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Tempero MA, Arnoletti JP, Behrman S, Ben-Josef E, Benson AB, Berlin JD, Cameron JL, Casper ES, Cohen SJ, Duff M, Ellenhorn JDI, Hawkins WG, Hoffman JP, Kuvshinoff BW, Malafa MP, Muscarella P, Nakakura EK, Sasson AR, Thayer SP, Tyler DS, Warren RS, Whiting S, Willett C, Wolff RA. Pancreatic adenocarcinoma. J Natl Compr Canc Netw 2010; 8:972-1017. [PMID: 20876541 DOI: 10.6004/jnccn.2010.0073] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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[Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation. A systematic review with meta-analysis]. Chirurg 2010; 81:454-71. [PMID: 20020091 DOI: 10.1007/s00104-009-1829-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Two surgical procedures are mainly performed for the treatment of pancreatic head cancer and periampullary carcinoma: the classical Whipple operation and the pylorus-preserving Whipple operation. METHODS This manuscript represents an extension of a systematic review and meta-analysis previously published in the Annals of Surgery. A systematic literature search was performed in MEDLINE, EMBASE and the Cochrane Library (central) to identify randomized controlled trials (RCTs) and observational studies. A meta-analysis based on a random-effects model was performed for the hazard ratios (HR) of survival and the odds ratios (OR) of postoperative mortality. The results of the different studies on quality of life (QoL) could not be summarized quantitatively in a meta-analysis and were therefore summarized qualitatively. Subgroup analyses were performed by study type, RCTs, prospective cohort studies (PSs), retrospective cohort studies (RSs), study quality and tumor localization (pancreatic head cancer versus periampullary carcinoma). RESULTS The systematic literature search retrieved 4,503 studies of which 4,460 did not fulfill the inclusion criteria. The remaining 43 studies (6 RCTs, 12 PSs and 25 RSs) representing 3,893 patients were finally included in the review. There was neither a significant survival difference for patients with pancreatic head cancer in the pooled estimate of the RCTs (HR 0.80; 95% CI 0.53-1.22; p=0.16) nor in the pooled estimate of the PSs (HR 0.84; 95% CI 0.7-1.0; p=0.95) or the RSs (HR 0.84; 95% CI 0.7-1.01; p=0.21). Survival of patients with periampullary carcinoma was not significantly different in the RCTs (HR 1.02; 95% CI 0.49-2.13; p=0.3), the PSs (HR 1.26; 95% CI 0.46-3.42; p=0.65) or the RSs (HR 0.86; 95% CI 0.6-1.24; p=0.33). Postoperative mortality was not significantly different after both types of operations (RCTs: HR 0.49; 95% CI 0.17-1.4; p=0.18; PSs: HR 0.63; 95% CI 0.34-1.18; p=0.15; RSs: HR 0.7; 95% CI 0.37-1.31; p=0.27). QoL was reported as either the same in both groups or in favor of the pylorus-preserving Whipple operation. CONCLUSIONS Mortality, survival and QoL were not significantly different between the classical Whipple and the pylorus-preserving Whipple operations. Given the poor quality of the underlying trials a pragmatic RCT is recommended to prove the findings of this systematic review.
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Iqbal N, Lovegrove R, Tilney H, Abraham A, Bhattacharya S, Tekkis P, Kocher H. A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: A meta-analysis of 2822 patients. Eur J Surg Oncol 2008; 34:1237-45. [DOI: 10.1016/j.ejso.2007.12.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 12/17/2007] [Indexed: 02/06/2023] Open
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Kawamoto M, Konomi H, Kobayashi K, Shimizu S, Yamaguchi K, Tanaka M. Type of gastrointestinal reconstruction affects postoperative recovery after pancreatic head resection. ACTA ACUST UNITED AC 2007; 13:336-43. [PMID: 16858546 DOI: 10.1007/s00534-005-1085-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2005] [Accepted: 11/10/2005] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE The postoperative recovery of gastric motility with various reconstructions after pancreatic head resection has been reported. However, little is known about this recovery after pancreatic head resection with segmental duodenectomy (PHRSD). Some have attributed gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD) to tube gastrostomy, but its effect on gastric motility has not been investigated. In this study, the postoperative recovery after PHRSD and PPPD, and gastric motility with and without gastrostomy after PPPD were investigated. METHODS We analyzed the first appearance of gastric phase III motility, postoperative systemic status, and body weight (BW; n = 32). The Imanaga PPPD and PHRSD were compared because the procedures differ only in the length of the remaining duodenum. Traverso and Roux-en-Y PPPDs were compared because the two procedures are similar except for the creation of gastrostomy. RESULTS (1) Times to first appearance of gastric phase III motility and BW recovery were significantly better after PHRSD than after the Imanaga PPPD (P < 0.05). (2) Times to first gastric phase III motility and resumption of a regular diet as well as periods of gastric sump tube use and postoperative hospital stay were significantly shorter after the Roux-en-Y than after the Traverso PPPD (P < 0.05). CONCLUSIONS Preservation of as long a portion of the duodenum as possible, the choice of a Roux-en-Y duodenojejunostomy, and the avoidance of peritoneal fixation of the gastric wall may be factors that improve the recovery of gastric motility and BW after pancreatic head resection.
