimal cut-off value of 227 ml. An ROC analysis also revealed that the DOV on POD 3 had a positive predictive value (AUC 0.753, sensitivity 70.1%, specificity 75.0%, 95% CI: 0.651–0.856), with a calculated optimal cut-off value of 332 ml. Conclusion A low DOV on POD 1 might be a postoperative warning sign for CR-POPF, similar to high drain amylase (DA) on POD 1, high DA on POD 3, and high CRP on POD 3. When the DOV on POD 1 after PD was low, surgeons should evaluate the reasons of a low DOV. A high DOV on POD 3 was a postoperative warning sign CR-CL, and might require an appropriate management of protein loss.
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Affiliation(s)
- Taro Fukui
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hiroshi Noda
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.
| | - Fumiaki Watanabe
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Takaharu Kato
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Yuhei Endo
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hidetoshi Aizawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Nao Kakizawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Masahiro Iseki
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
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Kushiya H, Nakamura T, Asano T, Okamura K, Tsuchikawa T, Murakami S, Kurashima Y, Ebihara Y, Noji T, Nakanishi Y, Tanaka K, Shichinohe T, Hirano S. Predicting the Outcomes of Postoperative Pancreatic Fistula After Pancreatoduodenectomy Using Prophylactic Drain Contrast Imaging. J Gastrointest Surg 2021; 25:1445-1450. [PMID: 32495135 DOI: 10.1007/s11605-020-04646-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/09/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a main cause of fatal complications post-pancreatoduodenectomy. However, no universally accepted drainage management exists for clinically relevant postoperative pancreatic fistulas. We retrospectively evaluated cases in which drain contrast imaging was used to determine its utility in identifying clinically relevant postoperative pancreatic fistulas post-pancreatoduodenectomy. METHODS Between January 2014 and December 2018, 209 consecutive patients who underwent pancreatoduodenectomy in our institute were retrospectively analyzed. Drain monitoring with contrast imaging was performed in 47 of the cases. We classified drain contrast type into three categories and evaluated postoperative outcome in each group: (1) fistulous tract group-only the fistula was contrasted; (2) fluid collection group - fluid collection connected to the drain fistula; and (3) pancreatico-anastomotic fistula group-fistula connected to the digestive tract. RESULTS The durations of postoperative hospital stay and drainage were significantly shorter in the fistulous tract group than in the fluid collection group (31 vs. 46 days, p = 0.0026; and 12 vs. 38 days, p < 0.0001, respectively). The cost and number of drain exchanges were significantly lower in the fistulous tract group than in the fluid collection group ($163.6 vs. 467.5, p < 0.0001; and 1 vs. 5.5, p < 0.0001, respectively). Notably, no patient had grade C postoperative pancreatic fistula. CONCLUSION Classification of prophylactic drain contrast type can aid in predicting outcomes of clinically relevant postoperative pancreatic fistulas and optimizing drainage management.
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Affiliation(s)
- Hiroki Kushiya
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
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Komokata T, Nuruki K, Tada N, Imada R, Aryal B, Kaieda M, Sane S. An invaginated pancreaticogastrostomy following subtotal stomach-preserving pancreaticoduodenectomy: A prospective observational study. Asian J Surg 2021; 44:1510-1514. [PMID: 33865665 DOI: 10.1016/j.asjsur.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/04/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Postoperative pancreatic fistula (POPF) leads to life-threatening complications after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) often adopted as a reconstruction technique after PD to prevent POPF. Delayed gastric emptying (DGE) following PD is the most common complication that compromises the quality of life. Subtotal stomach-preserving PD (SSPPD) preserves the pooling ability of the stomach and minimize the occurrence of DGE. This study aimed to describe our PG technique following SSPPD and evaluate the perioperative outcomes. METHODS The study included patients who underwent PG following SSPPD from August 2013 to July 2020 at our institution. An invaginated PG was performed by one-layer eight interrupted sutures with a lost stent. Patients' demographics and perioperative outcomes were documented. RESULTS This technique was applied in 72 patients with a median age of 75 years. The median operative time was 342 min. The clinically relevant POPF, DGE and post-pancreatectomy hemorrhage was 4 (5.6%), 5 (6.9%), and 10 (13.9%), respectively. Although the drain fluid amylase concentration on postoperative day 3 was significantly higher in clinically relevant POPF (CR-POPF) positive group (median, 2006 U/L vs. 74 U/L in CR-POPF negative group, p = 0.002), none of the risk factors including disease pathology, pancreatic duct diameter, texture of pancreas and excessive blood loss were significantly associated with CR-POPF. Other morbidity ≥ Clavien-Dindo classification II occurred in 29 patients (40.3%). The 90-days operative mortality was two (2.8%). CONCLUSIONS This novel method of one-layer invaginated PG following SSPPD is safe and dependable procedure with acceptable morbidity and mortality.
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Affiliation(s)
- Teruo Komokata
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan.
| | - Kensuke Nuruki
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Nobuhiro Tada
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Ryo Imada
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Bibek Aryal
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Mamoru Kaieda
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Soji Sane
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
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Management of postoperative pancreatic fistula after pancreatoduodenectomy: Analysis of 600 cases of pancreatoduodenectomy patients over a 10-year period at a single institution. Surgery 2021; 169:1446-1453. [PMID: 33618857 DOI: 10.1016/j.surg.2021.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/18/2020] [Accepted: 01/09/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although postoperative pancreatic fistula (POPF) is a common and critical complication of pancreatoduodenectomy (PD), effective strategies to prevent POPF have not yet been completely developed. Because appropriate management of POPF is important to reduce the mortality rate after PD, in this study we aimed to evaluate our approach for the management of POPF after PD, including the postoperative course. METHODS This retrospective study included 605 consecutive patients who underwent PD at our hospital between 2010 and 2020. All patients who developed POPF were first managed conservatively, with drainage tubes placed during surgery retained to manage POPF. In cases wherein conservative treatment was unsuccessful, open drainage, followed by continuous negative pressure and continuous irrigation, was used. For open drainage, the surgical wound was opened bluntly (approximate length, 5 cm) under local anesthesia, and the fluid was directly and completely drained. RESULTS The prevalence of POPF of grades B and C was 15.4% (n = 93) and 0.33% (n = 2), respectively. Of these patients, 1 required reoperation, 43 recovered with conservative management only, 47 required open drainage, and 4 required image-guided percutaneous drainage. Postoperative hemorrhage with a pseudoaneurysm was identified in 3 (0.66%) patients. The postoperative in-hospital mortality rate was low (n = 1, 0.16%). The rate of successful POPF management was 98.9%. CONCLUSION Based on our high success rate in POPF management, we consider open drainage to be a safe primary management method for POPF.
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A deep pancreas is a novel predictor of pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct. Surgery 2020; 169:1471-1479. [PMID: 33390302 DOI: 10.1016/j.surg.2020.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/20/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND We investigated the risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct. METHODS We investigated a total of 354 patients who underwent pancreaticoduodenectomy. The diameter of the main pancreatic duct, the shortest distance from the body surface to the pancreas (the pancreatic depth), and the computed tomography attenuation index (the difference between the pancreatic and splenic computed tomography attenuation) were measured in preoperative computed tomography. RESULTS One hundred eighty-one (51.1%) patients had a nondilated main pancreatic duct, and 50 (27.6%) of the 181 patients with a nondilated main pancreatic duct developed a clinically relevant postoperative pancreatic fistula. Univariate analyses revealed that the calculated body mass index (≥21.8 kg/m2) (P = .004), deep pancreas (pancreatic depth ≥51.2 mm) (P = .001), and low computed tomography attenuation index (≤-3.8 Hounsfield units) (P = .02) were significant risk factors for clinically relevant postoperative pancreatic fistula. The multivariate logistic regression analysis revealed that deep pancreas (odds ratio 2.370; 95% confidence interval 1.0019-5.590; P = .049) was an independent risk factor for clinically relevant postoperative pancreatic fistula. Among patients with a nondilated main pancreatic duct, deep pancreas (in comparison to patients without deep pancreas) was associated with male sex (72.7% vs 54.9%; P = .016), higher body mass index (22.5 kg/m2 vs 19.6 kg/m2; P < .001), a history of diabetes mellitus (24.5% vs 8.5%; P = .006), a lower computed tomography attenuation index (-9.6 Hounsfield units vs -4.6 Hounsfield units; P = .007), a longer operative time (454 minutes vs 420 minutes; P = .007), and a higher volume of intraoperative blood loss (723 mL vs 500 mL; P < .001), respectively. CONCLUSION Deep pancreas may be an important parameter associated with significant risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct.
