A prospective analysis of the factors influencing pancreaticojejunostomy performed using a single method, in 100 consecutive pancreaticoduodenectomies

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.

Postpancreatectomy Acute Pancreatitis (PPAP): Definition and Grading From the International Study Group for Pancreatic Surgery (ISGPS)

OBJECTIVE

The ISGPS aimed to develop a universally accepted definition for PPAP for standardized reporting and outcome comparison.

BACKGROUND

PPAP is an increasingly recognized complication after partial pancreatic resections, but its incidence and clinical impact, and even its existence are variable because an internationally accepted consensus definition and grading system are lacking.

METHODS

The ISGPS developed a consensus definition and grading of PPAP with its members after an evidence review and after a series of discussions and multiple revisions from April 2020 to May 2021.

RESULTS

We defined PPAP as an acute inflammatory condition of the pancreatic remnant beginning within the first 3 postoperative days after a partial pancreatic resection. The diagnosis requires (1) a sustained postoperative serum hyperamylasemia (POH) greater than the institutional upper limit of normal for at least the first 48 hours postoperatively, (2) associated with clinically relevant features, and (3) radiologic alterations consistent with PPAP. Three different PPAP grades were defined based on the clinical impact: (1) grade postoperative hyperamylasemia, biochemical changes only; (2) grade B, mild or moderate complications; and (3) grade C, severe life-threatening complications.

DISCUSSIONS

The present definition and grading scale of PPAP, based on biochemical, radiologic, and clinical criteria, are instrumental for a better understanding of PPAP and the spectrum of postoperative complications related to this emerging entity. The current terminology will serve as a reference point for standard assessment and lend itself to developing specific treatments and prevention strategies.

A novel hydrogel sheet prevents postoperative pancreatic fistula in a rat model

Aim

To evaluate the efficacy of a novel hydrogel sheet in preventing postoperative pancreatic fistula (POPF).

Background

Postoperative pancreatic fistula is a life‐threatening complication. As no study has reported the use of hydrogel sheets in preventing POPF, their effectiveness for that purpose remains unclear.

Methods

A novel hydrogel sheet made of polyvinyl alcohol (PVA) was prepared by the freeze‐thaw method. The pancreatic ducts and surrounding pancreatic parenchyma of rats were transected to induce a pancreatic fistula. Next, the sheet was attached to the transection site. Ascitic fluid amylase and lipase concentrations were measured. Neoveil^®, a nonwoven polyglycolic acid (PGA) felt, is already clinically used as an absorbable reinforcing material at pancreatic transection sites. Neoveil^® was used for comparison, as was VIEWGEL^®, which is marketed as a wound dressing.

Results

The hydrogel sheet remained in place 48 hours postoperatively. The ascitic amylase concentrations in the control, VIEWGEL^®‐treated, Neoveil^®‐treated, and hydrogel‐treated rats, respectively, were 4992.4 ± 5355.7, 1068.4 ± 269.1, 730.2 ± 425.2, and 303.1 ± 240.1 IU/L; the ascitic lipase concentrations were 2279.8 ± 3395.2, 169.5 ± 100.6, 90.4 ± 71.0, and 86.8 ± 59.8 IU/L. The ascitic amylase and lipase levels were significantly lower in the hydrogel group than in the other groups (P < .05).

Conclusions

This novel hydrogel sheet effectively prevents pancreatic fistulas and has promising clinical application potential.

Postoperative hyperamylasemia (POH) and acute pancreatitis after pancreatoduodenectomy (POAP): State of the art and systematic review

BACKGROUND

Postoperative hyperamylasemia is a frequent finding after pancreatoduodenectomy, but its incidence and clinical implications have not yet been analyzed systematically. The aim of this review is to reappraise the concept of postoperative hyperamylasemia with postoperative acute pancreatitis, including its definition, interpretation, and correlation.

METHODS

Online databases were used to search all available relevant literature published through June 2019. The following search terms were used: "pancreaticoduodenectomy," "amylase," and "pancreatitis." Surgical series reporting data on postoperative hyperamylasemia or postoperative acute pancreatitis were selected and screened.

RESULTS

Among 379 screened studies, 39 papers were included and comprised data from a total of 9,220 patients. Postoperative hyperamylasemia was rarely defined in most of these series, and serum amylase values were measured at different cutoff levels and reported on different postoperative days. The actual levels of serum amylase activity and the representative cutoff levels required to reach a diagnosis of postoperative acute pancreatitis were markedly greater on the first postoperative days and tended to decrease over time. Most studies analyzing postoperative hyperamylasemia focused on its correlation with postoperative pancreatic fistula and other postoperative morbidities. The incidence of postoperative acute pancreatitis varied markedly between studies, with its definition completely lacking in 40% of the analyzed papers. A soft pancreatic parenchyma, a small pancreatic duct, and pathology differing from cancer or chronic pancreatitis were all predisposing factors to the development of postoperative hyperamylasemia.

CONCLUSION

Postoperative hyperamylasemia has been proposed as the biochemical expression of pancreatic parenchymal injury related to localized ischemia and inflammation of the pancreatic stump. Such phenomena, analogous to those associated with acute pancreatitis, could perhaps be renamed as postoperative acute pancreatitis from a clinical standpoint. Patients with postoperative acute pancreatitis experienced an increased rate of all postoperative complications, particularly postoperative pancreatic fistula. Taken together, the discrepancies among previous studies of postoperative hyperamylasemia and postoperative acute pancreatitis outlined in the present review may provide a basis for stronger evidence necessary for the development of universally accepted definitions for postoperative hyperamylasemia and postoperative acute pancreatitis.

Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture

BACKGROUND

In 2016, the International Study Group of Pancreatic Fistula (ISGPS) proposed an updated definition for postoperative pancreatic fistula (POPF). Pancreas texture (PT) is an established risk factor of POPF. The definition of soft vs. hard texture, however, remains elusive.

METHODS

A systematic search was performed to identify PT definitions and a meta-analysis linking POPF to PT using the updated ISGPS definition.

RESULTS

122 studies including 22 376 patients were identified. Definition criteria for PT varied among studies and most classified PT in hard and soft based on intraoperative subjective assessment. The total POPF rate (pooled grades B and C) after pancreatoduodenectomy was 14.5% (n = 10 395) and 15.5% (n = 3767) after distal pancreatectomy. In pancreatoduodenectomy, POPF rate was higher in soft compared to hard pancreas (RR, 4.4, 3.3 to 6.1; p < 0.001; n = 6393), where PT grouped as soft and hard. No data were available for intermediate PT.

CONCLUSION

The reported POPF rates may be used in planning future prospective studies. A widely accepted definition of PT is lacking and a correlation with the risk of POPF is based on subjective evaluation, which is still acceptable. Classification of PT into 2-groups is more reasonable than classification into 3-groups.

A modified technique of pancreaticogastrostomy with short internal stent: A single surgeon's experience

BACKGROUND/OBJECTIVE

Postoperative pancreatic fistula (POPF) remains an important cause of morbidity and mortality after pancreaticoduodenectomy. Pancreaticogastrostomy (PG) as a reconstruction method after pancreaticoduodenectomy is a safe and optional surgical technique in decreasing the risk of POPF. In this study, a retrospective analysis was carried out to evaluate a new modification of PG technique that uses a two-layer anastomoses with an internal stent.

METHODS

Forty-seven patients underwent this newly modified PG technique between February 2012 and August 2016. Demographics, histopathological findings, type of surgery performed, perioperative parameters, postoperative length of stay, postoperative complications and interventional procedures, follow-up, and mortality data were collected and analyzed. Clavien-Dindo classification was used to grade the complications' severity.

RESULTS

Postoperative mortality was 4.25%, unrelated to POPF, and postoperative morbidity was 44.68%. Thirteen patients had severe (>Grade IIIa) complications, according to Clavien-Dindo classification. As classified in accordance to the International Study Group of Pancreatic Fistula, 24 (51.06%) patients developed Grade A POPF, and no occurrence of Grade B/C POPF was noted. All patients recovered uneventfully with successful treatment interventions.

CONCLUSION

The reported PG anastomotic technique is a safe and dependable reconstruction procedure with acceptable morbidity and mortality.

Randomized multicentre trial comparing external and internal pancreatic stenting during pancreaticoduodenectomy

BACKGROUND

There is no consensus on the best method of preventing postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). This multicentre, parallel group, randomized equivalence trial investigated the effect of two ways of pancreatic stenting after PD on the rate of POPF.

METHODS

Patients undergoing elective PD or pylorus-preserving PD with duct-to-mucosa pancreaticojejunostomy were enrolled from four tertiary referral hospitals. Randomization was stratified according to surgeon with a 1 : 1 allocation ratio to avoid any related technical factors. The primary endpoint was clinically relevant POPF rate. Secondary endpoints were nutritional index, remnant pancreatic volume, long-term complications and quality of life 2 years after PD.

RESULTS

A total of 328 patients were randomized to the external (164 patients) or internal (164) stent group between August 2010 and January 2014. The rates of clinically relevant POPF were 24·4 per cent in the external and 18·9 per cent in the internal stent group (risk difference 5·5 per cent). As the 90 per cent confidence interval (-2·0 to 13·0 per cent) did not fall within the predefined equivalence limits (-10 to 10 per cent), the clinically relevant POPF rates in the two groups were not equivalent. Similar results were observed for patients with soft pancreatic texture and high fistula risk score. Other postoperative outcomes were comparable between the two groups. Five stent-related complications occurred in the external stent group. Multivariable analysis revealed that soft pancreatic texture, non-pancreatic disease and high body mass index (23·3 kg/m² or above) predicted clinically relevant POPF.

CONCLUSION

External stenting after PD was associated with a higher rate of clinically relevant POPF than internal stenting. Registration number: NCT01023594 (https://www.clinicaltrials.gov).

Pancreatic surgery: evolution and current tailored approach

Surgical resection of pancreatic cancer offers the only chance for prolonged survival. Pancretic resections are technically challenging, and are accompanied by a substantial risk for postoperative complications, the most significant complication being a pancreatic fistula. Risk factors for development of pancreatic leakage are now well known, and several prophylactic pharmacological measures, as well as technical interventions have been suggested in prevention of pancreatic fistula. With better postoperative care and improved radiological interventions, most frequently complications can be managed conservatively. This review also attempts to address some of the controversies related to optimal management of the pancreatic remnant after pancreaticoduodenectomy.