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Affiliation(s)
- Masahiko Kawamoto
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka 812-8582, Japan
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Hayashibe A, Kameyama M, Shinbo M, Makimoto S. The surgical procedure and clinical results of subtotal stomach preserving pancreaticoduodenectomy (SSPPD) in comparison with pylorus preserving pancreaticoduodenectomy (PPPD). J Surg Oncol 2007; 95:106-9. [PMID: 17262740 DOI: 10.1002/jso.20608] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Subtotal stomach preserving pancreaticoduodenectomy (SSPPD) is compared retrospectively with pylorus preserving pancreaticoduodenectomy (PPPD). METHODS During 2002-2005, 21 patients (13 female, 8 male) underwent SSPPD. The mean age was 64.3 (range 33-80). PPPD was performed for 12 patients after 1999. Days of hospital stay, operation time, operative blood loss, postoperative morbidity and mortality, days of nasogastric intubation, days until liquid diet, delayed gastric emptying, postoperative change of serum Albumin value, were compared between SSPPD and PPPD. Clinical characteristics (age, gender, benign, or malignant condition, presence of preoperative jaundice, preoperative value of serum Albumin) were analyzed in both procedures. RESULTS In comparison of clinical characteristics, all factors were similar between PPPD and SSPPD. There were also quite similar results in days of hospital stay, operation time, operative blood loss, postoperative morbidity and mortality. Days of nasogastric intubation, days until liquid diet in PPPD were significantly longer than those in SSPPD and the incidence of delayed gastric emptying in PPPD was significantly higher than that in SSPPD. Finally, PPPD and SSPPD postoperative change of serum Albumin value were statistically similar. CONCLUSIONS We consider SSPPD as one of the most favorable procedures in patients who undergo pancreaticoduodenectomy.
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Affiliation(s)
- Akira Hayashibe
- Department of Surgery, Bell Land General Hospital, 500-8 Higashiyama, Sakai-city, Osaka 599-8247, Japan.
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Stefanović D, Knezević S, Djordjević Z, Kerkez M, Bulajić P, Marković L. [Surgical treatment of pain in chronic pancreatitis]. SRP ARK CELOK LEK 2006; 134:129-32. [PMID: 16915753 DOI: 10.2298/sarh0604129s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The principal indication for surgical intervention in chronic pancreatitis is intractable pain. Depending upon the presence of dilated pancreatic ductal system, pancreatic duct drainage procedures and different kinds of pancreatic resections are applied. OBJECTIVE The objective of the study was to show the most appropriate procedure to gain the most possible benefits in dependence of type of pathohistological process in chronic pancreatitis. METHOD Our study included 58 patients with intractable pain caused by chronic pancreatitis of alcoholic genesis. The first group consisted of 30 patients with dilated pancreatic ductal system more than 10 mm. The second group involved 28 patients without dilated pancreatic ductal system. Pain relief, weight gain and glucose tolerance were monitored. RESULTS All patients of Group I (30) underwent latero-lateral pancreaticojejunal--Puestow operation. 80% of patients had no pain after 6 month, 13.6% had rare pain and 2 patients, i.e. 6.4%, who continued to consume alcohol, had strong pain. Group II consisting of 28 patients was without dilated pancreatic ductal system. This group was subjected to various types of pancreatic resections. Whipple procedure (W) was done in 6 patients, pylorus preserving Whipple (PPW) in 7 cases, and duodenum preserving cephalic pancreatectomy (DPCP) was performed in 15 patients. Generally, 89.2% of patients had no pain 6 month after the operation. An average weight gain was 1.9 kg in W group, 2.8 kg in PPW group and 4.1 kg in DPCP group. Insulin-dependent diabetes was recorded in 66.6% in W group, 57.1% in PPW group and 0% in DPCP group. CONCLUSION According to our opinion, DPCP may be considered the procedure of choice for surgical treatment of pain in chronic pancreatitis in patients without dilatation of pancreas ductal system because of no serious postoperative metabolic consequences.
