Pancreatoduodenectomy with occlusion of the residual stump by Neoprene injection

Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers

Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO.

Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months.

Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive.

Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.

The using of sealants in pancreatic surgery: A Systematic Review

Background

POPF derives from the pancreatic stump, which follows pancreatic resection and the pancreatoenteric anastomosis following pancreaticoduodenectomy. Since 1978 sealants have been used in pancreatic surgery to prevent pancreatic fistula after resection of the pancreatic head and tail or for the management of trauma and the treatment of low-output pancreatic fistula. Different types of fibrin sealants have been evaluated for their potential to reduce the occurrence of POPF.

Methods

A systematic search of the electronic literature was performed using PubMed, Cochrane Library, and Scopus databases to obtain access to all publications, especially clinical trials, randomised controlled trials, and systematic reviews concerning fibrin sealants pancreatic surgery. Searching for “fibrin sealants pancreas,” we found a total of 73 results on Pubmed, 61 on Scopus, and 14 on Cochrane Library (148 total results).

Results

Eighteen studies were found on literature, following the criteria already described, concerning the use of fibrin sealants in pancreatic surgery. All articles described were published in the period between 1989 and 2019.

Most of these were single centre studies. A total of 1032 patients were enrolled in this review. In the studies, sealants were used to reinforce pancreatic anastomoses and for the occlusion of the main pancreatic duct.

Conclusion

CR-POPF is a fearful complication of pancreatic surgery; among the possible solutions to reduce the risk of onset, sealants were used on the pancreatic stump; today the sealants should be considered such as an option to reduce the CR-POPF, but the routine use in clinical practice has to be validated.

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Discuss the use of sealants in pancreatic surgery.

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Compare the application of sealants on pancreatic stump and the effect on p-popf

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Describe the previous experiences reported in literature.

Permanent Pancreatic Duct Occlusion With Neoprene-based Glue Injection After Pancreatoduodenectomy at High Risk of Pancreatic Fistula: A Prospective Clinical Study

The aim of this study was to assess safety and efficacy of pancreatic duct occlusion (PDO) with neoprene-based glue in selected patients undergoing pancreatoduodenectomy (PD) at high risk of postoperative pancreatic fistula (POPF).

Four hundred fifty-three consecutive pancreaticoduodenectomies with pancreaticogastrostomy

BACKGROUND

Patients who undergo pancreaticoduodenectomy (PD) have the pancreatic remnant (PR) anastomosed to the jejunum. In this study, all patients had the PR anastomosed to the stomach. Our aims are to evaluate postoperative outcomes of patients undergoing PD with pancreaticogastrostomy (PG).

METHODS

There was 453 patients who underwent PD with PG. Preoperative characteristics, intraoperative data, and postoperative outcomes were analyzed using univariate and multivariate models.

RESULTS

The patient cohort had a median age of 67 years and underwent resection for pancreatic (40.8%), ampullary (15.9%), duodenal (6.6%), distal bile duct (6.4%) cancers. Multivariate analysis revealed poor prognosis was related to age, tumor diameter, lymph node ratio, perineural invasion, and tumor differentiation in patients with periampullary adenocarcinoma.

CONCLUSIONS

This series of patients undergoing PD with PG shows that the operation can be performed safely with excellent outcomes for a variety of malignant and benign conditions.

How to prevent the postoperative pancreatic fistula with an ethylene vinyl alcohol copolymer (Onyx®): A proposal of a new technique

Backgrounds/Aims

Despite the advances in identifying risk factors, improving operative technique, and postoperative patient care, pancreatic leakage after pancreatic resection remains a highly debated topic. The aim of this study is to describe our technique and our initial experience with the intraoperative embolization of the main pancreatic duct with an Ethylene Vinyl Alcohol Copolymer (Onyx®).

Methods

Two patients of 63 and 64 years underwent pancreaticoduodenectomy for a cholangiocarcinoma of the extrahepatic bile duct and a pancreatic adenocarcinoma, respectively. At the time of pancreatic parenchyma resection, a Wirsung duct was identified and catheterized. A wirsungography was done and then, embolization with Onyx® was carried out under fluoroscopic control.

Results

Neither of the patients developed a postoperative pancreatic fistula. They were discharged to home on the 17^th and 18^th postoperative day, respectively. At the last follow-up, no recurrence was found. The two patients became diabetics; both needed the support of supplementary pancreatic enzymes.

Conclusions

To our knowledge, we are the first to describe this technique, which seems safe and reliable. Studies on this subject with more patients are needed to confirm the validity of this procedure.

The Role of Intraoperative Therapy by Electron Beam and Combination of Adjuvant Chemotherapy and External Radiotherapy in Carcinoma of the Pancreas

Aims and background

In the treatment of pancreatic carcinomas, one modality is intraoperative radiotherapy (IORT). A study was carried out to assess the feasibility of IORT alone or in a multimodality approach with postoperative adjuvant chemotherapy and external radiotherapy and to compare local control and survival of patients. Another objective of this retrospective study was to verify prognostic factors in resected patients treated with IORT.

Methods

From January 1985 through September 1992, 54 adenocarcinomas of the pancreas (unresectable and resected patients) were treated with IORT by electron beam at the San Raffaele Hospital and then analyzed. Comparison was also carried out between IORT-treated resected patients and a non-randomized control group of resected patients treated without IORT in the same period.

Results

In unresectable patients treated by laparotomy bypass and IORT, overall median survival was 6 months and 8 months in non-metastatic patients. Relief of severe pain present in 14 patients was observed in 85% within 12 days of IORT. As regards resected patients, the most important finding was that significantly better local control resulted from IORT. In fact, overall, local relapses were 25% in the IORT group and 55.8% in the non-IORT group (control group); instead, survival of the IORT group was not significantly longer than that of the control group. From a statistical analysis of resected patients treated with IORT and performed on prognostic factors on the basis of available data, survival was significantly influenced by tumor pathologic grading and diameter; postoperative adjuvant therapy was not a significant prognosis factor.

Conclusions

IORT has a role in local control of unresectable pancreatic carcinomas and in control of resultant severe pain. In resected patients, IORT is effective in decreasing local recurrences but has little impact on survival. To obtain more satisfactory results, new and more effective adjuvant therapies and better abdominal prophylaxis should be tested.