Evaluation of a new modification of pancreaticogastrostomy after pancreaticoduodenectomy: anastomosis of the pancreatic duct to the gastric mucosa with invagination of the pancreatic remnant end into the posterior gastric wall for patients with cancer head of pancreas and periampullary carcinoma in terms of postoperative pancreatic fistula formation

Background/Objectives. Postoperative pancreatic fistula (POPF) remains the main problem after pancreaticoduodenectomy and determines to a large extent the final outcome. We describe a new modification of pancreaticogastrostomy which combines duct to mucosa anastomosis with suturing the pancreatic capsule to posterior gastric wall and then invaginating the pancreatic remnant into the posterior gastric wall. This study was designed to assess the results of this new modification of pancreaticogastrostomy. Methods. The newly modified pancreaticogastrostomy was applied to 37 consecutive patients after pancreaticoduodenectomy for periampullary cancer (64.86%) or cancer head of the pancreas (35.14%). Eighteen patients (48.65%) had a soft pancreatic remnant, 13 patients (35.14%) had firm pancreatic remnant, and 6 patients (16.22%) had intermediate texture of pancreatic remnant. Rate of mortality, early postoperative complications, and hospital stay were also reported. Results. Operative mortality was zero and morbidity was 29.73%. Only three patients (8.11%) developed pancreatic leaks; they were treated conservatively. Eight patients (16.1%) had delayed gastric emptying, one patient (2.70%) had minor hemorrhage, one patient (2.70%) had biliary leak, and four patients (10.81%) had superficial wound infection. Conclusions. The new modified pancreatogastrostomy seems safe and reliable with low rate of POPF. However, further prospective controlled trials are essential to support these results.

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.

Development of a novel rat model with pancreatic fistula and the prevention of this complication using tissue-engineered myoblast sheets

BACKGROUND

Pancreatic fistula (PF) is one of the most important complications of pancreatic surgery. The aims of this study were to establish a PF model in rats and to investigate the efficacy of our new method for preventing PF, which utilizes myoblast sheets made using tissue engineering techniques.

METHODS

To establish a PF model, the rats underwent transection of each of four pancreatic ducts: the gastric, duodenal, common, and splenic ducts, respectively. Their ascitic amylase and lipase levels were then measured. To investigate the efficacy of myoblast sheets at preventing PF, a myoblast sheet was attached to the pancreatic stump in the PF models. The levels of amylase and lipase in both serum and ascites were then measured, and surgical specimens were investigated pathologically.

RESULTS

The new PF model established by transecting the splenic duct in rats may prove very useful. There were no significant differences in serum amylase and lipase levels between the myoblast sheet (+) group and the sheet (-) group. However, there were significant differences in ascitic amylase and lipase levels between the two groups (p < 0.05). Among the pathological findings, the number of inflammatory cells in the myoblast sheet group was smaller than that in the control group. In addition, the presence of the myoblast sheets on the surface of the pancreatic stump was confirmed by immunofluorescence staining.

CONCLUSION

Our data demonstrate the efficacy of the new rat model of PF presented herein, and that it might be possible to prevent PF using myoblast sheets.

External stent versus no stent for pancreaticojejunostomy: a meta-analysis of randomized controlled trials

BACKGROUND

The effectiveness of an external pancreatic duct stent for reduction of the pancreatic fistula after pancreaticoduodenectomy remains controversial.

METHODS

MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials (RCTs). Reviews of each trial were conducted and data were extracted. The primary outcome was pancreatic fistula. Statistical pooling used the fixed or random effects model and reported as risk ratio (RR) or mean difference (MD) with the corresponding 95 % confidence intervals (CI).

RESULTS

Four RCTs including a total of 416 patients were detected. Methodological quality assessment revealed a better quality of all analyzed trials. Placing an external stent across pancreaticojejunal anastomosis could significantly reduce the incidence of pancreatic fistula (RR = 0.57, 95 % CI = 0.41-0.80, P = 0.001, I (2) = 0 %), overall morbidity (RR = 0.79, 95 % CI = 0.64-0.98, P = 0.03), and the length of hospital stay (MD = -3.98 days, 95 % CI = -6.42 to -1.54, P = 0.001, I (2) = 13 %). No significant difference was found in terms of hospital mortality, delayed gastric emptying, operation time, operative blood loss, blood replacement, and reoperation rate.

CONCLUSIONS

This meta-analysis provides compelling evidence that the application of an external pancreatic duct stent after pancreaticoduodenectomy can decrease the incidence of pancreatic leakage when compared with no stent. Moreover, the external drainage of pancreatic juice is associated with lower postoperative overall morbidity and shorter hospital stay.

The pancreaticojejunal anastomotic stent: friend or foe?

BACKGROUND

The efficacy of pancreaticojejunal (P-J) anastomotic stents in preventing clinically relevant postoperative pancreatic fistulas (CR-POPF) after pancreatic resection is poorly understood. We sought to compare the outcomes of stented and nonstented patients in light of recognized risk-factors for the development of CR-POPF and to determine whether outcomes differed once there was a change in practice where use of stents was abandoned.

METHODS

A total of 444 patients underwent proximal pancreatic resection with P-J reconstruction from 2001 to 2011. At the surgeon's discretion, a PJ stent (5- or 8-Fr Silastic tube) was placed in 59 patients (13.3%; 46 internal, 13 external). Demographics, comorbidities, and adjusted outcomes were evaluated between groups of nonstented (n = 385) and stented patients; these outcomes included a subgroup analysis of internally and externally stented patients. Risk factors for CR-POPF (International Study Group on Pancreatic Fistula grade B/C) development have been previously defined as soft gland, small duct size, high-risk pathology, or excessive blood loss (>1,000 mL). Outcomes were interpreted in reference to the risk factor profile (the number of absolute risk factors present; 0-4), and to the fistula risk score, a prospectively validated score which accurately predicts the risk and impact of pancreatic fistula based on these variables.