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Is delayed gastric emptying associated with pylorus ring preservation in patients undergoing pancreaticoduodenectomy? Asian J Surg 2020; 44:137-142. [PMID: 32951961 DOI: 10.1016/j.asjsur.2020.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/OBJECTIVE A high incidence of delayed gastric emptying (DGE) is observed in patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). However, DGE incidence after pancreaticoduodenectomy varied because of heterogeneity in surgical techniques, number of surgeons, and DGE definition. This study aimed to evaluate the difference in the incidence of DGE following PpPD and pylorus-resecting pancreaticoduodenectomy (PrPD) and to analyze the risk factor of DGE by a single surgeon to determine whether pylorus preservation was the main factor of DGE. METHODS This retrospective study included 115 patients who underwent PpPD (with pylorus ring preservation) and PrPD (without pylorus ring preservation) with laparotomy by a single surgeon at a tertiary center. RESULTS The overall incidence of DGE was 23.1%. For comparison, 20 patients (39.2%) in the PpPD group and 5 patients (8.8%) in the PrPD group had DGE, showing a significant difference (p < 0.001). On univariate analysis, hypertension, PpPD, operation time, intraoperative bleeding, packed red blood cell transfusion ≥500 mL, and clinically relevant postoperative pancreatic fistula were associated with DGE. Multivariate analysis identified pylorus preservation and clinically relevant postoperative pancreatic fistula as risk factors for DGE. CONCLUSION Compared with PpPD, PrPD significantly reduced the incidence of DGE.
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Klaiber U, Probst P, Hüttner FJ, Bruckner T, Strobel O, Diener MK, Mihaljevic AL, Büchler MW, Hackert T. Randomized Trial of Pylorus-Preserving vs. Pylorus-Resecting Pancreatoduodenectomy: Long-Term Morbidity and Quality of Life. J Gastrointest Surg 2020; 24:341-352. [PMID: 30671796 DOI: 10.1007/s11605-018-04102-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/29/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The randomized controlled PROPP trial (DKRS00004191) showed that pylorus-resecting pancreatoduodenectomy (PR) is not superior to the pylorus-preserving procedure (PP) in terms of perioperative outcome, specifically in reduction of delayed gastric emptying. Non-superiority of PR was also confirmed in a recent meta-analysis of randomized controlled trials. However, long-term data on morbidity and quality of life after PP compared to PR are sparse. The aim of this study was to investigate long-term outcomes of patients included in the PROPP trial. METHODS Between February 2013 and June 2016, a total of 188 patients underwent PD and were intraoperatively randomized to either preservation or resection of the pylorus (95 vs. 93 patients). For long-term follow-up, morbidity and quality of life (EORTC QLQ-C30/PAN26) were monitored until January 1, 2018. Statistical analysis was performed on an intention-to-treat basis. RESULTS The mean duration of follow-up was 34.3 (± 11.3) months. Sixty-three of the 188 patients had died (PP n = 33, PR n = 30), 29 patients were lost to follow-up (PP n = 17, PR n = 12), and the remaining 96 patients were included in long-term follow-up (PP n = 45, PR n = 51). There was no difference between PP and PR patients regarding endocrine and exocrine pancreatic function, receipt of adjuvant/palliative chemotherapy, cancer recurrence, and other relevant characteristics. Late cholangitis occurred significantly more often in patients following pylorus resection (P = 0.042). Reoperations, readmissions to hospital, and quality of life scores except pain were comparable between the two study groups. CONCLUSIONS Similar to short-term results, long-term follow-up showed no significant differences between pylorus resection compared to pylorus preservation.
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Affiliation(s)
- Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Felix J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Pylorus Resection Does Not Reduce Delayed Gastric Emptying After Partial Pancreatoduodenectomy: A Blinded Randomized Controlled Trial (PROPP Study, DRKS00004191). Ann Surg 2019; 267:1021-1027. [PMID: 28885510 DOI: 10.1097/sla.0000000000002480] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the effect of pylorus resection on postoperative delayed gastric emptying (DGE) after partial pancreatoduodenectomy (PD). BACKGROUND PD is the standard treatment for tumors of the pancreatic head. Preservation of the pylorus has been widely accepted as standard procedure. DGE is a common complication causing impaired oral intake, prolonged hospital stay, and postponed further treatment. Recently, pylorus resection has been shown to reduce DGE. METHODS Patients undergoing PD for any indication at the University of Heidelberg were randomized to either PD with pylorus preservation (PP) or PD with pylorus resection and complete stomach preservation (PR). The primary endpoint was DGE within 30 days according to the International Study Group of Pancreatic Surgery definition. RESULTS Ninety-five patients were randomized to PP and 93 patients to PR. There were no baseline imbalances between the groups. Overall, 53 of 188 patients (28.2%) developed a DGE (grade: A 15.5%; B 8.8%; C 3.3%). In the PP group 24 of 95 patients (25.3%) and in the PR group 29 of 93 patients (31.2%) developed DGE (odds ratio 1.534, 95% confidence interval 0.788 to 2.987; P = 0.208). Higher BMI, indigestion, and intraabdominal major complications were significant risk factors for DGE. CONCLUSIONS In this randomized controlled trial, pylorus resection during PD did not reduce the incidence or severity of DGE. The development of DGE seems to be multifactorial rather than attributable to pyloric dysfunction alone. Pylorus preservation should therefore remain the standard of care in PD. TRIAL REGISTRATION German Clinical Trials Register DRKS00004191.
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Miyamoto R, Oshiro Y, Sano N, Inagawa S, Ohkohchi N. Remnant pancreatic volume as an indicator of poor prognosis in pancreatic cancer patients after resection. Pancreatology 2019; 19:716-721. [PMID: 31178397 DOI: 10.1016/j.pan.2019.05.464] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/21/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Remnant pancreatic volume (RPV) is a well-known marker for short-term outcomes in pancreatic cancer patients after resection. However, in terms of the long-term outcomes, the significance of the RPV value remains unclear. Here, we address whether the RPV value is a predictor of the long-term outcomes in pancreatic cancer patients after resection by comparing various cancer-, patient-, and surgery-related prognostic factors and systemic inflammatory response markers in a retrospective cohort. METHODS The RPV was measured on a three-dimensional (3D) image, revealing the actual pancreatic parenchymal remnant volume. Ninety-one patients who underwent pancreaticoduodenectomy were retrospectively enrolled. We divided the cohort into high- and low-RPV groups based on a cut-off value (>31.5 cm3, n = 66 and ≤31.5 cm3, n = 25, respectively). The median survival times (MSTs) were compared between the two groups. Using multivariate analysis, the RPV and other well-known prognostic factors were independently assessed. RESULTS The MSTs (days) were significantly different between the two groups (high, 823 vs. low, 482, p = 0.001). Multivariate analysis identified the RPV (≤31.5 cm3) (hazard ratio [HR], 2.015; p = 0.011), lymph node metastasis (HR, 8.415; p = 0.002), lack of adjuvant chemotherapy (HR, 5.352; p < 0.001), stage III/IV disease (HR, 2.352; p = 0.029), and pathological fibrosis (HR, 1.771; p = 0.031) as independent prognostic factors. CONCLUSIONS The present study suggests that the RPV value is also useful for predicting long-term outcomes in pancreatic cancer patients after resection.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan; Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Yukio Oshiro
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naoki Sano
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Satoshi Inagawa
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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14
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Hori T, Yamamoto H, Harada H, Yamamoto M, Yamada M, Yazawa T, Tani M, Kamada Y, Tani R, Aoyama R, Sasaki Y, Zaima M. Inferior Pancreaticoduodenal Artery Aneurysm Related with Groove Pancreatitis Persistently Repeated Hemosuccus Pancreaticus Even After Coil Embolization. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:567-574. [PMID: 31006768 PMCID: PMC6489418 DOI: 10.12659/ajcr.914832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patient: Male, 58 Final Diagnosis: Inferior pancreaticoduodenal artery aneurysm Symptoms: Bleding Medication: — Clinical Procedure: Pancreaticoduodenectomy Specialty: Surgery
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Affiliation(s)
- Tomohide Hori
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Hidekazu Yamamoto
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Hideki Harada
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | | | - Masahiro Yamada
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Takefumi Yazawa
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Masaki Tani
- Department of Surgery/Transplantation, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Yasuyuki Kamada
- Department of Surgery/Transplantation, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Ryotaro Tani
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Ryuhei Aoyama
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Yudai Sasaki
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
| | - Masazumi Zaima
- Department of Surgery, Shiga General Hospital, Moriyama, Shiga, Japan
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15
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Ellis RJ, Gupta AR, Hewitt DB, Merkow RP, Cohen ME, Ko CY, Bilimoria KY, Bentrem DJ, Yang AD. Risk factors for post-pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra-abdominal infection. J Surg Oncol 2019; 119:925-931. [PMID: 30737792 DOI: 10.1002/jso.25398] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/08/2019] [Accepted: 01/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), but the rate of DGE in the absence of other intra-abdominal complications is poorly understood. The objectives of this study were to define the incidence of DGE and identify risk factors for DGE in patients without pancreatic fistula or other intra-abdominal infections. METHODS Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy variables to identify patients with DGE following PD without evidence of fistula or intra-abdominal infection. Multivariable models were developed to assess preoperative, intraoperative, and technical factors associated with DGE. RESULTS The rate of DGE was 11.7% in 10502 cases without pancreatic fistula or intra-abdominal infection. Patients were more likely to develop DGE if age ≥75 (odds ratio [OR], 1.22; P = 0.003), male (OR, 1.29; P < 0.001), underwent pylorus-sparing PD (OR, 1.27; P = 0.004), or had a prolonged operative time (OR, 1.38 if greater than seven vs less than 5 hours; P = 0.005). Factors not associated with DGE included BMI, pathologic indication, and surgical approach. CONCLUSION The incidence of DGE after PD is notable even in patients without other abdominal complications. Identification of patients at increased risk for DGE may aid patient counseling as well as decisions regarding surgical technique, enteral feeding access, and enhanced-recovery pathways.