Engineered mesenchymal stem-cell-sheets patches prevents postoperative pancreatic leakage in a rat model

Post-operative pancreatic fistula (POPF) following pancreatic resection is a life-threatening surgical complication. Cell sheets were prepared and harvested using temperature-responsive culture dishes and transplanted as patches to seal POPF. Two different mesenchymal stem cell (MSC) sheets were compared in terms of the preventative ability for pancreatic leakage in a rat model. Both rat adipose-derived stem cell (rADSC) and bone marrow-derived stem cell (rBMSC) sheets were transplanted. Those rADSC and rBMSC sheets are created without enzymes and thus maintained their cell-cell junctions and adhesion proteins with intact fibronectin on the basal side, as well as characteristics of MSCs. The rats with post-pancreatectomy rADSC- or rBMSC-sheet patches had significantly decreased abdominal fluid leakage compared with the control group, demonstrated by MR image analysis and measurement of the volume of abdominal fluid. Amylase level was significantly lower in the rats with rADSC-sheet and rBMSC-sheet patches compared with the control groups. The rADSC sheet patches had increased adhesive and immune-cytokine profiles (ICAM-1, L-selectin, TIMP-1), and the rBMSC sheets had reduced immune reactions compared to the control. This is first project looking at the feasibility of tissue engineering therapy using MSC-sheets as tissue patches preventing leakage of abdominal fluid caused by POPF.

Pancreatic stump closure after pancreatoduodenectomy in elderly patients: a retrospective clinical study

BACKGROUND

Pancreatic fistula (PF) after pancreatoduodenectomy (PD) represents the major source of morbidity. Derivative procedures are preferred by pancreatic surgeons, but the optimal management of remnant pancreatic stump remains controversial.

AIMS

The purpose of this retrospective study is to evaluate the efficacy and safety of pancreatic stump closure in selected elderly patients (>65 years).

METHODS

Clinical data of 44 PD undergone mechanical closure of the pancreatic stump performed between 2001 and 2014 in two department of general and oncologic surgery were retrospectively collected. Considering the age, patients were divided into two groups: 21 patients of less than 65 years (Group A) and 23 patients of more than 65 years (Group B).

RESULTS

A soft pancreatic parenchyma with a not-dilated duct (diameter <3 mm) was reported in all the 44 patients. A grade-A PF, which did not required further treatments, developed in 20 cases (45.4%; 13 in group A and 7 in group B; p < 0.05), grade-B in 5 patients (11.4%; 3 in group A and 2 in group B; statistically not significant) and a grade-C PF was observed only in one patient (2.2%; 1 in group A and 0 in group B).

DISCUSSION

In selected "high risk" elderly patients (>65 years) with soft pancreatic texture, the closure of the pancreatic stump can be a useful tool in the surgical armamentarium with the aim to reduce the incidence of age-related complications.

CONCLUSIONS

Prospective randomized controlled trial to better evaluate PF risk factors is needed.

Indications and results of pancreatic stump duct occlusion after duodenopancreatectomy

Severe post-operative complications after pancreaticoduodenectomy (PD) are largely due to pancreatic fistula onset. The occlusion of the main pancreatic duct using synthetic glue may prevent these complications. Aim of this study is to describe this technique and to report short- and long-term results as well as the post-operative endocrine and exocrine insufficiency. Two hundred and four patients who underwent PD with occlusion of the main pancreatic duct in a period of 15 years were retrospectively analyzed. Post-operative complications and their management were the main aim of the study with particular focus on pancreatic fistula incidence and its treatment. At 1-year follow-up endocrine and exocrine functions were analyzed. We observed a 54 % pancreatic fistula incidence, most of which (77/204 patients) were a grade A fistula with little change in medical management. Twenty-eight patients developed a grade B fistula while only 2 % of patients (5/204) developed a grade C fistula. Nine patients required re-operation, 5 of whom had a post-operative grade C fistula. Post-operative mortality was 3.4 %. At 1-year follow-up, 31 % of patients developed a post-operative diabetes while exocrine insufficiency was encountered in 88 % of patients. The occlusion of the main pancreatic duct after PD can be considered a relatively safe and easy-to-perform procedure. It should be reserved to selected patients, especially in case of soft pancreatic texture and small pancreatic duct and in elderly patients with comorbidities, in whom pancreatic fistula-related complications could be life threatening.

Computed Tomography after Modified Whipple Procedure with Pancreatic Duct Occlusion

Eighty-two CT examinations performed on 28 patients who had undergone a modified Whipple procedure including pancreatic duct occlusion were reviewed. Reduction of the antero-posterior diameter of the body and tail of the pancreatic remnant was observed on consecutive scans in 8 patients (29%). Decreasing liver attenuation was seen in 4 patients (14%) postoperatively, and pseudocysts in the pancreatic remnant in 6 (21%). In 10 examinations performed because of suspected intraabdominal abscess postoperatively, abscess was diagnosed in 2 patients. In 62 routine follow-up CT examinations, significant positive findings were diagnosed in 5 patients: tumor recurrence or metastases in 4, and a large pseuodocyst in one. CT is of value in the early postoperative phase to reveal postoperative complications and in the follow-up of patients with specific symptoms indicating tumor recurrence or metastases.

Surgical management of the pancreatic stump following pancreato-duodenectomy

Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.

In Vivo Healing Effects of Ankaferd Blood Stopper on the Residual Pancreatic Tissue in a Swine Model of Distal Pancreatectomy

The aim of this study was to determine whether intraoperative Ankaferd blood stopper (ABS) application into the pancreatic channel and to the pancreatic remnant surface following distal pancreatectomy can or cannot prevent postoperative pancreatic fistula formation. Three pigs underwent distal pancreatectomy under general anesthesia. In two of the pigs, 0.5 ml of ABS was applied to the stump surface area after adding 0.5 ml of ABS into the pancreatic channel. The remaining one animal served as the control. The pigs were sacrificed on the seventh postoperative day for autopsy. The pancreatic remnants from the animals were then taken for histopathological analyses. It was observed that the oral intake had been broken and abdominal distention had developed in the control pig following on the third postoperative day. However, no significant clinical changes were observed in the ABS-applied pigs. In the autopsy, it was found that the control pig had generalized peritonitis with pancreatic necrosis. On the other hand, the ABS-applied pigs had either macroscopically and microscopically normal pancreatic tissue architecture with an occluded Wirsung duct at the pancreatic stump. It was concluded that application of ABS on the transected surface and into the pancreatic channel could prevent pancreatic fistula formation and improve wound healing in the residual pancreatic tissue following distal pancreatectomy.