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Evans JD, Wilson PG, Carver C, Bramhall SR, Buckels JAC, Mayer AD, McMaster P, Neoptolemos JP. Outcome of surgery for chronic pancreatitis. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02662.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Gerdes B, Ramaswamy A, Bartsch DK, Rothmund M. Peripyloric lymph node metastasis is a rare condition in carcinoma of the pancreatic head. Pancreas 2005; 31:88-92. [PMID: 15968254 DOI: 10.1097/01.mpa.0000168221.97967.98] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Pylorus preserving pancreatoduodenectomy (PPPD) was introduced to achieve a better functional result compared with the conventional Kausch-Whipple procedure (PD). In PPPD, peripyloric and perigastric lymphatic tissue is not removed compared with PD. The aim of this prospective study was to identify the frequency of peripyloric and perigastric lymph node metastases in ductal adenocarcinoma of the pancreatic head (PC). METHODS Fifty specimens following Kausch-Whipple procedure including partial gastric resection for PC were analyzed for peripyloric and perigastric lymph node metastases by a standardized clearing technique. All lymph nodes of the specimens were counted, discriminating between those not removed ("group A") and those removed ("group B") in pylorus preserving resection of the pancreatic head. Additionally, the duodenal wall and paraduodenal tissue at a potential duodenal resection margin 2 cm distal of the pylorus were investigated histologically. RESULTS Three of the 50 specimens (6%) carried peripyloric lymph node metastases, whereas 32 of the 50 specimens (64%) contained lymph node metastases in total. Four of 362 group A and 90 of 748 group B lymph nodes showed metastatic spread of the carcinoma. The 4 lymph node metastases in group A could be identified exclusively in 88 peripyloric lymph nodes but in none of the 274 perigastric lymph nodes at the lesser or greater curvature. In 2 of the 3 patients with peripyloric lymph node metastases, these lymph nodes were the only lymph nodes with metastatic involvement in the entire specimen. In 1 specimen, a small tumor nest of less than 2 mm in diameter was detected at a distance of less than 1 mm to the pylorus, although pyloric involvement was not suspected intraoperatively. The potential PPPD resection margin of the duodenal wall was not infiltrated by intramural tumor spread in any specimen. CONCLUSION In a minority of 6%, PC metastasizes in peripyloric lymph nodes. Lymph nodes of the lesser and greater curvature of the stomach are not involved in patients with PC. Thus, we conclude by the data of this prospective study that the limited benefits of the extended lymph node dissection in a conventional Kausch-Whipple resection are far outweighed by the disadvantages construed by this procedure.
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Affiliation(s)
- Berthold Gerdes
- Department of Surgery, Philipps-University of Marburg, Marburg, Germany.
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Johnson CD, Howse F, Fitzsimmons D, Harris S, Pickering R, George SL. Quality of life and functional long-term outcome after partial pancreatoduodenectomy: pancreatogastrostomy versus pancreatojejunostomy. Ann Surg Oncol 2005; 14:750-1. [PMID: 17151790 DOI: 10.1245/s10434-006-9173-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Accepted: 04/18/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND To determine the effects of pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) as types of reconstruction after partial pancreatoduodenectomy on postoperative quality of life and long-term gastrointestinal morbidity, the outcomes of 104 patients (PG, n = 63; PJ, n = 41) were evaluated. METHODS To compare the two groups, the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire (QLQ-PAN 26) standard and an additional self-developed questionnaire were used. The mean time after surgery was 6.4 +/- 3.4 years. RESULTS In the PG group, there was a significant reduction of gastric acid reflux, gastroduodenal ulcers, and pain compared with before surgery. However, a significant increase in steatorrhea, intolerance toward larger meals, and aversion against certain foods were observed. In the PJ group, no significant change of preoperative symptoms was present except for jaundice. The incidence of diabetes mellitus and the need for pancreatic enzyme substitution had increased significantly but similarly in both groups. The global quality of life was identical in both groups of patients. CONCLUSIONS This analysis demonstrates that the global quality of life was not affected by the type of reconstruction after partial pancreatoduodenectomy. Patients who underwent PG had a significant reduction of gastric reflux, pain, and abdominal discomfort compared with before surgery. Patients in both groups showed an impaired exocrine and endocrine pancreatic function of a similar extent.