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Affiliation(s)
- Ryan J Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Aakash R Gupta
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - D Brock Hewitt
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan P Merkow
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Mark E Cohen
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Clifford Y Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California.,VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Karl Y Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois.,Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - David J Bentrem
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Anthony D Yang
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
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16
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Miyamoto R, Oshiro Y, Sano N, Inagawa S, Ohkohchi N. Three-Dimensional Remnant Pancreatic Volumetry Predicts Postoperative Pancreatic Fistula in Pancreatic Cancer Patients after Pancreaticoduodenectomy. Gastrointest Tumors 2018; 5:90-99. [PMID: 30976580 DOI: 10.1159/000495406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background Postoperative pancreatic fistula (POPF) is a serious complication that can occur following pancreaticoduodenectomy (PD). Recent studies suggest that remnant pancreatic volume (RPV) values from preoperative multidetector computed tomography (MDCT) are highly predictive of POPF. We performed three-dimensional (3D) surgical simulation of PD including RPV measurements. The aim of this study was to determine whether 3D-measured RPV is predictive of POPF after PD. Methods We used the SYNAPSE VINCENT® medical imaging system (Fujifilm Medical Co., Ltd., Tokyo, Japan) to construct 3D images after integrating MDCT and magnetic resonance cholangiopancreatography images. RPV was measured using this 3D image, which simulated actual intraoperative pancreatic parenchymal remnant volume. Ninety-one patients who underwent PD were retrospectively enrolled. Using multivariate analysis, RPV and other well-known POPF risk factors were independently assessed. Results Multivariate analysis identified high RPV values (hazard ratio [HR] = 8.41, p = 0.01), pancreatic duct diameter < 3.0 mm (HR = 5.48, p < 0.01), no pathological fibrosis (HR = 3.41, p < 0.01), and body mass index > 25 kg/m2 (HR = 1.53, p = 0.02) as independent risk factors for POPF. Conclusion The present study indicates that preoperative 3D-measured RPV is predictive of POPF after PD.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan.,Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Yukio Oshiro
- Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Naoki Sano
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Satoshi Inagawa
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Nobuhiro Ohkohchi
- Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
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17
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Miyamoto R, Oshiro Y, Sano N, Inagawa S, Ohkohchi N. Three-dimensional surgical simulation of the bile duct and vascular arrangement in pancreatoduodenectomy: A retrospective cohort study. Ann Med Surg (Lond) 2018; 36:17-22. [PMID: 30370052 PMCID: PMC6199778 DOI: 10.1016/j.amsu.2018.09.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/21/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS We evaluated the usefulness of three-dimensional (3D) images for pancreatoduodenectomy (PD), including the classification of the bile duct and vascular arrangement, i.e., hepatic artery, inferior mesenteric vein (IMV) and left gastric vein (LGV). We evaluated the extent to which this simulation affected the perioperative outcomes of PD. METHODS In all, 117 patients who underwent PD were divided into the without-3D (n = 53) and with-3D (n = 64) groups, and perioperative outcomes were compared. We evaluated the arrangement of the accessory bile duct and the hepatic artery (type I: the right hepatic artery arising from the superior mesenteric artery, type II: the left hepatic artery arising from the left gastric artery, type III: the most common pattern) and the confluence pattern of the LGV and the IMV [type i: portal vein (PV):splenic vein (SV), type ii: PV:superior mesenteric vein (SMV), type iii: SV:SV, and type iv: SV:SMV] between the two groups. RESULTS Two patients had an accessory bile duct. The 3D images were classified as type I (n = 4), type II (n = 10), type III (n = 48) and other patterns (n = 2); type ii (n = 27) was the most frequent confluence pattern (p < 0.05). Intraoperative blood loss was reduced in the with-3D group (p < 0.05). CONCLUSIONS We propose that the 3D imaging technique is useful for preoperative assessment in PD.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Yukio Oshiro
- Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naoki Sano
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Satoshi Inagawa
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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18
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Impact of the gastrojejunal anatomic position as the mechanism of delayed gastric emptying after pancreatoduodenectomy. Surgery 2018; 163:1063-1070. [DOI: 10.1016/j.surg.2017.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 10/25/2017] [Accepted: 11/11/2017] [Indexed: 12/19/2022]
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19
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Klaiber U, Probst P, Strobel O, Michalski CW, Dörr-Harim C, Diener MK, Büchler MW, Hackert T. Meta-analysis of delayed gastric emptying after pylorus-preserving versus pylorus-resecting pancreatoduodenectomy. Br J Surg 2018; 105:339-349. [PMID: 29412453 DOI: 10.1002/bjs.10771] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/22/2017] [Accepted: 10/30/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pylorus-preserving pancreatoduodenectomy. Recent studies have suggested that resection of the pylorus is associated with decreased rates of DGE. However, superiority of pylorus-resecting pancreatoduodenectomy was not shown in a recent RCT. This meta-analysis summarized evidence of the effectiveness and safety of pylorus-preserving compared with pylorus-resecting pancreatoduodenectomy. METHODS RCTs and non-randomized studies comparing outcomes of pylorus-preserving and pylorus-resecting pancreatoduodenectomy were searched systematically in MEDLINE, Web of Science and CENTRAL. Random-effects meta-analyses were performed and the results presented as weighted odds ratios (ORs) or mean differences with their corresponding 95 per cent confidence intervals. Subgroup analyses were performed to account for interstudy heterogeneity between RCTs and non-randomized studies. RESULTS Three RCTs and eight non-randomized studies with a total of 992 patients were included. Quantitative synthesis across all studies showed superiority for pylorus-resecting pancreatoduodenectomy regarding DGE (OR 2·71, 95 per cent c.i. 1·48 to 4·96; P = 0·001) and length of hospital stay (mean difference 3·26 (95 per cent c.i. -1·04 to 5·48) days; P = 0·004). Subgroup analyses including only RCTs showed no significant statistical differences between the two procedures regarding DGE, and for all other effectiveness and safety measures. CONCLUSION Pylorus-resecting pancreatoduodenectomy is not superior to pylorus-preserving pancreatoduodenectomy for reducing DGE or other relevant complications.
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Affiliation(s)
- U Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - O Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C W Michalski
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C Dörr-Harim
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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20
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Miyamoto R, Oshiro Y, Nakayama K, Ohkohchi N. Impact of Three-Dimensional Surgical Simulation on Pancreatic Surgery. Gastrointest Tumors 2017; 4:84-89. [PMID: 29594109 DOI: 10.1159/000484894] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 11/02/2017] [Indexed: 01/22/2023] Open
Abstract
Background/Aims Anatomical variations are frequently encountered during hepato-biliary-pancreatic surgeries, requiring surgeons to have a precise understanding of the surgical anatomy in order to perform a safe surgery. We evaluated the impact of novel three-dimensional (3D) surgical simulation on pancreatic surgeries to enhance surgical residents' understanding. Methodology Between January 2013 and May 2014, 61 preoperative 3D surgical simulations were performed. The consistency (0-10, with 10 representing 100% consistency) among the 15 surgical residents' anatomical drawings from multidetector computed tomography images and the simulated 3D images by SYNAPSE VINCENT® was assessed. We divided the surgical residents into two groups - first- to fifth-year postgraduate doctors (group A) and sixth- to tenth-year postgraduate doctors (group B) - and compared the self-assessment scores between these two groups. Results In terms of the self-assessment scores, a statistically significant difference was observed between the two groups (p < 0.001). Conclusions In this study, 3D surgical simulation was useful for preoperative assessments prior to pancreatic surgery, especially in younger postgraduate surgeons.
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Affiliation(s)
- Ryoichi Miyamoto
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Yukio Oshiro
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Ken Nakayama
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Nobuhiro Ohkohchi
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
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21
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Klaiber U, Probst P, Büchler MW, Hackert T. Pylorus preservation pancreatectomy or not. Transl Gastroenterol Hepatol 2017; 2:100. [PMID: 29264438 DOI: 10.21037/tgh.2017.11.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is the treatment of choice for various benign and malignant tumors of the pancreatic head or the periampullary region, and the only hope for cure in patients with cancer at this side. While it has been associated with high morbidity and mortality rates in the last century, its centralization in specialized institutions together with refinements in the operative technique and better management of postoperative complications have made PD a standardized, safe procedure. Besides the classic Whipple procedure including distal gastrectomy, two variations of PD with or without pylorus resection, but preservation of the entire stomach in either procedure exist today. Pylorus-preserving PD has gained wide acceptance as standard procedure and is being performed by an increasing number of pancreatic surgeons. After its oncological adequacy was questioned initially, pylorus-preserving PD was shown to be equivalent to the classic Whipple procedure regarding tumor recurrence and long-term survival. Moreover, operation time and blood loss were shown to be reduced in the pylorus-preserving procedure and benefits in nutritional status and quality of life were observed. However, preservation of the pylorus has been suggested to result in an increased incidence of postoperative delayed gastric emptying (DGE). In this context, pylorus-resecting PD has become popular especially in Japan with the aim to prevent DGE by removal of the pylorus but preservation of the stomach. In contrast to positive results from early studies, latest high-quality randomized controlled trial (RCT) data show that pylorus resection does not reduce DGE compared to the pylorus-preserving operation. Non-superiority of pylorus resection was also confirmed in current meta-analysis on this topic. This article summarizes the existing evidence on PD with or without pylorus preservation and derives recommendations for daily practice.