Therapeutic effect of trans-drain administration of antibiotics in patients showing intractable pancreatic leak-associated pus drainage after pancreaticoduodenectomy

BACKGROUNDS/AIMS

To cope with intractable pus drainage from persistent pancreatic leak after pancreaticoduodenectomy (PD), we have empirically performed local administration of high-concentration antibiotics cocktail solution into abdominal drains. The purpose of this study was to assess its therapeutic effect in patients showing intractable pus drainage after PD.

METHODS

The study group was 10 patients who underwent trans-drain administration of high-concentration antibiotics cocktail solution. Another 10 patients were selected through propensity score matching for the control group. Their medical records were retrospectively reviewed with focus on comparison of pancreatic fistula (PF)-associated clinical sequences.

RESULTS

Postoperative PF of grade B and C occurred in 7 and 3 patients in the study group and 9 and 1 patient in the control group, respectively (p=0.58). In the study group, a mean of 1.8 sessions of antibiotics cocktail solution (imipenem 500 mg and vancomycin 500 mg dissolved in 20 ml of normal saline) was administered. Two patients showed procedure-associated febrile episodes that were spontaneously controlled within 48 hours. At 2-4 days after the first-session of antibiotics administration, pus-like drain discharge turned to be serous with significantly decreased amount. The study group showed shortened postoperative hospital stay comparing to the control group (25.2±4.6 vs. 31.8±5.6 days, p=0.011). In both groups, no patient received radiological or surgical intervention due to PF-associated complications.

CONCLUSIONS

The results of our study demonstrated that trans-drain administration of antibiotics could be an effective therapeutic option for pancreaticojejunostomy leak-associated infection. Further validation of our result is necessary in large patient populations from multiple centers.

Pancreatoduodenectomy - preventing complications

Increased awareness of periampullary & pancreatic head cancers, and the accompanying improved outcomes following pancreatoduodenectomy (PD), has possibly led to an increase in patients seeking treatment for the same. While there has definitely been a reduction in morbidity rates following PD in the last few decades, this decline has not mirrored the drastic fall in mortality. Amongst the foremost in the factors responsible for this reduction in mortality is the standardization of surgical technique and development of dedicated teams to manage all aspects of this demanding procedure. This review intends to provide the reader with an overview of major complications following this major surgery and measures to prevent them based on the authors' experience.

Complications after pancreatic resection: diagnosis, prevention and management

BACKGROUND

Although mortality after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has decreased, morbidity still remains high. The aim of this review article is to present, define, predict, prevent, and manage the main complications after pancreatic resection (PR).

METHODS

A non-systematic literature search on morbidity and mortality after PR was undertaken using the PubMed/MEDLINE and Embase databases.

RESULTS

The main complications after PR are delayed gastric emptying (DGE), pancreatic fistula (PF), and bleeding, as defined by the International Study Group on Pancreatic Surgery. PF occurs in 10% to 15% of patients after PD and in 10% to 30% of patients after DP. The different techniques of pancreatic anastomosis and pancreatic remnant closure do not show significant advantages in the prevention of PF, nor does the perioperative use of somatostatin and its analogues. The trend is for conservative or interventional radiology therapy for PF (with enteral nutrition), which achieves a success rate of approximately 80%. DGE after PD occurs in 20% to 50% of patients. Prophylactic erythromycin may reduce the incidence of DGE. Gastric aspiration with erythromycin is usually effective in one to three weeks. Bleeding (gastrointestinal and intraabdominal) occurs in 4% to 16% of patients after PD and in 2% to 3% of patients after DP. Endovascular treatment can only be used for a haemodynamically stable patient. In cases of haemodynamic instability or associated septic complications, surgical treatment is necessary. In expert centres, the mortality rates can be less than 1% after DP and less than 3% after PD.

CONCLUSION

There is a need for improved strategies to prevent and treat complications after PR.

How fibrosis influences imaging and surgical decisions in pancreatic cancer

Our understanding of pancreatic ductal adenocarcinoma (PDAC) is shifting away from a disease of malignant ductal cells-only, toward a complex system where tumor evolution is a result of interaction of cancer cells with their microenvironment. This change has led to intensification of research focusing on the fibrotic stroma of PDAC. Pancreatic stellate cells (PSCs) are the main fibroblastic cells of the pancreas which are responsible for producing the desmoplasia in chronic pancreatitis (CP) and PDAC. Clinically, the effect of desmoplasia is two-sided; on the negative side it is a hurdle in the diagnosis of PDAC because the fibrosis in cancer resembles that of CP. It is also believed that PSCs and pancreatic fibrosis are partially responsible for the therapy resistance in pancreatic cancer. On the positive side, a fibrotic pancreas is safer to operate on compared to a fatty and soft pancreas which is prone for postoperative pancreatic fistula. In this review the impact of pancreatic fibrosis on diagnosis of pancreatic cancer and surgical decisions are discussed from a clinical point of view.

Oesophagogastrectomy and pancreatoduodenectomy for caustic injury

Background

The justification for pancreatoduodenectomy (PD) for extended duodenal and pancreatic caustic necrosis is still a matter of debate.

Methods

This was a retrospective evaluation of patients who underwent PD in association with oesophagogastrectomy from a large single-centre cohort of patients with caustic injuries. Morbidity, mortality and long-term outcome were assessed.

Results

PD was performed in 18 (6·6 per cent) of 273 patients who underwent emergency surgery for caustic injuries. Biliary and pancreatic duct reconstruction during PD was performed in ten and six patients respectively. Seven patients died and 17 experienced operative complications after PD for caustic injuries. Twelve patients required at least one reoperation. Specific PD-related complications occurred in 13 patients. Initial (P = 0·038) or secondary (P &lt; 0·001) extension of necrosis to adjacent organs were independent predictors of operative death. After a median follow-up of 24 months following reconstruction, three patients had recovered nutritional autonomy. In an intention-to-treat analysis, functional success was recorded in three patients and the 5-year survival rate was 39 per cent after PD for caustic injury.

