The inclusion of an omental flap in pancreatoduodenectomy

Wrapping pancreaticojejunostomy using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a propensity score matching analysis

BACKGROUND AND OBJECTIVE

It is controversial whether wrapping around the pancreaticojejunostomy (PJ) could reduce the rate of postoperative pancreatic fistula (POPF), especially in laparoscopic pancreaticoduodenectomy (LPD). This study aims to summarize our single-center initial experience in wrapping around PJ using the ligamentum teres hepatis (LTH) and demonstrate the feasibility and safety of this method.

METHODS

Patients who underwent LPD applying the procedure of wrapping around the PJ were identified. The cohort was compared to the cohort with standard non-wrapping PJ. A 1:1 propensity score matching (PSM) was performed to compare the early postoperative outcomes of the two cohorts. Risk factors for POPF were determined by using univariate and multivariate logistic regression analysis.

RESULTS

Overall, 143 patients were analyzed (LPD without wrapping (n = 91) and LPD with wrapping (n = 52)). After 1:1 PSM, 48 patients in each cohort were selected for further analysis. Bile leakage, DGE, intra-abdominal infection, postoperative hospital stays, harvested lymph nodes, and R0 resection were comparable between the two cohorts. However, the wrapping cohort was associated with significantly less POPF B (1 vs 18, P = 0.003), POPF C (0 vs 8, P = 0.043), and Clavien-Dindo classification level III-V (5 vs 26, P = 0.010). No patients died due to the clinically relevant POPF in the two cohorts. No patients who underwent the LTH wrapping procedure developed complications directly related to the wrapping procedure. After PSM, whether wrapping was an independent risk factor for POPF (OR = 0.202; 95%CI:0.080-0.513; P = 0.001).

CONCLUSIONS

Wrapping the LTH around the PJ technique for LPD was safe, efficient, and reproducible with favorable perioperative outcomes in selected patients. However, further validations using high-quality RCTs are still required to confirm the findings of this study.

Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula

BACKGROUND

Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula.

METHODS

A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon.

RESULTS

Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula.

CONCLUSION

A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.

A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy

BACKGROUND

The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD.

METHODS

Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals.

RESULTS

Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620).

DISCUSSION

Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.

Different types of pancreatico-enteric anastomosis

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

Wrapping in pancreatic surgery: a systematic review

BACKGROUND

Wrapping in pancreatic surgery involves the use of the omentum or falciform ligament (FL) to wrap the local retroperitoneal vessels, the pancreatojejunal anastomosis or the pancreatic section of distal pancreatectomy. However, there is no clear evidence that wrapping in fact provides benefits. We have performed a systematic review of the literature about this topic.

METHODS

We conducted a literature search in the PubMed/MEDLINE database (1966-2012) for any language using various combinations of the following terms: wrapping, omental, omentum, pancreas, pancreatoduodenectomy and falciform ligament.

RESULTS

We selected 12 articles. Among five series that included a control group, only one obtained a statistically significant reduction in pancreatic fistula (PF) in the wrapping group and other series showed a lower percentage of post-operative haemorrhage in the wrapping group. In the seven series without control groups, a slight decrease in the rate of post-operative bleeding and PF was observed.

CONCLUSIONS

On the basis of the literature available at present, we cannot recommend the use of wrapping with omentum and/or FL in pancreatic surgery. Prospective randomized studies applying a systematic wrapping technique are needed in order to establish whether its use should be generalized.

Omental flap for hepatic artery coverage during liver transplantation

In 1994, a technique of omental flap interposition to cover the celiac and mesenteric vessels after pancreaticoduodenectomy was described. It aimed to isolate the pancreatic anastomosis from the vessels dissected during pancreaticoduodenectomy. In liver transplantation (LT), the omental flap was initially used to reduce the risk of hepatic artery (HA) kinking. Currently, we use this technique to cover the dissected HA, reducing the consequences of postoperative biliary fistula (BF), particularly the risk of postoperative complications (thrombosis/bleeding). We describe this technique adding a simple modification consisting of covering the HA with an omental flap after completion of the biliary anastomosis. We performed LT with an omental flap to cover the HA vessels in 62 (55 %) of the 112 consecutive patients who underwent LT between January 2012 and July 2013. No postoperative deaths occurred. The rate of BF was 9.7 % (six cases). In the omental flap series, no postoperative thrombosis, HA pseudoaneurysm, or complications occurred. In the six cases of BF, the dissected HAs were completely isolated from the biloma. This simple technique has no specific morbidity; it isolates the HA from the biliary anastomosis and therefore may reduce the risk of severe postoperative HA complications after LT.