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Affiliation(s)
- Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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22
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Tsutaho A, Nakamura T, Asano T, Okamura K, Tsuchikawa T, Noji T, Nakanishi Y, Tanaka K, Murakami S, Kurashima Y, Ebihara Y, Shichinohe T, Ito YM, Hirano S. Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Pancreaticoduodenectomy: Result of a Propensity Score Matching. J Gastrointest Surg 2017; 21:1635-1642. [PMID: 28819791 DOI: 10.1007/s11605-017-3540-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common morbidities of pancreaticoduodenectomy (PD). The aim of this study was to clarify whether the incidence of DGE can be reduced by side-to-side gastric greater curvature-to-jejunal anastomosis in subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). METHODS The clinical data of 253 patients who had undergone PD were examined. Of a total of 188 patients who had undergone SSPPD, a gastrojejunostomy (GJ) was performed with end-to-side anastomosis in 87 patients (SSPPD-ETS group), and a GJ was performed with a greater curvature side-to-jejunal side anastomosis in 101 patients (SSPPD-STS group). After propensity score matching, the matched cohort consisted of 74 patients in each group. The postoperative data were evaluated according to the International Study Group of Pancreatic Surgery grade of DGE. RESULTS The total incidence of DGE was 9.4% in the SSPPD-ETS group and 4% in the SSPPD-STS group, with no significant difference (p = 0.1902). A significant difference was observed between the two groups in the incidence of DGE grade C (p = 0.0426). CONCLUSIONS The incidence of total DGE was not reduced statistically in the STS group compared with the ETS group, but reduced DGE grade C. Side-to-side anastomosis might be associated with a reduced incidence of DGE grade C.
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Affiliation(s)
- Akio Tsutaho
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan.
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yoichi M Ito
- Department of Biostatistics, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
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Panwar R, Pal S. The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int 2017; 16:353-363. [PMID: 28823364 DOI: 10.1016/s1499-3872(17)60037-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 02/03/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence. DATA SOURCE We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles. RESULTS Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0-100%; median: 18.7%) and 14.3% (range: 1.8%-58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Braun's entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies. CONCLUSIONS ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.
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Affiliation(s)
- Rajesh Panwar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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C-Reactive Protein Was an Early Predictor of Postoperative Infectious Complications After Pancreaticoduodenectomy for Pancreatic Cancer. Int Surg 2017. [DOI: 10.9738/intsurg-d-16-00171.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
The study objective was to assess the predictive value of C-reactive protein (CRP) for the early detection of postoperative infectious complications (PICs) after pancreaticoduodenectomy.
Summary of Background Data
The incidence of PICs after pancreaticoduodenectomy still remains high and a clinically relevant problem, despite improvements in the surgical procedure.
Methods
We examined 110 consecutive patients who underwent pancreaticoduodenectomy for primary pancreatic cancer between 2006 and 2014. The predictive value was assessed by estimating the area under the receiver operating characteristic curve (AUC). Clinical and laboratory data, including CRP, were analyzed with univariate and multivariate logistic regression analyses to identify predictors of PICs of grade III or higher according to the Clavien-Dindo classification.
Results
PICs of grade III or higher occurred in 13 patients [11.8%; 95% confidence interval (CI), 6.45%–19.36%]. CRP level on postoperative day 3 (POD 3) was a good predictor of PICs (AUC, 0.815; 95% CI, 0.651–0.980), showing the highest accuracy among clinical and laboratory data. A cutoff value of 13.2 mg/dL yielded a sensitivity of 0.846 and a specificity of 0.794. On multivariate analysis, a POD 3 CRP level of 13.2 mg/dL or higher (odds ratio, 20.0; 95% CI, 4.07–97.9; P = 0.002) was a significant predictor of PICs after pancreaticoduodenectomy.
Conclusions
CRP elevation above 13.2 mg/dL on POD 3 is a significant predictive factor for PICs and should prompt an intense clinical search and therapeutic approach for PICs.
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In Patients with a Soft Pancreas, a Thick Parenchyma, a Small Duct, and Fatty Infiltration Are Significant Risks for Pancreatic Fistula After Pancreaticoduodenectomy. J Gastrointest Surg 2017; 21:846-854. [PMID: 28101719 DOI: 10.1007/s11605-017-3356-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/01/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study sought to characterize soft and hard pancreatic textures radiologically and histologically, and to identify specific risks in a soft pancreas associated with postoperative pancreatic fistula (POPF) formation after pancreaticoduodenectomy (PD). METHODS Consecutive 145 patients who underwent PD at a single institution between January 2010 and May 2013 were studied. Pancreatic consistency was intraoperatively judged as soft or hard. Pancreatic configuration was assessed using preoperative CT. Histologic components of the pancreatic stump were evaluated using a morphometric analysis. Clinicopathologic parameters were then analyzed for the risk of clinically relevant POPF. RESULTS Compared with patients with a hard pancreas (n = 66), those with a soft pancreas (n = 79) had a smaller main pancreatic duct (MPD) diameter and a larger parenchymal thickness on CT, had a smaller fibrosis ratio and a larger lobular ratio histologically, and developed clinically relevant POPF more frequently (P < 0.001 for all). In patients with a soft pancreas, an MPD diameter <2 mm, a parenchymal thickness ≥10 mm, a lobular ratio <75%, and a fat ratio ≥20% were independently associated with clinically relevant POPF (P < 0.010 for all). CONCLUSION In patients with a soft pancreas, a thick parenchyma, a small MPD, and fatty infiltration were strongly associated with clinically relevant POPF after PD.
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Torres OJM, Vasques RR, Torres CCS. THE OBITUARY OF THE PYLORUS-PRESERVING PANCREATODUODENECTOMY. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:71-2. [PMID: 27438028 PMCID: PMC4944737 DOI: 10.1590/0102-6720201600020001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Montagnini AL, Røsok BI, Asbun HJ, Barkun J, Besselink MG, Boggi U, Conlon KCP, Fingerhut A, Han HS, Hansen PD, Hogg ME, Kendrick ML, Palanivelu C, Shrikhande SV, Wakabayashi G, Zeh H, Vollmer CM, Kooby DA. Standardizing terminology for minimally invasive pancreatic resection. HPB (Oxford) 2017; 19:182-189. [PMID: 28317657 DOI: 10.1016/j.hpb.2017.01.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/05/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is a growing body of literature pertaining to minimally invasive pancreatic resection (MIPR). Heterogeneity in MIPR terminology, leads to confusion and inconsistency. The Organizing Committee of the State of the Art Conference on MIPR collaborated to standardize MIPR terminology. METHODS After formal literature review for "minimally invasive pancreatic surgery" term, key terminology elements were identified. A questionnaire was created assessing the type of resection, the approach, completion, and conversion. Delphi process was used to identify the level of agreement among the experts. RESULTS A systematic terminology template was developed based on combining the approach and resection taking into account the completion. For a solitary approach the term should combine "approach + resection" (e.g. "laparoscopic pancreatoduodenectomy); for combined approaches the term must combine "first approach + resection" with "second approach + reconstruction" (e.g. "laparoscopic central pancreatectomy" with "open pancreaticojejunostomy") and where conversion has resulted the recommended term is "first approach" + "converted to" + "second approach" + "resection" (e.g. "robot-assisted" "converted to open" "pancreatoduodenectomy") CONCLUSIONS: The guidelines presented are geared towards standardizing terminology for MIPR, establishing a basis for comparative analyses and registries and allow incorporating future surgical and technological advances in MIPR.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Paul D Hansen
- Portland Providence Cancer Center, Portland, OR, USA
| | - Melissa E Hogg
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | | - Herbert Zeh
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - David A Kooby
- Emory University School of Medicine, Atlanta, GA, USA
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Nishiguchi R, Kim DH, Honda M, Sakamoto T. Squamous cell carcinoma of the extrahepatic bile duct with metachronous para-aortic lymph node metastasis successfully treated with S-1 plus cisplatin. BMJ Case Rep 2016; 2016:bcr-2016-218177. [PMID: 27932438 DOI: 10.1136/bcr-2016-218177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The most common histological classification of bile duct cancer is adenocarcinoma and squamous cell carcinoma (SCC) is relatively rare. We report a case of a 78-year-old man with SCC of the extrahepatic bile duct associated with metachronous para-aortic lymph node metastasis. He had undergone subtotal stomach-preserving pancreatoduodenectomy. The pathological findings demonstrated moderately differentiated SCC of the distal extrahepatic bile duct (T1N1M0, stage IIB). 6 months after surgery, recurrence of the para-aortic lymph node was shown in abdominal CT. 5 courses of tegafur/gimeracil/oteracil (S-1) plus cisplatin therapy was performed and the para-aortic lymph node disappeared, confirmed as complete response by imaging findings. The patient is alive without recurrence, 10 months after recurrence and chemotherapy.