Conclusion

PD can save the lives of patients with caustic injuries extending beyond the pylorus, but has poor functional outcome. Immediate pancreatic duct reconstruction should be preferred to duct occlusion to decrease the rate of pancreatic complications.

Endoscopic ultrasonography-guided pancreaticogastrostomy for a case of occlusion of gastro-pancreatic anastomosis after pancreaticoduodenectomy

BACKGROUND

EUS-guided pancreaticogastrostomy is described as an alternative to surgery for ductal decompression when endoscopic transpapillary access is impossible. We report a case where EUS-guided pancreaticogastrostomy of the pancreatic duct was effective for dilatation of the pancreatic duct caused from occlusion of gastro-pancreatic anastomosis constructed after resection of pancreaticoduodenectomy.

PATIENTS AND METHODS

The patient was a 79-year-old woman who had undergone operation for IPMN in the pancreatic head in 1998. Nine years after the operation, she visited us for back pain, and conspicuous dilatation of the main pancreatic duct was found. By observing curved liner array EUS scope, we successfully punctured the main pancreatic duct and placed a plastic stent.

RESULTS

After the treatment, the subjective symptom was alleviated and reduction of the dilatation of pancreatic duct was observed in image findings.

CONCLUSION

Endoscopic ultrasonography guided pancreaticogastrostomy appears to be an effective treatment for a case of occlusion of gastro-pancreatic anastomosis after pancreaticoduodenectomy.

Decreasing the pancreatic leak rate after pancreaticoduodenectomy

Although pancreaticoduodenectomy has become a safe and effective procedure for benign and malignant pancreatic diseases in recent years, leakage of pancreaticoenteric anastomosis still remains a major cause of morbidity and even mortality. Various methods have been used to prevent pancreatic fistula with either pharmacologic or technical approaches. Based on meta-analysis of results from European and American trials, prophylactic use of octreotide to inhibit pancreatic secretion cannot be recommended for routine use in pancreaticoduodenectomy. Further randomized trials are required to clarify the role of selective use of octreotide in patients at high risk for pancreatic leakage. Technical improvement by surgeons is probably the most important approach to reduce pancreatic anastomotic leakage rate. Various technical modifications for pancreaticoenteric anastomosis have been suggested; some have been tested in randomized controlled trials, but data from randomized trials are generally scarce. Use of PG instead of PJ anastomosis, internal stenting of PJ anastomosis, pancreatic duct occlusion, and fibrin glue have not been shown to be effective in reducing pancreatic leakage rate after pancreaticoduodenectomy. One randomized trial recently showed significant reduction of pancreatic leakage rate using an external diverting stent after PJ anastomosis, and another randomized trial showed significant reduction in PJ anastomosis leakage using the binding PJ anastomosis technique. Nonetheless, further high-quality randomized controlled trials are needed to evaluate the benefit of these technical modifications in decreasing the pancreatic leakage rate after pancreaticoduodenectomy.

Pancreatic fistula after pancreatectomy: Evolving definitions, preventive strategies and modern management

Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a demanding procedure and whereas mortality after a pancreaticoduodenectomy is currently < 3%-5% in experienced high-volume centers, post-operative morbidity is considerable, about 30%-50%. At present, the single most significant cause of morbidity and mortality after pancreatectomy is the development of pancreatic leakage and fistula (PF). The occurrence of a PF increases the length of hospital stay and the cost of treatment, requires additional investigations and procedures, and can result in life-threatening complications. There is no universally accepted definition of PF that would allow standardized reporting and proper comparison of outcomes between different centers. However, early recognition of a PF and prompt institution of appropriate treatment is critical to the prevention of potentially devastating consequences. The present article, reviews the evolution of post resection pancreatic fistula as a concept, and discusses evolving definitions, the current preventive strategies and the management of this problem.

Effect of BioGlue on the incidence of pancreatic fistula following pancreas resection

BACKGROUND

Despite numerous modifications of surgical technique, pancreatic fistula remains a serious problem and occurs in about 10% of patients following pancreas resection. BioGlue is a new sealant that creates a flexible mechanical seal within minutes independent of the body's clotting mechanism.

HYPOTHESIS

Application of BioGlue sealant will reduce the incidence of pancreatic fistula following pancreas resection.

METHODS

A retrospective cohort study was performed with 64 patients undergoing pancreas resection. BioGlue sealant was applied to the pancreatic anastomosis (Whipple) or resection margin (distal pancreatectomy) in 32 cases. Factors that could affect the rate of postoperative pancreatic fistula were recorded. Pancreatic fistula was defined as greater than 50 ml of drain output with an amylase content greater than three times normal serum value after postoperative day 10. To improve the sensitivity of our study, we also examined pancreatic fistula with a strict definition of any drain output on or after postoperative day 3 with a high amylase content and graded the fistulas in terms of clinical severity. Grade A leaks were defined as subclinical. Grade B leaks required some response such as making the patient nil per os, parenteral nutrition, octreotide, antibiotics, or a prolonged hospital stay. Grade C leaks were defined as serious and life threatening. They were associated with hemorrhage, sepsis, resulted in deterioration of other organ systems, and mandated intensive care. Comparisons between the two groups were made using the chi-square test or Fisher's exact test for categorical variables and by the Wilcoxon rank-sum test for continuous variables. P values of 0.05 or less were deemed statistically significant.

RESULTS

There were no differences between the patients who received BioGlue and the control cohort in terms of comorbid conditions, tumor location, texture of the pancreas, size of the pancreatic duct, or surgical technique. By the common definition, pancreatic fistula occurred in 6% (control) vs. 22% (BioGlue). By the strict definition, a fistula occurred in 41% (control) vs. 60% (BioGlue). In the control group, ten were subclinical (grade A) and two were clinically apparent leaks (grade B). In the BioGlue group, seven were subclinical (grade A), five were clinically apparent (grade B), and three were severe (grade C). There were no statistically significant differences in the incidence or severity grades of postoperative pancreatic fistulas between the two groups.

CONCLUSION

Application of BioGlue sealant probably does not reduce the incidence of pancreatic fistula following pancreas resection.