RESULTS

Preoperative demographics of age, sex, body mass index, American Society of Anesthesiologists class, and physiologic and operative severity score for the enumeration of mortality and morbidity (ie, POSSUM) score were equivalent between cohorts. The CR-POPF risk-factor profile and fistula risk score were greater in stented patients (P < .01). When compared with nonstented patients, stented patients actually had greater rates of CR-POPF (29% vs 11%), major complications (29% vs 14%), greater mean duration of stay (13.7 days vs 9.6 days), and total costs ($33,594 vs $22,411; all P < .05). When high-risk cases were scrutinized, P-J stent use did not offer protection, as CR-POPF was uniformly more common when stents were used. Rates and severity of CR-POPF did not increase when the use of stents was abandoned, further implying that they did not confer protection from fistula development. Extended postoperative imaging was available for 23 stented patients. Of these, one-third of stents were retained past 6 weeks, and one-fourth beyond 6 months. Four patients required additional procedures to manage stent-related complications.

CONCLUSION

The use of P-J stents does not decrease the incidence or severity of CR-POPF after proximal pancreatic resection, both overall and for high-risk scenarios. In some patients, P-J stents may lead to short- and long-term adverse outcomes.

Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic leakage after pancreaticoduodenectomy is often serious. Although some studies have suggested that stenting the anastomosis can reduce the incidence of this complication, the value of stenting in the setting of pancreaticoduodenectomy remains unclear.

METHODS

Studies comparing outcomes of stent versus no stent, and internal versus external stent placement for pancreaticoduodenectomy were eligible for inclusion. Pooled odds ratios (ORs) with 95 per cent confidence intervals were calculated using fixed- or random-effects models.

RESULTS

From a search of the literature published between January 1973 and September 2011, five randomized clinical trials (RCTs) and 11 non-randomized observational clinical studies (OCS) involving 1726 patients were selected for inclusion in this review. Meta-analysis of RCTs revealed that placing a stent in the pancreatic duct did not reduce the incidence of postoperative pancreatic fistula. External stents had no advantage over internal stents in terms of clinical outcome. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RCTs: OR 0·42, 0·24 to 0·76, P = 0·004; OCS: OR 0·43, 0·27 to 0·68, P < 0·001), delayed gastric emptying (RCTs: OR 0·41, 0·19 to 0·87, P = 0·02) and postoperative morbidity (RCTs: OR 0·55, 0·34 to 0·89, P = 0·02) compared with no stent.

CONCLUSION

Pancreatic duct stenting did not reduce the incidence of pancreatic fistula and other complications in pancreaticoduodenectomy compared with no stenting. Although no difference was found between external and internal stents in terms of efficacy, external stents seemed to reduce the incidence of pancreatic fistula compared with control.

Pancreatic fistula after pancreatectomy: definitions, risk factors, preventive measures, and management-review

Resection of pancreas, in particular pancreaticoduodenectomy, is a complex procedure, commonly performed in appropriately selected patients with benign and malignant disease of the pancreas and periampullary region. Despite significant improvements in the safety and efficacy of pancreatic surgery, pancreaticoenteric anastomosis continues to be the “Achilles heel” of pancreaticoduodenectomy, due to its association with a measurable risk of leakage or failure of healing, leading to pancreatic fistula. The morbidity rate after pancreaticoduodenectomy remains high in the range of 30% to 65%, although the mortality has significantly dropped to below 5%. Most of these complications are related to pancreatic fistula, with serious complications of intra-abdominal abscess, postoperative bleeding, and multiorgan failure. Several pharmacological and technical interventions have been suggested to decrease the pancreatic fistula rate, but the results have been controversial. This paper considers definition and classification of pancreatic fistula, risk factors, and preventive approach and offers management strategy when they do occur.

Effectiveness of external drainage of the bile duct in pancreaticoduodenectomy: a single surgeon's experience

BACKGROUNDS/AIMS

The rates of surgery-related complications during and after pancreaticoduodenectomy (PD) remain very high, reaching up to 41%. They were primarily caused by leakage of pancreatic juice. We evaluated the effectiveness of external drainage of the bile duct using a pigtail drain to prevent pancreatic leakage in patients undergoing PD.

METHODS

We evaluated 79 patients who underwent PD using a single-layer continuous suture between the pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis by a single surgeon from April 2005 to December 2008. Of the 79, 44 underwent external drainage (ED) of the bile duct using a pigtail drain, performed in the intraoperative field via a retrograde transhepatic approach, whereas 35 did not undergo ED.

RESULTS

Age, sex distribution, number of total complications, pancreatic duct size, pancreatic texture and duration of hospital stay did not differ between patients who did and did not undergo ED. In groups with or without ED, 0 and 4 patients, respectively, showed leakage of pancreatic juice and the difference was statistically significant (p=0.02).

CONCLUSIONS

The fact that none of the patients who underwent external drainage experienced pancreatic leakage, suggests that external drainage of the bile duct with a pigtail drain to decompress the jejunum and to drain pancreatic and bile juice is useful in preventing the complications of pancreatic leakage.

Article Commentary: Risk Factors of Pancreatic Fistula after Pancreaticoduodenectomy: A Collective Review

Postoperative pancreatic fistula (POPF) is the most frequent complication after pancreaticoduodenectomy, results in increased morbidity and mortality, and adversely affects length of stay and costs. Reported rates of postoperative pancreatic fistula vary from 0 per cent up to more than 30 per cent. Plenty of randomized trails and meta-analysis were published to analyze the ideal procedure, technique of anastomosis, and perioperative management of patients undergoing pancreaticoduodenectomy; however, results are often discordant and clear evidence on the ideal management and surgical technique to reduce POPF rate is not yet provided. This collective review examined the current evidence about risk factors contributing to postoperative pancreatic fistula and delineates methods of diagnosis and treatment of this universally dreaded complication.