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Affiliation(s)
- Ryohei Nishiguchi
- Department of Surgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Dal Ho Kim
- Department of Surgery, Sainokuni Higashi Omiya Medical Center, Saitama, Japan
| | - Masayuki Honda
- Department of Surgery, Sainokuni Higashi Omiya Medical Center, Saitama, Japan
| | - Tsuguo Sakamoto
- Department of Surgery, Sainokuni Higashi Omiya Medical Center, Saitama, Japan
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Takemura N, Saiura A, Koga R, Yamamoto J, Yamaguchi T. Risk Factors for and Management of Postpancreatectomy Hepatic Steatosis. Scand J Surg 2016; 106:224-229. [DOI: 10.1177/1457496916669630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Relatively little is known about the risk factors and treatments for postpancreatectomy hepatic steatosis. Methods: The records of patients who underwent pancreaticoduodenectomy or total pancreatectomy between 2005 and 2010 and were followed up by periodic imaging were reviewed retrospectively. Risk factors and treatment for postpancreatectomy hepatic steatosis were analyzed. Results: A total of 253 patients were included in the analysis, including 137 males and 116 females, of median (5, 95 percentile) age 67 (47, 81) years. Of these 253 patients, 75 (29.6%) developed postpancreatectomy hepatic steatosis. Multivariable logistic regression analysis showed that female gender ( p = 0.005; odds ratio: 2.387; 95% confidence interval: 1.293–4.386), body mass index > 22.5 kg/m2 ( p = 0.007; odds ratio: 2.330; 95% confidence interval: 1.261–4.307), operative duration > 540 min ( p = 0.018; odds ratio: 2.286; 95% confidence interval: 1.153–4.533), and delayed gastric emptying ( p < 0.001; odds ratio: 4.598; 95% confidence interval: 1.979–10.678) were independent risk factors associated with postpancreatectomy hepatic steatosis. Treatment consisted of maintenance- or high-dose digestive enzyme replacement therapy. Of patients without obvious tumor recurrence after 6 months, 12 of 15 treated with high dose and only 6 of 35 treated with maintenance-dose digestive enzyme replacement therapy showed improvements in postpancreatectomy hepatic steatosis ( p = 0.006). Conclusion: Female gender, obesity, longer operative time, and occurrence of delayed gastric emptying are risk factors for postpancreatectomy hepatic steatosis. High-dose digestive enzyme replacement therapy may improve postpancreatectomy hepatic steatosis.
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Affiliation(s)
- N. Takemura
- Department of Gastroenterological Surgery, Cancer Institute Ariake Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - A. Saiura
- Department of Gastroenterological Surgery, Cancer Institute Ariake Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - R. Koga
- Department of Gastroenterological Surgery, Cancer Institute Ariake Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - J. Yamamoto
- Department of Surgery, National Defense Medical College, Saitama, Japan
| | - T. Yamaguchi
- Department of Gastroenterological Surgery, Cancer Institute Ariake Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Sato T, Matsuo Y, Shiga K, Morimoto M, Miyai H, Takeyama H. Factors that predict the occurrence of and recovery from non-alcoholic fatty liver disease after pancreatoduodenectomy. Surgery 2016; 160:318-30. [DOI: 10.1016/j.surg.2016.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/20/2016] [Accepted: 04/08/2016] [Indexed: 12/13/2022]
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Miyamoto R, Oshiro Y, Nakayama K, Kohno K, Hashimoto S, Fukunaga K, Oda T, Ohkohchi N. Three-dimensional simulation of pancreatic surgery showing the size and location of the main pancreatic duct. Surg Today 2016; 47:357-364. [PMID: 27368278 DOI: 10.1007/s00595-016-1377-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/17/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE We performed three-dimensional (3D) surgical simulation of pancreatic surgery, including the size and location of the main pancreatic duct on the resected pancreatic surface. METHODS The subjects of this retrospective analysis were 162 patients who underwent pancreatic surgery. This cohort was sequentially divided into a "without-3D" group (n = 81) and a "with-3D" group (n = 81). We compared the pancreatic duct diameter and its location, using nine sections in a grid pattern, with the intraoperative findings. The perioperative outcomes were also compared between patients who underwent pancreaticoduodenectomy (PD) and those who underwent distal pancreatectomy (DP). RESULTS There were no significant differences in the main pancreatic duct diameter between the 3D-simulated values and the operative findings. The 3D-simulated main pancreatic duct location was consistent with its actual location in 80 % of patients (65/81). In comparing the PD and DP groups, the intraoperative blood loss was 1174 ± 867 and 817 ± 925 ml in the without-3D group, and 828 ± 739 and 307 ± 192 ml in the with-3D group, respectively (p = 0.024, 0.026). CONCLUSION The 3D surgical simulation provided useful information to promote our understanding of the pancreatic anatomy, including details on the size and location of the main pancreatic duct.
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Affiliation(s)
- Ryoichi Miyamoto
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yukio Oshiro
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Ken Nakayama
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Keisuke Kohno
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinji Hashimoto
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kiyoshi Fukunaga
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Nobuhiro Ohkohchi
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Hanna MM, Gadde R, Allen CJ, Meizoso JP, Sleeman D, Livingstone AS, Merchant N, Yakoub D. Delayed gastric emptying after pancreaticoduodenectomy. J Surg Res 2016; 202:380-8. [DOI: 10.1016/j.jss.2015.12.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 12/26/2015] [Accepted: 12/31/2015] [Indexed: 12/15/2022]
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Hwang HK, Lee SH, Han DH, Choi SH, Kang CM, Lee WJ. Impact of Braun anastomosis on reducing delayed gastric emptying following pancreaticoduodenectomy: a prospective, randomized controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:364-72. [PMID: 27038406 DOI: 10.1002/jhbp.349] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The present study investigates the clinical impact of Braun anastomosis on delayed gastric emptying (DGE) after pylorus-preserving pancreaticoduodenectomy (PPPD). METHODS From February 2013 to June 2014, 60 patients were recruited for this randomized controlled trial. The incidence of DGE and its risk factors were analyzed according to whether or not Braun anastomosis was used after PPPD. RESULTS Thirty patients were respectively enrolled in No-Braun group and Braun group. A comparative analysis between the two groups showed no differences in sex, diagnosis, operation time, hospital stay, or postoperative complications, including pancreatic fistula. Overall DGE developed in eight patients (26.7%) in the Braun group and in 14 patients (46.7%) in the No-Braun group (P = 0.108). However, clinically relevant DGE (grades B and C) was marginally more frequent in the No-Braun group (23.3% vs. 3.3%, P = 0.052). In a multivariable analysis, No-Braun anastomosis was an independent risk factor for developing clinically relevant DGE (odds ratio = 16.489; 95% confidence interval: 1.287-211.195; P = 0.031). CONCLUSION The overall DGE occurrence was not different between the two groups. However, No-Braun anastomosis was an independent risk factor for developing clinically relevant DGE.
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Affiliation(s)
- Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Sung Hwan Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Dai Hoon Han
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Sung Hoon Choi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea.
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
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Postoperative Changes in Body Composition After Pancreaticoduodenectomy Using Multifrequency Bioelectrical Impedance Analysis. J Gastrointest Surg 2016; 20:611-8. [PMID: 26691149 DOI: 10.1007/s11605-015-3055-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 12/07/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Nutritional status is one of the most important clinical determinants of outcome after surgery. The aim of this study was to compare changes in the body composition of patients undergoing pancreaticoduodenectomy (PD), distal gastrectomy (DG), or total gastrectomy (TG). METHODS The parameters of body composition were measured using multifrequency bioelectrical impedance analysis with an inBody 720 (Biospace Inc. Tokyo. Japan) in 60 patients who had undergone PD (n = 18), DG (n = 30), or TG (n = 12). None of the patients had recurrence or were treated with chemotherapy. Changes between the preoperative data and results and those obtained 12 months after surgery were evaluated. RESULTS Twelve months after surgery, the body weight change in the PD group was significantly lower than in the TG and DG groups (-1.2 ± 3.8 vs -7.4 ± 4.4 and -4.0 ± 3.2 kg, respectively; p < 0.01 vs TG, p < 0.05 vs DG). The body weight change correlated with the fat mass change in all groups. CONCLUSIONS The type and extent of surgery has a different effect on long-term body weight and body composition. Bioelectric impedance analysis can be used to assess body composition and may be useful for nutritional assessment in patients who have undergone these surgeries.