External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial

OBJECTIVE

Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy. External drainage of pancreatic duct with a stent has been shown to reduce pancreatic fistula rate of pancreaticojejunostomy in a few retrospective or prospective nonrandomized studies, but no randomized controlled trial has been reported thus far. This single-center prospective randomized trial compared the results of pancreaticoduodenectomy with external drainage stent versus no stent for pancreaticojejunal anastomosis.

METHODS

A total of 120 patients undergoing pancreaticoduodenectomy with end-to-side pancreaticojejunal anastomosis were randomized to have either an external stent inserted across the anastomosis to drain the pancreatic duct (n = 60) or no stent (n = 60). Duct-to-mucosa anastomosis was performed in all cases.

RESULTS

The 2 groups were comparable in demographic data, underlying pathologies, pancreatic consistency, and duct diameter. Stented group had a significantly lower pancreatic fistula rate compared with nonstented group (6.7% vs. 20%, P = 0.032). Radiologic or surgical intervention for pancreatic fistula was required in 1 patient in the stented group and 4 patients in the nonstented group. There were no significant differences in overall morbidity (31.7% vs. 38.3%, P = 0.444) and hospital mortality (1.7% vs. 5%, P = 0.309). Two patients in the nonstented group and none in the stented group died of pancreatic fistula. Hospital stay was significantly shorter in the stented group (mean 17 vs. 23 days, P = 0.039). On multivariate analysis, no stenting and pancreatic duct diameter <3 mm were significant risk factors of pancreatic fistula.

CONCLUSION

External drainage of pancreatic duct with a stent reduced leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy.

Current management of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Pancreatic fistula (PF) is a major and serious complication following pancreaticoduodenectomy (PD). The purpose of this study was to outline our management of PF after PD.

METHODS

A retrospective review of a prospectively collected database of 396 patients undergoing PD for various indications at Loyola University Medical Center and Hines Veterans Administration Hospital from July 1, 1990, to December 31, 2005. Patients were divided group 1 (no PF) and group 2 (PF). Each group was compared regarding preoperative, intraoperative, and postoperative outcomes.

RESULTS

Of the patients included in the study, 65 patients (16%) developed a PF. PF was more common after PD for ampullary neoplasms (28%), duodenal neoplasms (35%), and serous cystic neoplasms (44%), and was uncommon after PD for pancreatic cancer (6%). Associated complications with PF was 51% when compared with patients with no PF (21%; P </= .001). Duration of hospital stay was 16 days in PF versus 9 days in no PF (</=.001). Intraoperative blood loss was greater in the PF versus no PF group (P = .01). Clinically serious postoperative complications in the PF versus no PF group were mortality (P = .03), intraabdominal abscess (P </= .001), wound infection (P </= .001), hemorrhage (P = .01), cardiac (P </= .001), bile leak (P </= .001), and reoperation (P = .02). Of the 62 surviving patients with PF, 36 (58%) were treated with maintenance of oral diet, 25 (40%) with parenteral nutrition, and 1 (1.6%) required surgery for closure of PF.

CONCLUSIONS

PF is a serious complication after PD and is associated with substantial mortality and other complications. The majority of patients with PF can be managed conservatively with either maintenance of oral diet or parenteral nutrition until closure of the PF.

Pancreatic anastomoses after pancreaticoduodenectomy: do we need further studies?

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

Duct-to-mucosa pancreaticogastrostomy is a safe anastomosis following pancreaticoduodenectomy

BACKGROUND

Pancreatic fistula following pancreaticoduodenectomy is relatively common, and remains a major cause of morbidity and mortality. The aim of this study was to evaluate the results of two-layered duct-to-mucosa pancreaticogastrostomy as a method for restoring pancreaticoenteric continuity.

METHODS

Prospectively collected data from 100 consecutive patients who underwent Whipple's pancreaticoduodenectomy for tumour were evaluated. All operations were performed by the same surgeon.

RESULTS

The perioperative 60-day mortality rate was 1.0 per cent. There were no pancreatic fistulas or anastomotic leaks. Sixteen patients had significant complications that delayed discharge from hospital. Twenty-one patients subsequently required empirical pancreatic exocrine supplements.

CONCLUSION

Two-layered duct-to-mucosa pancreaticogastrostomy for restoration of pancreaticoenteric continuity after pancreaticoduodenectomy is associated with a low incidence of complications.

Meta-analysis of the value of somatostatin and its analogues in reducing complications associated with pancreatic surgery

BACKGROUND

The role of somatostatin and its analogues in reducing complications after pancreatic resection is controversial. This is a meta-analysis of the evidence of benefit.

METHODS

A literature search using Medline and ISI Proceedings with exploration of the references identified 22 studies. Of these, ten met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random-effects models. The effect was calculated as an odds ratio (OR) with 95 per cent confidence intervals (c.i.) using the Mantel-Haenszel method. Level of significance was set at P < 0.050.

RESULTS

Outcomes for 1918 patients were compared. Somatostatin and its analogues did not reduce the mortality rate after pancreatic surgery (OR 1.17 (0.70 to 1.94); P = 0.545) but did reduce both the total morbidity (OR 0.62 (0.46 to 0.85); P = 0.003) and pancreas-specific complications (OR 0.56 (0.39 to 0.81); P = 0.002). Somatostatin and its analogues reduced the rate of biochemical fistula (OR 0.45 (0.33 to 0.62); P < 0.001) but not the incidence of clinical anastomotic disruption (OR 0.80 (0.44 to 1.45); P = 0.459).

CONCLUSION

Somatostatin and its analogues reduce the incidence of complications after surgery.

Risk factors of pancreatic leakage after pancreaticoduodenectomy

AIM: To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage.

METHODS: Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage.

RESULTS: Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) devel-oped postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical signific-ance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P = 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy.

CONCLUSION: Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.

Ligation of the pancreatic duct during difficult operative circumstances

BACKGROUND

The current approach to managing the distal pancreas after pancreaticoduodenectomy is to anastomose the stump to either the jejunum or stomach, but pancreatic ductal occlusion without anastomosis of the pancreatic remnant remains an option during difficult operative circumstances. This article describes some situations in which distal pancreatic ductal ligation may be of use and reviews the morbidity associated with this procedure.