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Jimenez RE, Fernandez-Del Castillo C, Rattner DW, Warshaw AL. Pylorus-preserving pancreaticoduodenectomy in the treatment of chronic pancreatitis. World J Surg 2003; 27:1211-6. [PMID: 14508610 DOI: 10.1007/s00268-003-7240-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The pylorus-preserving pancreaticoduodenectomy (PPPD) is an alternative to the standard Whipple resection in the treatment of chronic pancreatitis. The operation is safe and can be performed with a low mortality rate. The most common early complication is delayed gastric emptying, which occurs in 25% to 30% of patients, and generally results in longer hospital stays than the standard Whipple procedure. Follow-up studies show that both operations are equally effective in relieving pain in approximately 75% of selected patients. In the long term, the PPPD successfully preserves physiologic gastric emptying, but at the cost of a higher marginal ulceration rate. The purported nutritional advantages of the PPPD over the classic Whipple resection have not been clearly established. At present, the PPPD is the procedure of choice for patients with chronic pancreatitis requiring panceraticoduodenectomy. Based on available information, this recommendation appears to arise form the fact that the PPPD is less radical than the regular Whipple procedure, and some surgeons find it technically easier. Our experience fails to show a distinct superiority of the PPPD over the Whipple operation.
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Affiliation(s)
- Ramon E Jimenez
- Department of Surgery, Hartford Hospital, University of Connecticut School of Medicine, 80 Seymour Street, P. O. Box 5037, Hartford, Connecticut 06102, USA
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Affiliation(s)
- Ake Andrén-Sandberg
- Queen Silvia's Hospital for Children, Sahlgrenska University Hospital, SE-416 85 Gothenburg, Sweden.
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Ohtsuka T, Yamaguchi K, Chijiiwa K, Tanaka M. Postoperative pancreatic exocrine function influences body weight maintenance after pylorus-preserving pancreatoduodenectomy. Am J Surg 2001; 182:524-9. [PMID: 11754863 DOI: 10.1016/s0002-9610(01)00745-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Most patients who undergo pylorus-preserving pancreatoduodenectomy (PPPD) are able to gain their weight postoperatively. However, sometimes patients experience a lack of weight gain even at long term after PPPD. The aim of this study was to examine factors influencing a body weight change after PPPD. METHODS In 34 Japanese patients with PPPD, 28 clinical parameters were assessed as possible factors affecting body weight maintenance at long term (1 year) after the operation by univariate and multivariate analyses. RESULTS Univariate analysis showed that long operation time (P = 0.02), extended retroperitoneal lymph node dissection (P = 0.0005), intraoperative radiotherapy (P = 0.02), adjuvant postoperative chemotherapy (P = 0.02), histopathological diagnosis of pancreatic cancer (P = 0.02), postoperative ulceration (P = 0.007), and insufficient postoperative pancreatic exocrine function (P = 0.002) were significantly related with the lack of weight gain at long term after PPPD. Multivariate analysis regarding the seven profound factors revealed that the insufficient postoperative pancreatic exocrine function significantly affected the lack of weight gain after PPPD. The use of ordinary amount of pancreatic exocrine enzymes did not influence the weight gain after PPPD (P = 0.23). CONCLUSIONS In patients refractory to an ordinary amount of medicine, a large dosage of enzymes may be necessary to gain weight after PPPD.