Analysis of procedure-related complications after pancreatodoudenectomy

PURPOSE

To analyze the procedure-related complications after pancreaticoduodenctomy (PD) and their risk factors.

METHODS

One hundred twenty-six patients underwent pancreatoduodenectomy for diseases at region of pancreatic head were reviewed retrospectively.

RESULTS

The overall surgical morbidity was 40.5% (51/126). Ten (7.9%) of 51 patients were identified as having pancreatic leakage, others included delayed gastric emptying (8.7%, 11), abdominal infection and abscess (7.9%, 10), abdominal bleeding (5.6%, 7), wound infection (4.8%, 6), wound dehiscence (2.4%, 3), biliary fistula (1.6%, 2) and operative death (1.6%, 2). Other postoperative complications were lung inflammation (3.9%, 5) and newly developed diabetes mellitus (2.3%, 3). Age (>60 years), coexisting diabetes mellitus, small main pancreatic duct (≤0.5 cm), and surgeon's experience (<10 patients within 5 years) were demonstrated to be independent risk factors by both univariate and multivariate analysis (p < 0.01).

CONCLUSIONS

Old patients with coexisting diabetes mellitus and small main pancreatic duct undergo pancreatoduodenectomy by a less experienced surgeon may be at high risk of procedure-related complications.

Do transanastomotic pancreatic ductal stents after pancreatic resections improve outcomes?

OBJECTIVES

Despite strategies aimed at reducing a postoperative pancreatic fistula (POPF) after pancreatectomies, the overall incidence remains unchanged. One such procedure, until now incompletely explored, is transanastomotic pancreatic (TAP) ductal stenting.

METHODS

We conducted a systematic search using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1983-2008 to determine if TAP ductal stents provide any benefit and, if so, in which clinical scenarios they can be recommended.

RESULTS

Stents can be internal or external, intraoperative only, or temporary (several days). One randomized trial on internal stents across pancreaticojejunostomy (PJ) suggested a higher POPF rate in the stented group. One nonrandomized study using an internal stent for pancreaticogastrostomy (PG) revealed a 0% POPF rate. Results from studies where external stents were used across PJ/PG reported a lower incidence of POPF. No statistically significant difference was reported in a POPF incidence when internal stents were compared with externalized stents. Available data suggest improved outcomes of pancreatoenteric anastomosis when TAP ductal stent is inserted in small ducts (< or =3 mm).

CONCLUSIONS

There is insufficient evidence to support or refute improved outcomes after TAP ductal stent insertion in patients with PJ/PG with small ducts (< or =3 mm) or soft pancreata. More evidence of benefit is needed before use of external stents can be recommended.

Surgical morphology of the pancreatic isthmus

BACKGROUND

Pancreatic isthmus method anastomosis following pancreatic resection is an important factor of postoperative fistula formation. While the anatomy and vascular supply of the pancreatic head have been studied in detail, little is known about the morphology of the pancreatic isthmus. The authors determine the anatomy and morphology of the pancreatic isthmus.

METHODS

99 consecutive cadaveric pancreatic specimens were taken during standard autopsy. Organs were transected at the isthmus and pancreatograms and microscopic specimens of the transection plane were analyzed.

RESULTS

The mean size of the Wirsung duct at the isthmus was 2.89 mm (+/-0.87 mm, from 1.4 to 6 mm). The main pancreatic duct was located approximately in the middle of the pancreatic cross-section plane in almost all specimens. The total number of second-degree pancreatic ducts visible on pancreatograms within the isthmus was 1.77 (+/-1.00, from 0 to 4) and 1.83 (+/-1.4, from 0 to 5) on microscopic analysis.

CONCLUSIONS

The presence of second-degree pancreatic ducts at the transection site might favor the use of a pancreaticoenteric anastomosis with stump invagination to reduce the risk of anastomotic leakage. and IAP.

Pancreatic fistula following pancreaticoduodenectomy: clinical predictors and patient outcomes

Pancreatic fistula continues to be a common complication following PD. This study seeks to identify clinical factors which may predict pancreatic fistula (PF) and evaluate the effect of PF on outcomes following pancreaticoduodenectomy (PD). We performed a retrospective analysis of a clinical database at an academic tertiary care hospital with a high volume of pancreatic surgery. Five hundred ten consecutive patients underwent PD, and PF occurred in 46 patients (9%). Perioperative mortality of patients with PF was 0%. Forty-five of 46 PF (98%) closed without reoperation with a mean time to closure of 34 days. Patients who developed PF showed a higher incidence of wound infection, intra-abdominal abscess, need for reoperation, and hospital length of stay. Multivariate analysis demonstrated an invaginated pancreatic anastomosis and closed suction intraperitoneal drainage were associated with PF whereas a diagnosis of chronic pancreatitis and endoscopic stenting conferred protection. Development of PF following PD in this series was predicted by gender, preoperative stenting, pancreatic anastomotic technique, and pancreas pathology. Outcomes in patients with PF are remarkable for a higher rate of septic complications, longer hospital stays, but in this study, no increased mortality.

Prevention and management of pancreatic fistula

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

Distinguishing between parenchymal and anastomotic leakage at duct-to-mucosa pancreatic reconstruction in pancreaticoduodenectomy

AIM: To distinguish anastomotic from parenchymal leakage at duct-to-mucosa reconstruction of the pancreatic remnant.