STUDY DESIGN

Review was done of a prospectively kept database of operative and pathology reports and of both immediate and 3-month to 6-year followup data of seven patients who underwent ductal occlusion during pancreaticoduodenectomy or central pancreatectomy.

RESULTS

Ductal occlusion was performed in three circumstances: 1. necessity for expedient termination of the operation; 2. short jejunal mesentery allowing only a tension-free biliary or pancreatic anastomosis; and 3. massive jejunal edema that would result in a tenuous anastomosis. Two patients developed a fistula. One patient had dense residual pancreatic fibrosis, which resolved after 5 days; the other patient had a normal residual pancreas and subsequently underwent a pancreaticojejunostomy. Three patients developed acute pancreatitis (two had a normal and one had mild to moderate fibrosis in the residual pancreas) and one of these developed a peripancreatic abscess and late pseudocyst. Four patients with dense fibrosis did not develop acute pancreatitis. No patient developed either overt or worsening diabetes during the limited followup. None of the patients required enzyme supplementation, but all voluntarily maintained a low-fat diet.

CONCLUSIONS

The development of complications after ductal ligation appears to be associated with the degree of fibrosis of the residual distal gland. Acute pancreatitis and fistula are the major complications but are associated with a low mortality. Diabetes is a potential late problem. The morbidity associated with ductal ligation is generally accepted as being greater than anastomosis, but ligation can be considered as an alternative in difficult circumstances where anastomosis of the distal pancreatic stump is believed to be unwise.

[Extensive digestive caustic burns: what are the limits for resection? A series of 12 patients]

AIM OF THE STUDY

To report the results of oesogastric resections extended to surrounding organs following caustic ingestion, and to precise indications for resection and results of reconstruction.

PATIENTS AND METHODS

From 1988 to 2001, 12 patients underwent oesophago-gastrectomy, extended to duodenum and pancreatic head (n = 6), jejunum (n = 4), colon (n = 2), spleen (n = 2) or pancreatic body (n = 1). Early morbidity and mortality, specificities of reconstruction, and quality of oral feeding were assessed retrospectively.

RESULTS

Mean intensive care unit stay was 50 days (range: 16-152 days). All patients developed complications. Six patients were reoperated for secondary extension of caustic burns, mainly to colon (n = 4), small bowel (n = 2) and pancreas (n = 2). Three patients died on postoperative days 17, 20, and 130. Secondarily, eight patients (75%) underwent a substernal right ileocoloplasty. Six patients (50%) survived initial resection, and esophageal reconstruction. After a mean follow-up of 35 months (range: 7-87 months), four patients (33%) eat normally.

CONCLUSIONS

After caustic burn, oesogastric resections extended to surrounding organs are associated with high morbidity and mortality. However, return of normal oral feeding can be expected in 33% of cases. Secondary extension of caustic burns to adjacent organs is a common eventuality, and may lead to prompt reintervention. Massive injury to small bowel or colon may compromise digestive function or secondary esophageal reconstruction, and thus may be the reasonable limit for resection.

Role of somatostatin in the prevention of pancreatic stump-related morbidity following elective pancreaticoduodenectomy in high-risk patients and elimination of surgeon-related factors: prospective, randomized, controlled trial

A prospective, randomized, controlled trial was performed to determine the efficacy of somatostatin in the prevention of pancreatic stump-related complications with elimination of surgeon-related factors in high-risk patients undergoing pancreaticoduodenectomy. From August 1997 to December 2000, 54 patients, 28 men and 26 women, with age ranged from 32 to 89 years, were randomly assigned to somatostatin group ( n = 27) or placebo group ( n = 27). Ninety-four percent of the patients had pancreatic and periampullary lesions; 6% had secondary lesion involving the duodenum such as local recurrent colon carcinoma and renal cell carcinoma. These patients received either standard pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy. An experienced surgeon performed all operations in same fashion to minimize the surgical factor. A transanastomotic tube was inserted into the pancreatic duct for diversion of pancreatic juice in the pancreaticojejunostomy for a 3-weeks period postoperatively. Intravenous infusion of somatostatin was given at a dose of 250 microg/hr in the somastotatin group and normal saline was given to the control group for 7 days postoperatively. There was one perioperative death in each group, resulting in a 3.7% mortality rate. In the somastotatin group, as compared to the placebo group, the incidence of overall morbidity and pancreatic stump related complications were significantly lower with a mean decrease of 50% pancreatic juice output and a slightly shorter duration of hospital stays. In conclusion, after excluding surgeon related factor, prophylactic use of somatostatin reduces the incidence and severity of pancreatic stump related complications in high-risk patients having pancreaticoduodenectomy via decreased secretion of pancreatic exocrine.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial

OBJECTIVE

To determine whether temporary occlusion of the main pancreatic duct with human fibrin glue decreases the incidence of intra-abdominal complications after pancreatoduodenectomy (PD) or distal pancreatectomy (DP).

SUMMARY BACKGROUND DATA

To the authors' knowledge, there are no randomized studies comparing outcomes after pancreatic resection with or without main pancreatic duct occlusion by injection of fibrin glue. Of three nonrandomized studies, two reported no fistulas after intracanal injection and ductal occlusion with fibrin glue after PD with immediate pancreatodigestive anastomosis, while another study reported no protective effect of glue injection.

METHODS

This prospective, randomized, single-blinded, multicenter study, conducted between January 1995 and January 1999, included 182 consecutive patients undergoing PD followed by immediate pancreatic anastomosis or DP, whether for benign or malignant tumor or for chronic pancreatitis. One hundred two underwent pancreatic resection followed by ductal occlusion with fibrin glue (made slowly resorbable by the addition of aprotinin); 80 underwent resection without ductal occlusion. The main end point was the number of patients with one or more of the following intra-abdominal complications: pancreatic or other digestive tract fistula, intra-abdominal collections (infected or not), acute pancreatitis, or intra-abdominal or digestive tract hemorrhage. Severity factors included postoperative mortality, repeat operations, and length of hospital stay.