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Affiliation(s)
- T Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 812-8582, Fukuoka, Japan
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Jimenez RE, Fernandez-del Castillo C, Rattner DW, Chang Y, Warshaw AL. Outcome of pancreaticoduodenectomy with pylorus preservation or with antrectomy in the treatment of chronic pancreatitis. Ann Surg 2000; 231:293-300. [PMID: 10714621 PMCID: PMC1420999 DOI: 10.1097/00000658-200003000-00001] [Citation(s) in RCA: 156] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare the short- and long-term results of pancreaticoduodenectomy with pylorus preservation (PPPD) or with antrectomy (Whipple procedure) in the treatment of selected patients with chronic pancreatitis. BACKGROUND PPPD may be preferred over Whipple because of its purported nutritional advantages and the reduced likelihood of postgastrectomy syndromes. METHODS A retrospective review was performed of 72 consecutive patients undergoing pancreaticoduodenectomy for chronic pancreatitis between 1991 and 1997. RESULTS PPPD was performed in 39 patients and Whipple in 33. The two patient populations had similar characteristics. Short-term complications included (PPPD vs. Whipple): pancreatic or biliary fistulas (5.1% vs. 15%), delayed gastric emptying (33% vs. 12%), cholangitis (2.6% vs. 6.1%), and death (0 vs. 3%). Delayed gastric emptying was not associated with other complications and resulted in longer hospital stays for PPPD than for Whipple patients (15 vs. 12 days). The duration of follow-up averaged 41 +/- 24 months. Long-term weight status was similar, with body-mass indices of 22.1 and 22.9 after PPPD and Whipple, respectively. Postoperative enzyme supplementation (63% vs. 77%) and new-onset diabetes (10% vs. 12%) did not differ significantly between the PPPD and Whipple groups. Dumping, bile gastritis, or peptic ulcer disease occurred in three patients after PPPD and in three after Whipple. Complete or partial pain relief was attained in 60% and 70% of patients after PPPD and Whipple, respectively. Multivariate analysis of preoperative variables revealed that site-specific pathology in the head of the pancreas was the only independent factor associated with successful pain relief after pancreatic resection. CONCLUSION PPPD results in higher frequencies of postoperative delayed gastric emptying compared with the Whipple procedure. Both operations achieve comparable long-term nutritional results, cause new insulin dependence in surprisingly few patients, and provide equivalent pain relief to 65% of selected patients. Patients with disproportionate pathology in the head of the pancreas have a higher likelihood of successful pain relief.
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Affiliation(s)
- R E Jimenez
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston 02114, USA
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Lin PW, Lin YJ. Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy. Br J Surg 1999; 86:603-7. [PMID: 10361177 DOI: 10.1046/j.1365-2168.1999.01074.x] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy, with either gastrectomy (Whipple procedure) or pylorus-preserving pancreaticoduodenectomy (PPPD), is a complex procedure. Technical diversity, variation and sampling bias exist among surgeons. Previous reports comparing these two procedures are retrospective and not randomized. These factors should be considered seriously and eliminated in comparisons between the two procedures. METHODS From August 1994 to August 1997, a prospective randomized comparison was conducted between the Whipple procedure and PPPD performed by the same surgeon with the same approach and same anastomotic fashion for periampullary cancer. After exclusion of seven patients, 31 patients were eligible for the study, 16 receiving PPPD and 15 a Whipple procedure. No significant difference in the age, sex distribution, tumour localization or staging was noted between the two groups. RESULTS One operative death after PPPD and no operative death after the Whipple procedure resulted in a 3 per cent mortality rate in the 31 patients. Median duration of the Whipple operation was 235 (range 195-305) min, with a median blood loss of 500 (range 230-3100) ml and a median blood transfusion of 0 (range 0-10) units. In the patients who had PPPD, median operating time was 230 (range 170-275) min, median blood loss was 350 (range 100-1200) ml and median blood transfusion was 0 (range 0-4) units. There were two minor leaks from the pancreaticojejunostomy after the Whipple procedure and no leakage after PPPD, resulting in 6 per cent minor leakage in 31 patients. These outcomes were not significantly different. Delayed gastric emptying was observed more frequently after PPPD (six of 16 patients) than after the Whipple procedure (one of 15 patients), with marginal significance (P = 0.08, two-sided Fisher's exact test). CONCLUSION In this prospective randomized study, both PPPD and the Whipple procedure were associated with low mortality and operative morbidity rates. There was no significant difference between PPPD and Whipple resection in terms of operative mortality and morbidity, operating time, blood loss and blood transfusion. PPPD was associated with more frequent delayed gastric emptying, although study of more patients is needed to confirm this.