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Barakat O, Cagigas MN, Bozorgui S, Ozaki CF, Wood RP. Proximal Roux-en-y Gastrojejunal Anastomosis with Pyloric Ring Resection Improves Gastric Emptying After Pancreaticoduodenectomy. J Gastrointest Surg 2016; 20:914-23. [PMID: 26850262 PMCID: PMC4850182 DOI: 10.1007/s11605-016-3091-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/21/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication of pancreaticoduodenectomy. We determined the efficiency of a new reconstruction technique, designed to preserve motilin-secreting cells and maximize the utility of their receptors, in reducing the incidence of DGE after pancreaticoduodenectomy. METHODS From April 2005 to September 2014, 217 consecutive patients underwent pancreaticoduodenectomy at our institution. Nine patients who underwent total pancreatectomy were excluded. We compared outcomes between patients who underwent pancreaticoduodenectomy with resection of the pyloric ring followed by proximal Roux-en-y gastrojejunal anastomosis (group I, n = 90) and patients who underwent standard pancreaticoduodenectomy with the orthotopic reconstruction technique (group II, n = 118). RESULTS Overall and clinically relevant rates of DGE were significantly lower in group I than in group II (10 and 2.2 % vs. 57 and 24 %, respectively; p < 0.05). Length of hospital stay as a result of DGE was shorter in group I than in group II. In univariate analysis, older age, comorbidities, ASA grade 4, operative time, preoperative diabetes, standard reconstruction technique, and postoperative complications were significant risk factors for DGE. In multivariate analysis, older age, standard technique, and postoperative complications were independent risk factors for DGE. CONCLUSION Our new reconstruction technique reduces the occurrence of DGE after pancreaticoduodenectomy.
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Affiliation(s)
- Omar Barakat
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
| | - Martha N. Cagigas
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
| | - Shima Bozorgui
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
| | - Claire F. Ozaki
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
| | - R. Patrick Wood
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
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Is there comparable morbidity in pylorus-preserving and pylorus-resecting pancreaticoduodenectomy? A meta-analysis. ACTA ACUST UNITED AC 2015; 35:793-800. [PMID: 26670427 DOI: 10.1007/s11596-015-1509-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 11/08/2015] [Indexed: 12/17/2022]
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Nakamura T, Ambo Y, Noji T, Okada N, Takada M, Shimizu T, Suzuki O, Nakamura F, Kashimura N, Kishida A, Hirano S. Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy. J Gastrointest Surg 2015; 19:1425-32. [PMID: 26063079 DOI: 10.1007/s11605-015-2870-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/30/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND One of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5-20%. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal end-to-side anastomosis in SSPPD. METHODS Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007-March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010-September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively. RESULTS The incidence of DGE was 21.3% in the SSPPD-ETS group and 2.5% in the SSPPD-STS group (P = 0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different. CONCLUSIONS The greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD.
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Affiliation(s)
- Toru Nakamura
- Department of Surgery, Teine-Keijinkai Hospital, Teine-ku, Sapporo, Japan,
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Hanna MM, Gadde R, Tamariz L, Allen CJ, Meizoso JP, Sleeman D, Livingstone AS, Yakoub D, Sleeman D, Livingstone AS, Livingstone A, Yakoub D. Delayed Gastric Emptying After Pancreaticoduodenectomy: Is Subtotal Stomach Preserving Better or Pylorus Preserving? J Gastrointest Surg 2015; 19:1542-52. [PMID: 25862001 DOI: 10.1007/s11605-015-2816-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/29/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the main complications after pancreaticoduodenectomy (PD). Literature review and meta-analysis were used to evaluate whether subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) may have less incidence than pylorus-preserving pancreaticoduodenectomy (PPPD). METHODS Online search for studies comparing PPPD to SSPPD was done. Primary outcome was DGE. Quality of included studies was evaluated and heterogeneity was assessed. Relative risk (RR) and 95% confidence intervals (CI) were calculated from pooled data in RCTs and retrospective studies. RESULTS Eight studies met our selection criteria, with a total of 663 patients undergoing pancreaticoduodenectomy; 309 underwent PPPD and 354 underwent SSPPD. Median age was 66 years. Average male/female ratio was 57 vs. 43%, respectively. There was lower incidence of DGE with SSPPD (RR 0.527; 95% CI 0.363-0.763; p < 0.001) and less nasogastric tube days with SSPPD (RR -0.544; 95% CI -876 to -0.008; p = 0.047). Operative blood loss was more in SSPPD (RR 0.285; 95% CI 0.071-0.499; p = 0.009). There was no statistical difference between the two groups regarding length of hospital stay, incidence of pancreatic fistula, abscesses, overall morbidity, or postoperative mortality. CONCLUSION SSPPD was associated with less DGE than PPPD. Larger prospective randomized studies are needed to investigate the association of this result with other complications in more depth.
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Affiliation(s)
- Mena M Hanna
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Huang W, Xiong JJ, Wan MH, Szatmary P, Bharucha S, Gomatos I, Nunes QM, Xia Q, Sutton R, Liu XB. Meta-analysis of subtotal stomach-preserving pancreaticoduodenectomy vs pylorus preserving pancreaticoduodenectomy. World J Gastroenterol 2015; 21:6361-6373. [PMID: 26034372 PMCID: PMC4445114 DOI: 10.3748/wjg.v21.i20.6361] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 10/10/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the differences in outcome following pylorus preserving pancreaticoduodenectomy (PPPD) and subtotal stomach-preserving pancreaticoduodenectomy (SSPPD).
METHODS: Major databases including PubMed (Medline), EMBASE and Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched for comparative studies between patients with PPPD and SSPPD published between January 1978 and July 2014. Studies were selected based on specific inclusion and exclusion criteria. The primary outcome was delayed gastric emptying (DGE). Secondary outcomes included operation time, intraoperative blood loss, pancreatic fistula, postoperative hemorrhage, intraabdominal abscess, wound infection, time to starting liquid diet, time to starting solid diet, period of nasogastric intubation, reinsertion of nasogastric tube, mortality and hospital stay. The pooled odds ratios (OR) or weighted mean difference (WMD) with 95% confidence intervals (95%CI) were calculated using either a fixed-effects or random-effects model.
RESULTS: Eight comparative studies recruiting 650 patients were analyzed, which include two RCTs, one non-randomized prospective and 5 retrospective trial designs. Patients undergoing SSPPD experienced significantly lower rates of DGE (OR = 2.75; 95%CI: 1.75-4.30, P < 0.00001) and a shorter period of nasogastric intubation (OR = 2.68; 95%CI: 0.77-4.58, P < 0.00001), with a tendency towards shorter time to liquid (WMD = 2.97, 95%CI: -0.46-7.83; P = 0.09) and solid diets (WMD = 3.69, 95%CI: -0.46-7.83; P = 0.08) as well as shorter inpatient stay (WMD = 3.92, 95%CI: -0.37-8.22; P = 0.07), although these latter three did not reach statistical significance. PPPD, however, was associated with less intraoperative blood loss than SSPPD [WMD = -217.70, 95%CI: -429.77-(-5.63); P = 0.04]. There were no differences in other parameters between the two approaches, including operative time (WMD = -5.30, 95%CI: -43.44-32.84; P = 0.79), pancreatic fistula (OR = 0.91; 95%CI: 0.56-1.49; P = 0.70), postoperative hemorrhage (OR = 0.51; 95%CI: 0.15-1.74; P = 0.29), intraabdominal abscess (OR = 1.05; 95%CI: 0.54-2.05; P = 0.89), wound infection (OR = 0.88; 95%CI: 0.39-1.97; P = 0.75), reinsertion of nasogastric tube (OR = 1.90; 95%CI: 0.91-3.97; P = 0.09) and mortality (OR = 0.31; 95%CI: 0.05-2.01; P = 0.22).
CONCLUSION: SSPPD may improve intraoperative and short-term postoperative outcomes compared to PPPD, especially DGE. However, these findings need to be further ascertained by well-designed randomized controlled trials.
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Pancreatectomy with major arterial resection after neoadjuvant chemoradiotherapy gemcitabine and S-1 and concurrent radiotherapy for locally advanced unresectable pancreatic cancer. Surgery 2015; 158:191-200. [PMID: 25900035 DOI: 10.1016/j.surg.2015.02.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/07/2015] [Accepted: 02/19/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreatic cancer (PC) with arterial invasion is currently a contraindication to resection and has a miserable prognosis. METHODS Seventeen patients with locally advanced PC involving the celiac axis and/or common hepatic artery (CHA) who received chemoradiotherapy (CRT) composed of gemcitabine, S-1, and external beam irradiation over the last 2 years were investigated. Thirteen patients underwent pancreatectomy with major arterial resection: 6 distal pancreatectomies with resection of the celiac axis, 4 total pancreatectomies with resection of both the celiac axis and the CHA, and 3 pancreatoduodenectomies with resection of the CHA. Preoperative arterial embolization and/or arterial reconstruction to prevent ischemic gastropathy and hepatopathy was performed in 7 of the 13 patients. RESULTS Distant metastases were found in 3 patients after CRT. One patient did not consent to operation after CRT. The morbidity rate of the 13 patients who underwent surgery was 62% (8/13), but no deaths occurred. Although there were no responders on CT, >90% of tumor cells were necrotic on histopathology in 5 of 13 tumors after CRT. Invasion of the celiac axis remained in 5 tumors, and extrapancreatic plexus invasion remained in 8 tumors, but an R0 resection was achieved in 12 of 13 tumors. Lymph node metastases were found in 3 of 13 cases. The overall 1-year survival rate from commencement of CRT and resection was 12 of 13 patients. CONCLUSION Neoadjuvant CRT containing gemcitabine and S-1 and subsequent pancreatectomy with major arterial resection for patients with locally advanced PC with arterial invasion were carried out safely with an acceptable R0 resection acceptable morbidity and mortality, and encouraging survival (12 of 13) at 1 year postoperatively.