RESULTS

The two groups were similar in pre- and intraoperative characteristics except that there were significantly more patients in the ductal occlusion group who were receiving octreotide, who had reinforcement of their anastomosis by fibrin glue, and who had fibrotic pancreatic stumps. However, the rate of patients with one or more intra-abdominal complications, and notably with pancreatic fistula, did not differ significantly between the two groups. There was still no significant difference found after statistical adjustment for these patient characteristic discrepancies, confirming the inefficacy of fibrin glue. The rate of intra-abdominal complications was significantly higher in the presence of a normal, nonfibrotic pancreatic stump and main pancreatic duct diameter less than 3 mm, whereas reinforcement of the anastomosis with fibrin glue or use of octreotide did not influence outcome. In multivariate analysis, however, normal pancreatic parenchyma was the only independent risk factor for intra-abdominal complications. No significant differences were found in the severity of complications between the two groups.

CONCLUSIONS

Ductal occlusion by intracanal injection of fibrin glue decreases neither the rate nor the severity of intra-abdominal complications after pancreatic resection.

Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial

OBJECTIVE

Using a prospective randomized study to assess postoperative morbidity and pancreatic function after pancreaticoduodenectomy with pancreaticojejunostomy and duct occlusion without pancreaticojejunostomy.

SUMMARY BACKGROUND DATA

Postoperative complications after pancreaticoduodenectomy are largely due to leakage of the pancreaticoenterostomy. Pancreatic duct occlusion without anastomosis of the pancreatic remnant may prevent these complications.

METHODS

A prospective randomized study was performed in a nonselected series of 169 patients with suspected pancreatic and periampullary cancer. In 86 patients the pancreatic duct was occluded without anastomosis to pancreatic remnant, and in 83 patients a pancreaticojejunostomy was performed after pancreaticoduodenectomy. Postoperative complications were the endpoint of the study. All relevant data concerning patient demographics and postoperative morbidity and mortality as well as endocrine and exocrine function were analyzed. At 3 and 12 months after surgery, evaluation of weight loss, stools, and the use of antidiabetics and pancreatic enzyme was repeated.

RESULTS

Patient characteristics were comparable in both groups. There were no differences in median blood loss, duration of operation, and hospital stay. No significant difference was noted in postoperative complications, mortality, and exocrine insufficiency. The incidence of diabetes mellitus was significantly higher in patients with duct occlusion.

CONCLUSIONS

Duct occlusion without pancreaticojejunostomy does not reduce postoperative complications but significantly increases the risk of endocrine pancreatic insufficiency after duct occlusion.

Permeability and functionality of pancreaticogastrostomy after pancreaticoduodenectomy with dynamic magnetic resonance pancreatography after secretin stimulation

BACKGROUND

The aim of this study was to evaluate pancreatogastrostomy (PG) permeability after duodenopancreatectomy (PD) and to determine a correlation with pancreatic endocrine and exocrine functions.

STUDY DESIGN

This prospective study included 19 patients who underwent PD with PG between 1992 and 1999. There were 12 men and 7 women, with a mean age of 58 years (range 35 to 76 years). The mean interval between operation and evaluation was 40.3 months (range 3 to 104 months). Indications for pancreatectomy were benign lesions (n = 13) or adenocarcinoma (n = 6). Histology of the pancreatic resection margin was normal in all patients with malignancy, and the pancreatic remnant was macroscopically normal without evidence of obstructive pancreatitis. Pancreatic exocrine and endocrine functions were respectively evaluated by fecal-1 elastase and fasting blood glucose concentrations. PG permeability was determined by secretin magnetic resonance cholangiopancreatography (Secretin-MRCP).

RESULTS

Anastomotic permeability was considered good in seven patients (group 1, 36.8%), moderately stenosed in six patients (group 2, 31.6%), significantly stenosed in four patients (group 3, 21.1%), and obstructed in two patients (group 4, 10.5%). Fecal-1 elastase concentration was decreased in 18 patients, with a mean concentration of 80 microg/g in group 1, 98 microg/g in group 2, 67 microg/g in group 3, and 0 microg/g in group 4. There was a statistically significant correlation between Secretin-MRCP group and fecal-1 elastase concentration. Results of fasting glucose estimation were normal for 14 of 19 patients. There was no correlation between pancreatic endocrine function and Secretin-MRCP group.

CONCLUSIONS

Exocrine pancreatic insufficiency was presented in 95% of the patients despite a PG permeability in 68.4%. These results may be explained in part by neutralization of pancreatic enzymatic secretions by gastric acid.

Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy

BACKGROUND

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

DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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

Determinants of pancreaticoenteric anastomotic leak following pancreaticoduodenectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Artificial nutrition after pancreaticoduodenectomy

Patients undergoing pancreaticoduodenectomy (PD) often require postoperative artificial nutrition. This trial was undertaken to evaluate whether the route of administration and the composition of the postoperative nutritional support could affect the immunometabolic response and outcome. A prospective, randomized trial was carried out in 212 subjects who underwent PD. Patients were randomized to receive a standard enteral formula (standard group, n = 73) or an enteral formula enriched with arginine, omega-3 fatty acids, and RNA (immunonutrition group, n = 71), or total parenteral nutrition (parenteral group, n = 68). Postoperative feeding started 6 hours after surgery. The three regimens were isocaloric and isonitrogenous. Assessed parameters were phagocytosis ability of polymorphonuclear cells, plasma interleukin-2 receptors, C-reactive protein, retinol binding protein, tolerance of enteral feeding, rate of postoperative complications, and length of hospital stay (LOS). Full nutritional goal (25 kcal/kg) was achieved in 87% of enterally fed patients versus 95% in the parenteral group. Subjects receiving immunonutrition had a significantly better recovery of the immunometabolic parameters on postoperative day 8 compared to the other two groups. The rate of postoperative complications was lower in the immunonutrition group (33.8%) than in either the standard (43.8%) or parenteral group (58.8%) (p = 0.005 immunonutrition vs. parenteral). Also, the mean LOS was shorter in the immunonutrition group than in the standard and parenteral groups (15.1 vs. 17.0 vs. 18.8 days, respectively; p < 0.05). Early postoperative enteral feeding may safely and effectively replace parenteral nutrition in patients undergoing PD. Immunonutrition ameliorates the immunometabolic response and improves outcome compared to parenteral feeding.

Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial

OBJECTIVE

To evaluate the endpoints of complications (specifically pancreatic fistula and total complications) and death in patients undergoing pancreaticoduodenectomy.