Pancreaticodigestive anastomosis and the postoperative management strategies to prevent postoperative pancreatic fistula formation after pancreaticoduodenectomy

Over the past 100 years, advances in surgical techniques and perioperative management have reduced the morbidity and mortality after pancreaticoduodenectomy (PD). Many techniques have been proposed for the reconstruction of the pancreaticodigestive anastomosis to prevent the development of a postoperative pancreatic fistula (POPF), but which is the best approach is still highly debated. We carried out a systematic review to determine and compare the effectiveness of various methods of anastomosis after PD. A meta-analysis and most randomized controlled trials (RCTs) showed that the mortality, POPF rate and incidence of other postoperative complications were not statistically different between the pancreaticogastrostomy and pancreaticojejunostomy (PJ) groups. One RCT showed that a binding PJ significantly decreased the risk of POPF and other postoperative complications compared with conventional PJ. External duct stenting reduced the risk of clinically relevant POPF in a meta-analysis and RCTs. The prophylactic use of octreotide after PD does not result in a reduced incidence of POPF. In conclusion, our findings suggest that the successful management of pancreatic anastomoses may depend more on the meticulous surgical technique, surgical volume, and other management parameters than on the type of technique used. However, some new approaches, such as binding PJ, and the use of external stents should be considered in further RCTs.

Use of omentum or falciform ligament does not decrease complications after pancreaticoduodenectomy: nationwide survey of the Japanese Society of Pancreatic Surgery

BACKGROUND

Wrapping is thought to prevent pancreatic fistula and postoperative hemorrhage for pancreaticoduodenectomy (PD), and we analyzed whether omentum/falciform ligament wrapping decreases postoperative complications after PD.

METHODS

This is a retrospective study of wrapping using the omentum/falciform ligament in patients that underwent PD between January 2006 and June 2008 in 139 institutions that were members of the Japanese Society of Pancreatic Surgery.

RESULTS

Ninety-one institutions responded to the questionnaires, and data were accumulated from 3,288 patients. The data from 2,597 patients were acceptable for analysis; 918 (35.3%) patients underwent wrapping and 1,679 patients did not. A pancreatic fistula occurred in 623 patients (37.3%) in the nonwrapping group, in comparison to 393 patients (42.8%) in the wrapping group (P = .006). The incidence of a grade B/C pancreatic fistula was lower in the nonwrapping group than the wrapping group (16.7% vs. 21.5%; P = .002). An intra-abdominal hemorrhage occurred in 54 patients (3.2%) in the nonwrapping group, which was similar to the incidence in the wrapping group (32 patients; 3.5%). The mortality was 1.3% and 1.0% in nonwrapping and wrapping groups, respectively. A multivariate analysis revealed 7 independent risk factors for pancreatic fistula; male, hypoalbuminemia, soft pancreas, long operation time, extended resection, pylorus preservation, and omentum wrapping. There were 4 independent risk factors for early intra-abdominal hemorrhage and 2 independent risk factors for late intra-abdominal hemorrhage.

CONCLUSION

This retrospective study revealed that omentum wrapping did not decrease the incidence of pancreatic fistula. An additional validation study is necessary to evaluate the efficacy of wrapping for PD.

Using the greater omental flap to cover the cut surface of the liver for prevention of delayed gastric emptying after left-sided hepatobiliary resection: a prospective randomized controlled trial

OBJECTIVE

The aim of this randomized controlled trial is to evaluate the effect on delayed gastric emptying (DGE) of using the greater omental flap to cover the cut surface of the liver after left-sided hepatobiliary resection.