METHODS: We reviewed the charts of 68 pancreaticod-uodenectomies performed between 5/2000 and 12/2005 with end-to-side duct-to-mucosa pancreatojejunostomy (PJ). The results of pancreatography, as well as peripancreatic drain volumes, and amylase levels were analyzed.

RESULTS: Of 68 pancreatojejunostomies, 48 had no leak by pancreatography and had low-drain amylase (normal); eight had no pancreatographic leak but had elevated drain amylase (parenchymal leak); and 12 had pancreatographic leak and elevated drain amylase (anastomotic leak). Although drain volumes in the parenchymal leak group were significantly elevated at postoperative day (POD) 4, no difference was found at POD 7. Drain amylase level was not significantly different at POD 4. In contrast, at POD 7, the anastomotic-leak group had significantly elevated drain amylase level compared with normal and parenchymal-leak groups (14158 ± 24083 IU/L vs 89 ± 139 IU/L and 1707 ± 1515 IU/L, respectively, P = 0.012).

CONCLUSION: For pancreatic remnant reconstruction after pancreaticoduodenectomy, a combination of pancreatogram and peripancreatic drain amylase levels can be used to distinguish between parenchymal and anastomotic leakage at pancreatic remnant reconstruction.

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.

Risk prediction for development of pancreatic fistula using the ISGPF classification scheme

BACKGROUND

The International Study Group on Pancreatic Fistula (ISGPF) classification scheme has become a useful system for characterizing the clinical impact of pancreatic fistula. We sought to identify predictive factors that predispose patients to fistula, specifically those with clinical relevance (grades B/C), and to describe the clinical and economic significance of risk stratification within this framework.

METHODS

Overall, 233 consecutive pancreatoduodenectomies were performed between October 2001 and March 2007 in our institution. Pancreatic fistula is defined according to the ISGPF classification scheme. Logistic regression analysis was performed to identify risk factors for pancreatic fistula development. These features were then analyzed to determine whether additive risk severity equates to worsening clinical and economic impact.

RESULTS

Fistulas of any extent occurred in 60 patients, but only 31 (14%) were clinically relevant. There are no identifiable risk factors for grade A biochemical fistulas. Multivariate analysis shows that small pancreatic duct size (<3 mm); soft gland texture; ampullary, duodenal, cystic, or islet cell pathology; and increased intraoperative blood loss (>1,000 ml) are associated with clinically relevant fistulae. An additive effect is further illustrated, in which clinical and economic outcomes progressively worsen as risk profile increases. Each additional risk factor increases the odds of developing a clinically relevant fistula by 52%.

CONCLUSIONS

For pancreatoduodenectomy, small duct size; soft gland texture; ampullary, duodenal, cystic, or islet cell pathology; and increased intraoperative blood loss are convincing risk factors for the development clinically relevant fistulae as judged by ISGPF classification. As risk profile accrues, patients suffer more complications, encounter longer hospital stays, and incur greater hospital costs. These outcomes can be predicted in the operating room through accurate delineation of high-risk glands.

Duct-to-mucosa pancreaticojejunostomies with a hard pancreas and dilated pancreatic duct and duct-to-mucosa pancreaticojejunostomies with a soft pancreas and non-dilated duct

BACKGROUND

We performed duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa in 55 patients, and here compare the clinical results between duct-to-mucosa pancreaticojejunostomies with a non-dilated pancreatic duct and those with a dilated duct.

PATIENTS AND METHODS

In the period 1999 to 2005, 55 patients (27 F, 28 M; mean age 63.4 years) underwent duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa. A non-dilated pancreatic duct was observe in 29 patients in group A and a dilated pancreatic duct in 26 patients in group B. Clinical characteristics (age, gender, benign or malignant condition, presence of diabetes mellitus, anastomotic time) were analyzed in both groups and postoperative complications were compared between groups.

RESULTS

In a comparison of clinical characteristics, all factors were similar between groups. In group A, the postoperative complication occurred in 4 (wound infection in 2, pulmonary embolism in 1, gastric ulcer in 1) of 29 patients (13.8%), and in group B in 1 (pneumothorax) of 26 patients (3.8%). No pancreatic leakage was observed in either group. The difference between group A and group B in the rate of postoperative complication was not statistically significant.

CONCLUSIONS

There was no statistical difference in the rate of postoperative complications, including pancreatic leakage, between duct-to-mucosa pancreaticojejunostomies with a dilated pancreatic duct and those with a non-dilated duct. We consider that the diameter of the pancreatic duct is irrelevant to results of duct-to-mucosa pancreaticojejunostomy.

Selective Administration of Prophylactic Octreotide During Pancreaticoduodenectomy: A Clinical and Cost-Benefit Analysis in Low- and High-Risk Glands

BACKGROUND

The efficacy of prophylactic octreotide after pancreaticoduodenectomy has been rigorously scrutinized, yet few studies have specifically illustrated its impact in patients at high risk for pancreatic fistula. Applying a previously validated clinical classification scheme (International Study Group on Pancreatic Fistula) for postoperative pancreatic fistula severity, we examined whether prophylactic octreotide could effectuate a clinical or fiscal benefit, or both, after pancreatic resection.