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Affiliation(s)
- P W Lin
- Department of Surgery, Medical College, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan
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Sielezneff I, Lécuyer J, Pirro N, Césari J, Brunet C, Sastre B. [Malignant tumors of the ampulla of Vater. Results of radical excision. A study of 39 cases]. CHIRURGIE; MEMOIRES DE L'ACADEMIE DE CHIRURGIE 1998; 123:560-7. [PMID: 9922595 DOI: 10.1016/s0001-4001(99)80004-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
STUDY AIM From 1971 to 1995, 39 patients underwent curative resection of a malignant tumor of the ampulla of Vater. The aim of this retrospective study was to report long-term results and to determine factors influencing survival in these patients. PATIENTS AND METHODS Data was collected from patient record analysis, correspondence with patients, their family or general physician. Kaplan-Meier method was used to compare survival data by the log-rank test. Multivariate analysis evaluated the impact of each variable on survival. Values with a P value of 0.05 or less were considered statistically significant. RESULTS Resection consisted of pylorus preserving pancreaticoduodenectomy (n = 21) or pancreatico-duodenectomy associated with an antrectomy (n = 18). Overall mortality rate after resection was 10% (n = 4). General and specific morbidity rates were 71% and 2.5%. During the course of the follow-up (completeness: 100%) mean survival was 80 months (median: 37 months, range: 6-227 months). Five-year survival rate was 35%. Factors favorably influencing long-term outcome were exposed protruding and well differentiated tumors (P = 0.03, P = 0.01, respectively) and negative lymph node status (P = 0.0001). Prognosis was poorer if tumor was extended into the pancreas (P = 0.04). Among proposed histoprognostic classifications (classifications of Martin, Talbot, Shiraï, Yamaguchi), an excellent correlation was obtained only with TNM classification (P = 0.0001). CONCLUSION Results of the present study suggest that prolonged survival can be obtained following radical resection of a malignant tumor of the ampulla of Vater, especially for exposed protruding and well differentiated tumors, without extension into the pancreas or lymph node metastasis. TNM classification provides an excellent predictive value and should be used more systematically.
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Affiliation(s)
- I Sielezneff
- Service de chirurgie générale et digestive, hôpital Sainte-Marguerite, Marseille, France
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Clavien PA, Selzner M. End-to-end pancreaticoduodenostomy: an alternative reconstruction for partial resection of the head of the pancreas. J Am Coll Surg 1998; 187:330-2. [PMID: 9740192 DOI: 10.1016/s1072-7515(98)00161-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- P A Clavien
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Evans JD, Wilson PG, Carver C, Bramhall SR, Buckels JAC, Mayer AD, McMaster P, Neoptolemos JP. Outcome of surgery for chronic pancreatitis. Br J Surg 1997. [DOI: 10.1002/bjs.1800840512] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Naritomi G, Tanaka M, Matsunaga H, Yokohata K, Ogawa Y, Chijiiwa K, Yamaguchi K. Pancreatic head resection with and without preservation of the duodenum: different postoperative gastric motility. Surgery 1996; 120:831-7. [PMID: 8909518 DOI: 10.1016/s0039-6060(96)80091-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early gastric stasis is a unique complication of pylorus-preserving pancreatoduodenectomy. Because the duodenum proved to be important in the initiation and consolidation of phase III activity of the migrating motor complex of the stomach, the absence of the duodenum and hence gastric phase III may be a cause of gastric stasis. METHODS Postoperative gastrointestinal motility was measured with a pneumohydraulic capillary infusion system in nine patients who had undergone pylorus-preserving pancreatoduodenectomy through an indwelling tube assembly placed at operation, and compared with that in six patients who had undergone duodenum-preserving pancreatic head resection. Plasma motilin concentrations were measured by radioimmunoassay. RESULTS The mean period until the first occurrence of gastric phase III was significantly longer in patients who had undergone a pylorus-preserving pancreatoduodenectomy (40.6 +/- 4.6 days or more) than in patients who had undergone a duodenum-preserving pancreatic head resection (18.8 +/- 4.3 days; p < 0.05). On the day of the first observation of gastric phase III, the plasma concentration of motilin at proximal jejunal phase III in patients who underwent a pylorus-preserving pancreatoduodenectomy (50.2 +/- 9.8 pg/ml) was significantly lower than that at duodenal phase III in patients who underwent a duodenum-preserving pancreatic head resection (184.6 +/- 48.6 pg/ml; p < 0.05). CONCLUSIONS Gastric stasis after a pylorus-preserving pancreatoduodenectomy may be in part attributable to the low concentration of plasma motilin caused by the resection of the duodenum.