SUMMARY BACKGROUND DATA

Four randomized, placebo-controlled, multicenter trials from Europe have evaluated prophylactic octreotide (the long-acting synthetic analog of native somatostatin) in patients undergoing pancreatic resection. Each trial reported significant decreases in overall complication rates, and two of the four reported significantly lowered rates of pancreatic fistula in patients receiving prophylactic octreotide. However, none of these four trials studied only pancreaticoduodenal resections, and all trials had high pancreatic fistula rates (>19%) in the placebo group. A fifth randomized trial from the United States evaluated the use of prophylactic octreotide in patients undergoing pancreaticoduodenectomy and found no benefit to the use of octreotide. Prophylactic use of octreotide adds more than $75 to the daily hospital charge in the United States. In calendar year 1996, 288 patients received octreotide on the surgical service at the authors' institution, for total billed charges of $74,652.

METHODS

Between February 1998 and February 2000, 383 patients were recruited into this study on the basis of preoperative anticipation of pancreaticoduodenal resection. Patients who gave consent were randomized to saline control versus octreotide 250 microg subcutaneously every 8 hours for 7 days, to start 1 to 2 hours before surgery. The primary postoperative endpoints were pancreatic fistula, total complications, death, and length of hospital stay.

RESULTS

Two hundred eleven patients underwent pancreaticoduodenectomy with pancreatic-enteric anastomosis, received appropriate saline/octreotide doses, and were available for endpoint analysis. The two groups were comparable with respect to demographics (54% male, median age 66 years), type of pancreaticoduodenal resection (60% pylorus-preserving), type of pancreatic-enteric anastomosis (87% end-to-side pancreaticojejunostomy), and pathologic diagnosis. The pancreatic fistula rates were 9% in the control group and 11% in the octreotide group. The overall complication rates were 34% in the control group and 40% in the octreotide group; the in-hospital death rates were 0% versus 1%, respectively. The median postoperative length of hospital stay was 9 days in both groups.

CONCLUSIONS

These data demonstrate that the prophylactic use of perioperative octreotide does not reduce the incidence of pancreatic fistula or total complications after pancreaticoduodenectomy. Prophylactic octreotide use in this setting should be eliminated, at a considerable cost savings.

[Pancreatojejunal or pancreatogastric anastomosis after cephalic duodenopancreatectomy. A comparative retrospective study]

AIM OF THE STUDY

The aim of this retrospective study was to compare pancreatico-jejunostomy vs pancreatico-gastrostomy with regard to safety of pancreatic anastomosis after pancreatico-duodenectomy.

PATIENTS AND METHODS

From January 1980 to June 1995, 171 patients underwent pancreatico-duodenectomy, 136 for pancreas, ampulla, distal bile duct or duodenum cancers, and 36 for chronic pancreatitis. Pancreatic anastomosis was realised by pancreatico-jejunostomy in 91 cases and by pancreatico-gastrostomy in 80 cases. There was no significant difference between the two groups (age, gender and primary disease). Comparison between the two groups concerned mainly postoperative mortality and morbidity.

RESULTS

The overall postoperative mortality rate was significantly higher in the pancreatico-jejunostomy group (12%) than in the pancreatico-gastrostomy group (3.7%) (P = 0.05); death was directly related to necrosis of the remnant pancreas in four cases among the 14 postoperative deaths. The postoperative morbidity rate was respectively 23% after pancreatico-jejunostomy and 12.5% after pancreatico-gastrostomy; the pancreatic leakage and/or necrosis rate was higher in the pancreatico-jejunostomy group (13%) than in the pancreatico-gastrostomy group (3.75%) (P = 0.029).

CONCLUSION

This study seems to demonstrate the superiority of the pancreatico-gastric anastomosis, but these results have to be confirmed or invalidated by a prospective multicentric randomised trial.

Pancreaticogastrostomy for reconstruction of pancreatic stump after pancreaticoduodenectomy for ampullary carcinoma

BACKGROUND

Management of the pancreatic stump after pancreaticoduodenectomy (PD) is still a matter of debate. Pancreaticojejunostomy (PJ) is used commonly but is associated with a significant incidence of pancreatic leaks. Pancreaticogastrostomy (PG) is an alternative that has been reported to be safer.

METHODS

The study is a retrospective analysis of all patients having PD for ampullary carcinoma in one surgical unit at All India Institute of Medical Sciences over 18 years, with PG being the only drainage procedure for the pancreatic stump.

RESULTS

Among 125 patients having PD for ampullary carcinoma, overall morbidity rate was 28%, mortality rate was 4.8%, with no cases of leakage from the pancreaticogastrostomy.

CONCLUSIONS

In world literature (including the current series), the leakage rate of PG is 2.5% (14 of 553) with only 2 deaths (2 of 14) due to leakage from PG. Our large experience and these data conclusively prove the safety of pancreaticogastrostomy, which should be the drainage procedure of choice for the pancreatic stump following pancreaticoduodenectomy.

Complications requiring reoperation following pancreatectomy

CONCLUSIONS

In this series, the overall reoperative rate following pancreatic surgery is 9%. Complications following pancreatectomy that require reoperation fall into four categories: hemorrhage, infectious, delayed gastric emptying, and anastomotic leak. A delay in the management of these types of complications can be fatal.

BACKGROUND

Despite the improvement in the morbidity and mortality rates associated with pancreatic resection, complication still arise that require surgical intervention. This study reviews the pancreatic surgical experience at a major medical center to determine the overall reoperative complication rate.

STUDY DESIGN

From 1985 to 1995, 107 patients underwent pancreatic resection. There were 50 pancreaticoduodenectomies, 20 total pancreatectomies, and 37 distal pancreatectomies for 102 periampullary or pancreatic cancers and five for chronic pancreatitis. The operative mortality rate was 6.5% and the morbidity rate was 43%. Ten patients (9%) developed complications that required reoperation.

RESULTS

Re-exploration was performed in five patients for hemorrhage. Four patients had bleeding intra-abdominally and one had a suture line bleed. One patient developed a wound infection and fascial necrosis which necessitated reoperation. Three patients were explored for sepsis and one was found to have a pancreatic leak. One patient had persistent gastric outlet obstruction and he required conversion of the gastrojejunostomy to a Roux-en-y anastomosis. The mortality rate for re-exploration was 3/10 (30%).