STUDY DESIGN

There were 227 consecutive patients who underwent pancreaticoduodenectomy from October 2001 to January 2007. At the surgeon's discretion, prophylactic octreotide was administered intraoperatively and continued postoperatively. Clinically relevant fistulas, requiring therapeutic interventions or resulting in severe clinical sequelae, were identified, as were other complications. Through multivariate analysis, risk factors for fistula were defined as soft gland texture; small duct size; ampullary, duodenal, cystic, or islet cell pathology; and increased blood loss. Beyond a traditional review of clinical outcomes, a novel economic cost-benefit analysis of octreotide prophylaxis was performed, with concentration of impact on high-risk glands (one or more risk factors).

RESULTS

Overall, 55% of patients had at least one risk factor. Clinically relevant fistulas were present in 14.9% of all patients. High-risk glands resulted in significantly worse clinical and economic outcomes compared with low-risk glands (no risk factors present). Prophylactic octreotide in low-risk glands was neither clinically effective nor cost efficient after pancreaticoduodenectomy, contributing to $781 in overspending per patient--approximately equivalent to a 7-day postoperative course of octreotide. But in patients with high-risk glands, octreotide prophylaxis was associated with a decreased incidence (20% versus 35%) and morbidity of clinically relevant fistulas. These improved clinical outcomes were associated with reduced resource use, translating to considerable cost savings ($11,849) per high-risk patient.

CONCLUSIONS

Octreotide prophylaxis is an effective approach to mitigate the negative impact of pancreatic fistulas, but to obtain maximal clinical value and cost benefit, octreotide should be administered exclusively to patients with high-risk glands.

Emprego da anastomose pancreatojejunal tipo ducto-mucosa sem cateter transanastomótico em pâncreas de consistência mole e ducto fino: experiência inicial do Instituto Nacional de Câncer

OBJETIVO: O objetivo deste trabalho foi relatar a morbimortalidade associada à técnica de reconstrução pancreática utilizando anastomose pancreato-jejunal tipo ducto-mucosa, sem cateter transanastomótico, em pâncreas de consistência mole e ducto de Wirsung menor que três mm. MÉTODOS: Analisamos consecutivamente os resultados de 16 pacientes submetidos à GDP com técnica de anastomose pancreato-jejunal tipo ducto-mucosa no Serviço de Cirurgia Abdômino-pélvica do INCA. Todos pacientes eram portadores de pâncreas de consistência mole e ducto pancreático fino (< 3mm). RESULTADOS: Dos 16 pacientes analisados, oito eram do sexo masculino e com mediana de idade de 55 anos. No período pós-operatório um paciente apresentou fístula pancreática e houve um caso que evoluiu para óbito. CONCLUSÃO: Acreditamos que é possível a realização de anastomose pancreática tipo ducto-mucosa, sem cateter transanastomótico, em pacientes com ducto pancreático menor que três mm sem aumento da morbimortalidade.

Pancreatic fistula after pancreaticoduodenectomy: diagnosed according to International Study Group Pancreatic Fistula (ISGPF) definition

AIMS

The aim of the study is to validate a new classification of pancreatic fistula (PF) and to document risk factors for PF.

METHODS

A retrospective study was performed on 100 patients who underwent pancreaticoduodenectomy (PD) within a 2-year period. PF was diagnosed according to the criteria developed by an International Study Group on Pancreatic Fistula (ISGPF). Sixteen pre- and intraoperative risk factors for PF were analyzed.

RESULTS

Of 100 patients 32 developed PF; grade A in 21 patients, grade B in 10, and grade C in 1. Four risk factors including pathological diagnosis, concomitant surgery, diameter of pancreatic duct, and texture of the remnant pancreas were found to be significantly associated with PF by univariate analysis. Texture of the remnant pancreas and concomitant surgery were demonstrated to be independent risk factors by multivariate logistic regression. If a PF occurred, advanced age was found to be a risk factor for PF grade B by univariate analysis, but age was not an independent risk factor by multivariate logistic regression.

CONCLUSIONS

The status of the remnant pancreas is identified asa substantial risk factor for PF after PD. When soft remnant pancreas is encountered, more careful handling is required in an attempt to minimize the rate of PF. This study confirms that the ISGPF classification of PF is useful.

Jejunal loop drainage versus direct pancreatic duct drainage after pancreatic head resection

PURPOSE

Perioperative mortality after pancreatic head resection has fallen to below 5% in high-volume centers, but dehiscence of the pancreatojejunostomy remains a major concern. Despite various methods of protection, insufficiency rates still range from 6% to 19%. External drainage of pancreatic juice from the anastomotic site has shown promising results in the last decade. We compared the morbidity and mortality of two widely used drainage systems.

METHODS

The subjects were 143 patients who underwent pancreatic head resection, followed by jejunal loop drainage with the top of the drain being placed between the pancreatojejunostomy and hepaticojejunostomy in 89, and by direct drainage of the pancreatic duct in 54.

RESULTS

The median age was similar in both groups. Pancreatic fistula developed in 3 (5%) patients with a pancreatic drain and 6 (7%) with a loop drain. Breakdown of the pancreatojejunostomy occurred in 1 (2%) patient with a pancreatic drain and 2 (2%) with a loop drain. The overall perioperative mortality was 0.7%. The surgical and medical complications and postoperative course were similar in the two groups.

CONCLUSION

The choice of drainage system did not impact on the number or severity of postoperative complications or survival, indicating that loop drainage is as safe and effective as direct pancreatic duct drainage.