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Affiliation(s)
- G Naritomi
- Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan
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Abstract
A personal series is reported of 52 patients who underwent proximal pancreatoduodenectomy for severe chronic pancreatitis between 1979 and 1994. There were 13 women and 39 men of median age 42.2 (range 12-70) years. Disease predominantly affected the head of pancreas, with calcification present in 37 patients. Indications for operation were chronic pain (47 patients), obstructive jaundice (19) and duodenal stenosis (six); cancer was suspected in 12. In addition, 14 patients had a pseudocyst, two pancreatic endocrine failure and 20 exocrine failure. Aetiology was chronic alcohol abuse in 34, recurrent acute pancreatitis in five and unknown in 13. Pylorus-preserving proximal pancreatoduodenectomy was performed in 45 patients, while the remaining seven had partial gastrectomy. Drainage of a dilated distal pancreatic duct by side-to-side pancreaticojejunal anastomosis was included in 15 patients. Mean operating time was 6.2 (range 4.5-9.5) h and mean blood loss was 2.7 (range 0.2-13.0) litres. There were no hospital deaths, but three patients required a second operation and five had percutaneous drainage of infected collections. During a median follow-up of 54 months, six patients required completion distal pancreatectomy for renewed pain and four others had persistent pain. Four patients required intervention for stricture at the biliary-enteric anastomosis. Ten patients have died from causes not directly related to chronic pancreatitis. Proximal pancreatoduodenectomy is a relatively safe procedure, effectively palliating pain in 80 per cent of patients with chronic pancreatitis.
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Affiliation(s)
- G N Stapleton
- Department of Surgery, Hammersmith Hospital, London, UK
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21
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Zerbi A, Balzano G, Patuzzo R, Calori G, Braga M, Di Carlo V. Comparison between pylorus-preserving and Whipple pancreatoduodenectomy. Br J Surg 1995; 82:975-9. [PMID: 7648124 DOI: 10.1002/bjs.1800820738] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Between 1989 and 1993, 62 patients underwent Whipple pancreatoduodenectomy and 75 pylorus-preserving pancreatoduodenectomy (PPPD); 35 patients in the first group and 37 in the second had pancreatic adenocarcinoma while 17 and 21 patients respectively had periampullary adenocarcinoma. The aim of this retrospective study was the comparison of operative outcome, nutritional recovery and survival of patients who underwent these two operations. No significant differences were found between the two groups in operative mortality or morbidity, duration of gastric aspiration and time to start of solid meals. Patients who underwent PPPD had a better nutritional recovery: the increase of both body-weight and serum albumin level at 6 months after discharge was significantly higher for those who had preservation of the whole stomach (P < 0.001 and P < 0.05 respectively). No significant difference in survival was found between the two procedures when patients with pancreatic or periampullary adenocarcinoma were analysed separately.
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Affiliation(s)
- A Zerbi
- Department of General Surgery, San Raffaele Hospital, University of Milan, Italy
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22
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Rossi RL, Tsao JI. Invited commentary. World J Surg 1995. [DOI: 10.1007/bf00316990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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23
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Shirai Y, Tsukada K, Ohtani T, Koyama S, Muto T, Watanabe H, Hatakeyama K. Carcinoma of the ampulla of Vater: histopathologic analysis of tumor spread in Whipple pancreatoduodenectomy specimens. World J Surg 1995; 19:102-6; discussion 106-7. [PMID: 7740792 DOI: 10.1007/bf00316989] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Controversies exist regarding the application of the pylorus-preserving pancreatoduodenectomy (PPPD) to malignancies. This study was intended to disclose the pattern of spread of ampullary cancer and to substantiate that tumor spread at resectable stages does not involve the tissues preserved by PPPD. We examined 40 consecutive Whipple pancreatoduodenectomy specimens: mucosal cancer, 4 cases; cancer invading (but not penetrating) the sphincter of Oddi, 1; cancer invading the submucosa of the duodenum, 12; cancer invading the proper muscle of the duodenum, 5; cancer invading the subserosal layer of the duodenum, 7; and cancer invading pancreatic parenchyma, 11. Five cases of mucosal cancer or cancer invading (but not penetrating) the sphincter spread locally without nodal involvement and showed a 5-year survival of 80% without recurrence, being better (p < 0.05) than the 40% survival for patients with more advanced cancers. Sixty-three percent of the remaining 35 cases had metastasis to regional lymph nodes. The 5-year survival of 28% among those with cancer penetrating the proper muscle was worse (p < 0.05) than the 59% survival for those with less advanced cancers. No cases had involved the anatomic structures that would have been preserved by a PPPD. In three cases (7.5%), gastric cancer coexisted. In conclusion, ampullary cancer not penetrating the sphincter spreads locally. Once penetrating the sphincter, it often spreads regionally and causes recurrence. Cancer penetrating the proper muscle of the duodenum bears a worse prognosis. PPPD is an attractive alternative to the Whipple operation for ampullary cancer because no involvement was found in the tissue preserved by the PPPD. However, surgeons should be aware of a concomitant gastric cancer when doing a PPPD.