METHODS

From June 2007 to December 2008, all eligible patients were randomly assigned to either the greater omental flap group (OF group) or the control group (non-OF group).

RESULTS

A total of 40 patients remained for final analysis. The incidence of DGE after left-sided hepatobiliary resection was 25%. The incidence of DGE showed no statistically significant differences between the OF group (10%) and the non-OF group (40%) (p = 0.065). The assessment of DGE using radiopaque rings revealed that changes over time in the gastric emptying ratio (GER, percentage of rings excreted from stomach) did not differ in a significant manner between the two groups. There were significant differences in changes over time in GER (p = 0.044) between the patients with and without DGE. The patients with DGE also showed higher GER at 5 h (p = 0.042) and at 6 h (p = 0.034) than those without DGE.

CONCLUSIONS

Using the greater omental flap to cover the cut surface of the liver may reduce the incidence of DGE after left-sided hepatobiliary resection. Assessment using radiopaque markers may be useful to evaluate DGE.

Wrapping of skeletonized and divided vessels using the falciform ligament in distal pancreatectomy

BACKGROUND

A pancreatic fistula is a major cause of morbidity in patients undergoing distal pancreatectomy (DP). A pancreatic fistula may expose skeletonized or divided vessels directly to pancreatic juice, creating a setting for vessel erosion and delayed intra-abdominal hemorrhage (DIH). With the aim of protecting vessels near the pancreatic stump from potential pancreatic fistulas, we have adopted a surgical option by which these vessels are wrapped using a pedicled falciform ligament.

METHODS

After completing DP, the pedicled falciform ligament is spread out widely on major vessels exposed during resection near the pancreatic stump, and fixed to the surrounding retroperitoneal connective tissue. These procedures allow the complete separation of these vessels from the pancreatic stump. We reviewed the cases of 8 patients who underwent DP including these procedures.

RESULTS

The mobilization of the falciform ligament and the wrapping of the vessels were successfully performed without any complications. Although 2 patients (14.5%) developed pancreatic fistulas, DIH did not occur in any of the patients.

CONCLUSIONS

The wrapping of the skeletonized and divided vessels using a pedicled falciform ligament is simple and easy, and may be an effective prophylactic measure against DIH following DP.

Omental flap in pancreaticoduodenectomy for protection of splanchnic vessels

Intraabdominal bleeding, the most life-threatening complication following pancreaticoduodenectomy (PD), most often is associated with failure of a pancreaticojejunostomy anastomosis or with intraabdominal infection. We investigated whether placement of an omental flap around the splanchnic vessels in PD could reduce the occurrence of intraabdominal bleeding and other postoperative complications. One hundred consecutive patients who underwent PD at the authors' institution between January 2000 and October 2004 were enrolled in this prospective study. After dissection of the hepatoduodenal ligament, the major splanchnic arteries and the portal vein were covered by the omental flap. Preoperative condition, incidence of pancreatic fistula, intra-abdominal bleeding, other complications, treatment mortality, and hospital stay were analyzed for interrelationships. The frequency of pancreatic fistula (20%) differed little from those in previous reports. However, intraabdominal bleeding was observed in only 1 (1.0%) patient, who was considered to have too thin a flap. No intraabdominal abscess was encountered. No mortality or complications occurred in relation to the omental flap. Thus, wrapping an omental flap around dissected splanchnic vessels in PD reduced postoperative intraabdominal bleeding and infection, but failed to prevent pancreatic fistulas.

Renal cell carcinoma with solitary synchronous pancreaticoduodenal and metachronous periprostatic metastases: report of a case

We report herein the case of a patient who underwent successful resection of a solitary metachronous periprostatic metastasis 12 months after undergoing a right radical nephrectomy with pylorus-preserving pancreaticoduodenectomy for renal cell carcinoma (RCC) with a synchronous pancreaticoduodenal metastasis. At present the patient is free of any signs of recurrence 12 months after removal of the metachronous mass in the periprostate. This case report supports the opinion that an aggressive surgical approach is appropriate for RCC metastasis.