Duodenopancreatectomia: avaliação dos resultados em 41 pacientes

OBJETIVO: Apresentar os resultados do Hospital Israel Pinheiro - IPSEMG em 41 duodenopancreatectomias realizadas para neoplasias. MÉTODO: Foram coletados dados referentes a 41 pacientes submetidos a duodenopancreatectomias entre 1997 e 2004. A principal operação realizada foi a Whipple "clássica" sem preservação do piloro. A anastomose pancreático-jejunal foi realizada por meio de sutura ducto-mucosa. Foram analisadas a mortalidade e as complicações pós-operatórias. Para avaliar se havia diferença de resultados com a maior experiência da equipe, o estudo foi dividido em dois períodos de quatro anos cada: 1997 a 2000 e 2001 a 2004. RESULTADOS: As complicações pós-operatórias ocorreram em 58% dos casos e a mortalidade foi de 22%. As principais complicações foram pneumonia e infecção de ferida operatória. Quatro pacientes (10%) evoluíram com fistulas pancreáticas, porém obteve-se sucesso com o tratamento conservador em todos os casos. A necessidade de hemotransfusão no peroperatório relacionou-se a um pior prognóstico. Observou-se uma redução das taxas de morbi-mortalidade no período de 2001 a 2004, entretanto sem significância estatística. Os pacientes apresentaram sobrevida global em cinco anos de 35% e de 26% quando considerados apenas aqueles com adenocarcinoma de cabeça de pâncreas. CONCLUSÕES: A duodenopancreatectomia é um procedimento cirúrgico complexo, com elevada morbi-mortalidade. Entretanto, com o aumento da experiência das equipes cirúrgica, anestésica e de medicina intensiva, observa-se uma redução nas taxas de complicação.

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.

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.

Morbimortalidade relacionada à técnica de anastomose pancreática (ducto-mucosa x telescopagem) após cirurgia de Whipple

OBJETIVOS: A gastroduodenopancreatectomia (GDP) é atualmente a única forma de tratamento segura e eficaz para pacientes selecionados com doenças benignas e malignas do pâncreas e da região periampular. Entre as complicações pós-operatórias, a fístula pancreática continua sendo a mais importante, com uma incidência que varia de 5 a 25% nas grandes séries. Os objetivos deste trabalho são os de avaliar a morbimortalidade relacionada a duas técnicas de anastomoses pancreatojejunais (ducto-mucosa X telescopagem), e comparar seus resultados. MÉTODO: Foram analisados retrospectivamente 64 pacientes submetidos à GDP, no Serviço de Cirurgia Abdômino-Pélvica, do INCA, no período de 1987 a 2002. Destes doentes, 42 foram submetidos à anastomose tipo ducto-mucosa e 22 à telescopagem. A análise estatística foi realizada através do teste de Fischer. RESULTADOS: A taxa de fístula pancreática no grupo ducto-mucosa foi de 12% e no telescopagem foi 36%. Esta diferença percentual se mostrou estatisticamente significativa (p = 0,02). A mortalidade operatória relacionada à fístula pancreática foi de 2,4% para o grupo ducto-mucosa e 4,5% para o telescopagem, com nível de significância estatística > 5%. CONCLUSÕES: A técnica de anastomose pancreatojejunal tipo ducto-mucosa é associada a menores índices de fístula pancreática em relação a técnica de telescopagem, enquanto que a mortalidade operatória relacionada a fístula não mostrou diferença estatística entre os dois grupos estudados.

Complications of pancreatic surgery

Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.

Complications of temporary pancreatic stent insertion for pancreaticojejunal anastomosis during pancreaticoduodenectomy

BACKGROUND

Morbidity associated with pancreaticoduodenectomy usually results from complications associated with the pancreaticojejunal anastomosis, in particular, a pancreatic leak. Four patients with retained transanastomotic pancreatic stent-induced complications after pancreaticduodenectomy were identified.

METHODS

Medical records for the 4 patients were reviewed, and telephone interviews were conducted.

OBSERVATIONS

Each patient underwent pancreaticoduodenectomy for a peripapillary tumor with creation of a pancreaticojejunal anastomosis by using an internal 8F Silastic stent. Subsequent evaluation for steatorrhea (n=3) or recurrent pancreatitis (n=1) led to discovery of a retained pancreatic stent. In one patient, the stent was incidentally discovered. Steatorrhea significantly improved (n=1) or resolved (n=2) after stent removal. The patient with pancreatitis has not experienced another episode.

CONCLUSIONS

The possibility of a retained stent should be considered in patients presenting with steatorrhea or pancreatitis after pancreaticoduodenectomy.

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.

Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery

BACKGROUND

Anastomotic leak after gastrointestinal surgery is an important postoperative event that leads to significant morbidity and mortality. Postoperative leak rates are frequently used as an indicator of the quality of surgical care provided. Comparison of rates between and within institutions depends on the use of standard definitions and methods of measurement of anastomotic leak. The aim of this study was to review the definition and measurement of anastomotic leak after oesophagogastric, hepatopancreaticobiliary and lower gastrointestinal surgery.

METHODS

A systematic review was undertaken of the published literature. Searches were carried out on five bibliographical databases (Medline, Embase, The Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and HealthSTAR) for English language articles published between 1993 and 1999. Articles were critically appraised by two independent reviewers and data on definition and measurement of anastomotic leak were extracted.

RESULTS

Ninety-seven studies were reviewed and a total of 56 separate definitions of anastomotic leak were identified at three sites: upper gastrointestinal (13 definitions), hepatopancreaticobiliary (14) and lower gastrointestinal (29). The majority of studies used a combination of clinical features and radiological investigations to define and detect anastomotic leak.

CONCLUSION

There is no universally accepted definition of anastomotic leak at any site. The definitions and values used to measure anastomotic failure vary extensively and preclude accurate comparison of rates between studies and institutions.