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Zhou Y, Lin L, Wu L, Xu D, Li B. A case-matched comparison and meta-analysis comparing pylorus-resecting pancreaticoduodenectomy with pylorus-preserving pancreaticoduodenectomy for the incidence of postoperative delayed gastric emptying. HPB (Oxford) 2015; 17:337-43. [PMID: 25388024 PMCID: PMC4368398 DOI: 10.1111/hpb.12358] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 09/25/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study was conducted to compare the incidences of delayed gastric emptying (DGE) following pylorus-resecting pancreaticoduodenectomy (PrPD) and pylorus-preserving pancreaticoduodenectomy (PpPD), respectively. METHODS Data for 37 patients submitted to PrPD were compared with data for a matched number of patients submitted to PpPD during the same period. A meta-analysis of comparative studies of the two techniques was also carried out. The primary endpoint was the rate of DGE (grades A-C) defined according to the International Study Group of Pancreatic Surgery criteria. RESULTS In the case-matched comparison, both overall DGE (six PrPD patients and 17 PpPD patients; P = 0.006) and clinically relevant DGE (one PrPD and eight PpPD patients; P = 0.013) occurred significantly less often in the PrPD group than in the PpPD group. Based on eight non-randomized clinical trials and two randomized clinical trials involving 804 subjects, the meta-analysis further confirmed a significant reduction in DGE with pooled odds ratios of 0.33 [95% confidence interval (CI) 0.17-0.63; P < 0.001] and 0.13 (95% CI 0.05-0.40; P < 0.001) for overall DGE and clinically relevant DGE, respectively. Other complications and mortality were similar in both groups. CONCLUSIONS Pylorus-resecting pancreaticoduodenectomy is a safe procedure associated with less severe and less frequent postoperative DGE than PpPD.
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Affiliation(s)
- Yanming Zhou
- Department of Hepato-Biliary-Pancreato-Vascular Surgery, First Affiliated Hospital of Xiamen UniversityXiamen, China
| | - Liang Lin
- Department of Hepato-Biliary-Pancreato-Vascular Surgery, First Affiliated Hospital of Xiamen UniversityXiamen, China
| | - Lupeng Wu
- Department of Hepato-Biliary-Pancreato-Vascular Surgery, First Affiliated Hospital of Xiamen UniversityXiamen, China
| | - Donghui Xu
- Department of Hepato-Biliary-Pancreato-Vascular Surgery, First Affiliated Hospital of Xiamen UniversityXiamen, China
| | - Bin Li
- Department of Hepato-Biliary-Pancreato-Vascular Surgery, First Affiliated Hospital of Xiamen UniversityXiamen, China,Correspondence, Bin Li, Department of Hepato-Biliary-Pancreato-Vascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen 361003, China. Tel: + 86 592 213 9708. Fax: + 86 592 213 9908. E-mail:
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Pancreatic perfusion data and post-pancreaticoduodenectomy outcomes. J Surg Res 2014; 194:441-449. [PMID: 25541236 DOI: 10.1016/j.jss.2014.11.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/10/2014] [Accepted: 11/26/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Precise risk assessment for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) may be facilitated using imaging modalities. Computed tomography perfusion (CTP) of the pancreas may represent histologic findings. This study aimed to evaluate the utility of CTP data for the risk of POPF after PD, in relation to histologic findings. METHODS Twenty patients who underwent preoperative pancreatic CTP measurement using 320-detector row CT before PD were investigated. Clinicopathologic findings, including CTP data, were analyzed to assess the occurrence of POPF. In addition, the correlation between CTP data and histologic findings was evaluated. RESULTS POPF occurred in 11 cases (grade A, 6; grade B, 5; and grade C, 0). In CTP data, both high arterial flow (AF) and short mean transit time (MTT) were related to POPF occurrence (P = 0.001, P = 0.001). AF was negatively correlated with fibrosis in the pancreatic parenchyma (r = -0.680), whereas MTT was positively correlated with fibrosis (r = 0.725). AF >80 mL/min/100 mL and MTT <16 s showed high sensitivity, specificity, positive predictive value, and negative predictive value (80.0%, 100.0%, 100.0%, and 83.3%, respectively) for the occurrence of POPF. CONCLUSIONS CTP data for the pancreas were found to be correlated with the occurrence of POPF after PD. Alterations in the blood flow to the remnant pancreas may reflect histological changes, including fibrosis in the pancreatic stump, and influence the outcome after PD. CTP may thus facilitate objective and quantitative risk assessment of POPF after PD.
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Sato G, Ishizaki Y, Yoshimoto J, Sugo H, Imamura H, Kawasaki S. Factors influencing clinically significant delayed gastric emptying after subtotal stomach-preserving pancreatoduodenectomy. World J Surg 2014; 38:968-75. [PMID: 24136719 DOI: 10.1007/s00268-013-2288-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pylorus ring is resected and most of the stomach is preserved, has been performed recently in Japan. This study was undertaken to clarify the incidence of delayed gastric emptying (DGE) after SSPPD at a high-volume hospital and to determine the independent factors that influence the development of DGE after SSPPD. METHODS Between 2002 and 2011, 201 consecutive patients underwent standardized SSPPD. After SSPPD, DGE (defined according to the International Study Group of Pancreatic Surgery) was analyzed, and associated variables were assessed by univariate and multivariate analyses, retrospectively. RESULTS Clinically significant DGE (grades B and C) occurred in 35 (17 %) of the 201 patients; 26 patients had other accompanying abdominal complications (secondary DGE), and pancreatic leakage was the sole risk factor for DGE (odds ratio 6.63, 95 % CI 2.86-15.74; p < 0.001). Only nine (4 % of all patients) of the 35 patients with clinically significant DGE were classified as having DGE that had arisen without any obvious etiology (primary DGE). CONCLUSIONS DGE after SSPPD is strongly linked to the occurrence of other postoperative intra-abdominal complications such as pancreatic fistula. The incidence rate of primary DGE after SSPPD was 4 %. Although the ISGPS classification of DGE is clearly applicable, the grades do not explain why DGE occurs. Primary and secondary DGE should therefore be defined separately.
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Affiliation(s)
- Go Sato
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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The effect of pylorus removal on delayed gastric emptying after pancreaticoduodenectomy: a meta-analysis of 2,599 patients. PLoS One 2014; 9:e108380. [PMID: 25272034 PMCID: PMC4182728 DOI: 10.1371/journal.pone.0108380] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 08/19/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Delayed gastric emptying is a serious complication of pancreaticoduodenectomy. The effect of pylorus removal on delayed gastric emptying has not been well evaluated. STUDY DESIGN We searched five databases (PubMed, EMBASE and the Cochrane Central Register of Controlled Trials, Scopus and Web of Science) up to July 2014. The meta-regression analysis was performed to evaluate any factors accountable for the heterogeneity. Publication bias was assessed by Egger's test, and corrected by Duval's trim and fill method. Subgroup analyses were conducted for different surgical techniques of pyloric removal. Other intraoperative and postoperative parameters were compared between two groups. RESULTS We included 27 studies involving 2,599 patients, with a moderate-high heterogeneity for primary outcome (I(2) = 63%). Meta-regression analysis showed that four variables primarily contributed to the heterogeneity, namely nasogastric tube intubation time, solid food start time, preoperative diabetes percentage and the number of patients in pylorus-preserving group. After excluding four studies, the remaining twenty-three studies showed reduced heterogeneity (I(2) = 51%). Then we used Duval's trim and fill method to correct publication bias. The corrected MH odds ratio was 0.78 (95% CI: 0.52-1.17). A subgroup analysis showed that pylorus removal tends to reduce delayed gastric emptying incidence for subtotal stomach-preserving pancreaticoduodenectomy or pylorus-resecting pancreaticoduodenectomy, compared with pylorus-preserving group. However, standard Whipple procedure failed to show any significant reduction of DGE compared with pylorus-removal group. No significant differences were observed in terms of length of hospital stay, infection and pancreatic fistula; however, pylorus removal resulted in longer operation time, more blood loss and higher mortality. CONCLUSION The pylorus removal does not significantly reduce the overall incidence of delayed gastric emptying. Subtotal stomach-preserving pancreaticoduodenectomy or pylorus-resecting pancreaticoduodenectomy tends to reduce delayed gastric emptying incidence, but needs further validation.
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Hirata K, Nakata B, Amano R, Yamazoe S, Kimura K, Hirakawa K. Predictive factors for change of diabetes mellitus status after pancreatectomy in preoperative diabetic and nondiabetic patients. J Gastrointest Surg 2014; 18:1597-603. [PMID: 25002020 DOI: 10.1007/s11605-014-2521-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 03/31/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION This study aimed to determine risk factors for exacerbation of diabetes mellitus (DM) after pancreatectomy. METHODS Medical records of 167 patients with benign and malignant pancreaticobiliary diseases who underwent pancreaticoduodenectomy or distal pancreatectomy were retrospectively analyzed. DM was diagnosed by diabetic history or American Diabetes Association criteria. Worsened and improved DM after pancreatectomy was defined when treatment intensity or insulin/oral antidiabetic drug dosage increased or decreased, respectively, postoperatively. Long-standing DM was defined as a duration of >2 years. RESULTS In 76 preoperative diabetic patients, worsened and improved DM was observed postoperatively in 46 (60.5 %) and 9 (11.8 %) patients, respectively. In 91 preoperative nondiabetic patients, 22 (24.2 %) developed new-onset DM after pancreatectomy. Multivariate logistic analysis of the preoperative diabetic patients demonstrated long-standing DM and malignancy as independent predictors for postoperative worsened DM. No patients with long-standing DM or insulin treatment experienced improved DM after pancreatectomy. Multivariate logistic analysis of the preoperative nondiabetic patients showed body mass index of ≥25 and hard pancreatic texture as independent risk factors for new-onset postoperative DM. CONCLUSIONS These results may enable preoperative evaluation of risk factors for worsened or new-onset DM after pancreatectomy and may help plan intensive care for patients at a high risk of postoperative worsened DM.