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Affiliation(s)
- Y Shirai
- Department of Surgery, Niigata University School of Medicine, Japan
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24
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Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis. Ann Surg 1994. [PMID: 7524454 DOI: 10.1097/00000658-199410000-00008] [Citation(s) in RCA: 198] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
UNLABELLED OPERATION: Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts. PATIENT MATERIAL The operation has been performed on 50 patients. There were five late deaths among the 50 patients; two at 6 months, and one each at 24, 26, and 91 months. Eighty percent of the patients were alcoholics, 50% had pseudocysts, and 80% had calcification. ASSESSMENT Pain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal-Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate--Vicodin weekly daily; and major--meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily. RESULTS Pain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperatively and postoperatively. Postoperatively, 11% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively. CONCLUSIONS The LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force.
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25
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Frey CF, Amikura K. Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis. Ann Surg 1994; 220:492-504; discussion 504-7. [PMID: 7524454 PMCID: PMC1234422 DOI: 10.1007/bf02348284] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED OPERATION: Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts. PATIENT MATERIAL The operation has been performed on 50 patients. There were five late deaths among the 50 patients; two at 6 months, and one each at 24, 26, and 91 months. Eighty percent of the patients were alcoholics, 50% had pseudocysts, and 80% had calcification. ASSESSMENT Pain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal-Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate--Vicodin weekly daily; and major--meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily. RESULTS Pain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperatively and postoperatively. Postoperatively, 11% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively. CONCLUSIONS The LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force.
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Affiliation(s)
- C F Frey
- Department of Surgery, University of California, Davis Medical Center, Sacramento
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26
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Fleming WR, Williamson RCN. Preservation of the pylorus in resection of the head of the pancreas. ACTA ACUST UNITED AC 1994. [DOI: 10.1007/bf02391096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Braasch JW. Preservation of the pylorus and resection of the head of the pancreas. ACTA ACUST UNITED AC 1994. [DOI: 10.1007/bf02391094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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28
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Prinz RA. Surgical options in chronic pancreatitis. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1993; 14:97-105. [PMID: 8283084 DOI: 10.1007/bf02786115] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Chronic pancreatitis is primarily a medical disease but surgery is indicated to treat complications, rule out malignancy, and ameliorate intractable pain. The ideal operation for chronic pancreatitis would relieve this pain while preserving exocrine and endocrine function. No one procedure achieves these goals in all patients so surgeons must tailor their operations to individual patient needs. In patients with a dilated pancreatic duct, complete ductal decompression with a lateral pancreaticojejunostomy is usually indicated. Pancreatic resection is useful in patients with localized disease, nondialated ducts, or in whom cancer cannot be ruled out. More rigorous documentation of the type and outcome of therapeutic interventions for chronic pancreatitis and the patient populations to whom they are applied is needed. Subjective measurements must be replaced by objective findings so that the true benefits of these procedures can be better assessed and compared.
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Affiliation(s)
- R A Prinz
- Department of Surgery, Loyola University Medical Center, Maywood, IL 60153
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29
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Taylor I. General surgery. Postgrad Med J 1991; 67:876-91. [PMID: 1758797 PMCID: PMC2399165 DOI: 10.1136/pgmj.67.792.876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- I Taylor
- University Surgical Unit, Southampton General Hospital, UK
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