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Affiliation(s)
- Keiichiro Hirata
- Department of Surgical Oncology, Graduate School of Medicine, Osaka City University, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
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Matsumoto I, Shinzeki M, Asari S, Goto T, Shirakawa S, Ajiki T, Fukumoto T, Suzuki Y, Ku Y. A prospective randomized comparison between pylorus- and subtotal stomach-preserving pancreatoduodenectomy on postoperative delayed gastric emptying occurrence and long-term nutritional status. J Surg Oncol 2014; 109:690-696. [DOI: 10.1002/jso.23566] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Ippei Matsumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery; Kobe University Graduate School of Medicine; Kobe Japan
| | - Makoto Shinzeki
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery; Kobe University Graduate School of Medicine; Kobe Japan
| | - Sadaki Asari
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery; Kobe University Graduate School of Medicine; Kobe Japan
| | - Tadahiro Goto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery; Kobe University Graduate School of Medicine; Kobe Japan
| | - Sachiyo Shirakawa
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery; Kobe University Graduate School of Medicine; Kobe Japan
| | - Tetsuo Ajiki
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery; Kobe University Graduate School of Medicine; Kobe Japan
| | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery; Kobe University Graduate School of Medicine; Kobe Japan
| | - Yasuyuki Suzuki
- Faculty of Medicine, Department of Gastroenterological Surgery; Kagawa University; Kagawa Japan
| | - Yonson Ku
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery; Kobe University Graduate School of Medicine; Kobe Japan
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Cao SS, Lin QY, He MX, Zhang GQ. Effect of antecolic versus retrocolic reconstruction for gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A meta-analysis. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Shuang-Shuang Cao
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Qi-Yuan Lin
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Man-Xi He
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Guang-Quan Zhang
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
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Cordesmeyer S, Lodde S, Zeden K, Kabar I, Hoffmann MW. Prevention of delayed gastric emptying after pylorus-preserving pancreatoduodenectomy with antecolic reconstruction, a long jejunal loop, and a jejuno-jejunostomy. J Gastrointest Surg 2014; 18:662-73. [PMID: 24553874 DOI: 10.1007/s11605-013-2446-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 12/18/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the major complications following pylorus-preserving pancreatoduodenectomy (PPPD). It leads to significant patient distress and prolonged hospitalization and therefore increased treatment costs. DGE etiology remains unclear but seems to be multifactorial. In order to decrease DGE rates, reconstruction methods have been modified. The presented retrospective study was to evaluate outcomes of different surgical techniques at our institution with special emphasis on retrocolic and antecolic reconstruction types. MATERIAL AND METHODS One hundred thirteen consecutive patients underwent PPPD between September 2004 and December 2011 for periampullary and bile duct lesions of the pancreatic head and the papilla of Vater. These patients were reviewed for DGE occurrence and other factors. Four different types of reconstruction were applied: the classic retrocolic reconstruction using a short jejunal loop (short loop, n = 40) and three types of reconstructions using a long loop: one with a long loop and retrocolic duodenojejunostomy (n = 22), another with a long loop and an additional latero-lateral enterostomy (Braun's anastomosis, n = 23), and finally, an antecolic group with Braun's anastomosis (n = 28). Patients were reviewed for DGE incidence and severity following the International Study Group of Pancreatic Surgery definition of DGE. RESULTS The highest DGE occurrence was noted in the retrocolic group using a short jejunal loop (15 of 32 patients, 46.9%), whereas the reconstruction types using long loops showed a notable decrease: DGE occurred in 4 of 16 patients (25%) in the retrocolic group, in 6 of 21 patients (28.6%) in the retrocolic group with an additional latero-lateral enterostomy (Braun's anastomosis), and finally, only 1 of 22 patients (4.5%, p = 0.009) in the antecolic group with Braun's anastomosis presenting with DGE, grade A. However, neither hospitalization time nor days in the intensive care unit were significantly different. There was no difference in DGE rates between the retrocolic long-loop groups with and without Braun's anastomosis. CONCLUSION The results of this retrospective study suggest that the antecolic route with a long jejunal loop and Braun's anastomosis minimizes DGE rates.
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Affiliation(s)
- S Cordesmeyer
- Department of General and Visceral Surgery, Raphaelsklinik, Loerstraße 23, 48143, Münster, Germany,
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Riediger H, Schulz A, Adam U, Krüger CM. Intraoperative Schnellschnittuntersuchungen parapylorischer Lymphknoten bei der pyloruserhaltenden Pankreaskopfresektion: Gibt es eine klinische Relevanz? VISZERALMEDIZIN 2014; 30:61-4. [PMID: 26286487 PMCID: PMC4513812 DOI: 10.1159/000358773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hintergrund Die pyloruserhaltende Pankreaskopfresektion (PPPD) ist als onkologisches Standardverfahren etabliert. Lokal fortgeschrittene Tumoren können eine erweiterte Resektion erforderlich machen. Ebenso soll früheren Arbeiten zufolge bei Tumornachweis in den parapylorischen Lymphknoten (PLK) eine distale Magenresektion im Sinne einer klassischen Whipple-Operation indiziert sein. Entsprechend diesen Empfehlungen haben wir intraoperative Schnellschnittuntersuchungen der PLK in unseren Routineablauf integriert. Im Rahmen dieser Studie haben wir die klinische Relevanz dieses Vorgehens hinterfragt. Methoden Bei 105 onkologischen Patienten im Zeitraum von 2006-2012 bestand die Indikation zur PPPD. In allen Fällen erfolgte eine intraoperative Schnellschnittuntersuchung der PLK. Die Patienten wurden bezüglich Primärtumor, Anzahl der untersuchten Lymphknoten (LK) (gesamt und parapylorisch) sowie Auswirkungen auf das operative Konzept untersucht. Es handelt sich um eine retrospektive Studie, die auf prospektiv erhobenen Daten unserer Pankreasdatenbank basiert. Ergebnisse Die Primärtumoren waren 72 Pankreaskopfkarzinome und 33 extrapankreatische Karzinome (Gallengangskarzinom, Ampullenkarzinom, Duodenalkarzinom). 73 Patienten waren nodalpositiv. Insgesamt wurden 2391 LK untersucht, von denen 325 parapylorisch lokalisiert waren. Die intraoperative Schnellschnittuntersuchung erbrachte lediglich bei 4 Patienten mit Pankreaskopfkarzinom jeweils einen positiven PLK; daraufhin erfolgte eine distale Magenresektion. In keinem der distalen Magenresektate waren Tumorresiduen nachweisbar. Lokale chirurgisch-technische Probleme im Sinne von Durchblutungsstörungen des Magens ergaben sich durch die regionale Lymphadenektomie nicht. PLK waren nur beim Pankreaskarzinom positiv. In der Subgruppe der nodalpositiven Patienten mit Pankreaskopfkarzinom hatten 8% der Patienten einen positiven PLK. Schlussfolgerung Die regionale parapylorische Lymphadenektomie ist beim Pankreaskarzinom in einigen (5%) Fällen onkologisch sinnvoll. Der Nutzen einer intraoperativen Schnellschnittuntersuchung mit nachfolgender Konsequenz für eine etwaige distale Magenresektion ist anhand unserer Daten nicht belegbar.
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Affiliation(s)
- Hartwig Riediger
- Klinik für Chirurgie - Viszeral- und Gefäßchirurgie, Vivantes-Humboldt-Klinikum, Berlin, Deutschland
| | - Antje Schulz
- Klinik für Chirurgie - Viszeral- und Gefäßchirurgie, Vivantes-Humboldt-Klinikum, Berlin, Deutschland
| | - Ulrich Adam
- Klinik für Chirurgie - Viszeral- und Gefäßchirurgie, Vivantes-Humboldt-Klinikum, Berlin, Deutschland
| | - Colin M Krüger
- Klinik für Chirurgie - Viszeral- und Gefäßchirurgie, Vivantes-Humboldt-Klinikum, Berlin, Deutschland
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Wang L, Su AP, Zhang Y, Yang M, Yue PJ, Tian BL. Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy. J Surg Res 2014; 189:41-7. [PMID: 24679695 DOI: 10.1016/j.jss.2014.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/12/2013] [Accepted: 01/16/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma. MATERIALS AND METHODS All 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up). RESULTS Patients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced. CONCLUSIONS In patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.
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Affiliation(s)
- Li Wang
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - An ping Su
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yi Zhang
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Min Yang
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Peng ju Yue
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo le Tian
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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