Marginal ulceration after pylorus-preserving pancreaticoduodenectomy

A Prospective Study of Neoadjuvant Gemcitabine Plus Nab-paclitaxel in Patients with Borderline-resectable Pancreatic Cancer

Objectives Neoadjuvant therapy followed by radical resection improves the borderline-resectable pancreatic cancer (BRPC) prognosis; however, the optimal therapeutic regimen remains unclear. Gemcitabine plus nab-paclitaxel (GnP) showed a high anti-tumor effect in primary lesions in a prospective study for metastatic disease. However, evidence concerning its feasibility is still lacking in patients with BRPC. We therefore evaluated the tolerability of neoadjuvant GnP (NAC-GnP) for BRPC. Methods This single-center prospective study evaluated 10 patients with BRPC who were treated with two cycles of NAC-GnP. The primary endpoint was feasibility for NAC-GnP. Treatment feasibility was defined as a successful outcome in at least eight patients. Results Ten patients who had BRPC in contact with the celiac artery (n=5), superior mesenteric artery (n=3), or hepatic artery (n=2) were enrolled. The median age was 75 (range, 40-82) years old. Grade 3 anorexia and grade 2 pneumonia occurred in one patient each, so treatment was feasible in eight patients. The median primary tumor reduction and response rates were 33% (range, 0-68%) and 60%, respectively. Six of eight patients who had abnormal CA19-9 levels at the time of enrolment showed a decrease in CA19-9 levels, with a median decrease of 72%. Five patients underwent radical resection, including R0 resection in four. Postoperative grade IIIa Clavien-Dindo complications occurred in one patient (upper gastrointestinal bleeding and pancreatic fistula). Conclusion Two-cycle NAC-GnP is a feasible treatment for patients with BRPC. Further studies on NAC-GnP in patients with BRPC are warranted.

Clinical outcomes of marginal ulcer bleeding compared with those of peptic ulcer bleeding

BACKGROUND

Marginal ulcer bleeding (MUB) is a complication that can occur following several types of surgery. However, few studies exist on it. Therefore, this study aimed to compare the clinical outcomes of MUB with those of peptic ulcer bleeding (PUB).

METHODS

Between January 2013 and December 2017, 5,076 patients underwent emergent esophagogastroduodenoscopy for suspected upper gastrointestinal bleeding. We retrospectively reviewed and analyzed the medical records of MUB and PUB patients and developed a propensity score matching (PSM) method to adjust for between-group differences in baseline characteristics with 1:2 ratios. Sex, age, body mass index (BMI), underlying diseases, and drugs were included as matching factors.

RESULTS

A total of 64 and 678 patients were diagnosed with MUB and PUB, respectively, on emergent esophagogastroduodenoscopy, and 62 and 124 patients with MUB and PUB, respectively, were selected after PSM. Rebleeding was significantly higher in patients with MUB than in those with PUB (57.8% vs 9.1%, p < 0.001). Mortality caused by bleeding was higher in patients with MUB than in those with PUB (4.7% vs. 0.4%, p < 0.001). Multivariate analysis revealed that proton pump inhibitor (PPI) administration (odds ratio [OR], 0.14; 95% confidence interval [CI], 0.03-0.56; p = 0.011) after first bleeding was inversely correlated with MUB rebleeding. Large ulcer size (> 1 cm) (OR, 6.69; 95% CI, 1.95-27.94; p = 0.005) and surgery covering pancreas (OR, 3.97; 95% CI, 1.19-15.04) were independent risk factors for MUB rebleeding.

CONCLUSIONS

MUB showed a severe clinical course than PUB. Therefore, MUB should be managed more cautiously, especially for large ulcers and pancreatic surgery. Prophylactic PPI administration may be helpful in reducing rebleeding in MUB.

Acetazolamide-eluting biodegradable tubular stent prevents pancreaticojejunal anastomotic leakage

Postoperative pancreatic fistula at the early stage can lead to auto-digestion, which may delay the recovery of the pancreaticojejunal (PJ) anastomosis. The efficacy and safety of an acetazolamide-eluting biodegradable tubular stent (AZ-BTS) for the prevention of self-digestion and intra-abdominal inflammatory diseases caused by pancreatic juice leakage after PJ anastomosis in a porcine model were investigated. The AZ-BTS was successfully fabricated using a multiple dip-coating process. Then, the drug amount and release profile were analyzed. The therapeutic effects of AZ were examined in vitro using two kinds of pancreatic cancer cell lines, AsPC-1 and PANC-1. The efficacy of AZ-BTS was assessed in a porcine PJ leakage model, with animals were each assigned to a leakage group, a BTS group and an AZ-BTS group. The overall mortality rates in these three groups were 44.4%, 16.6%, and 0%, respectively. Mean α-amylase concentrations were significantly higher in the leakage and BTS groups than in the AZ-BTS group on day 2-5 (p < 0.05 each all). The luminal diameters and areas of the pancreatic duct were significantly larger in the leakage group than in the BTS and AZ-BTS groups (p < 0.05 each all). These findings indicate that AZ-BTS can significantly suppress intra-abdominal inflammatory diseases caused by pancreatic juice leakage and also prevent late stricture formation at the PJ anastomotic site in a porcine model.

Risk factors for perforated marginal ulcers following pancreaticoduodenectomy and prospective analysis of marginal ulcer development

Background

Perforated marginal ulcers (PMUs) are a feared long-term complication following pancreaticoduodenectomy (PD), which always require relaparotomy compared to marginal ulcers.

Methods

First, we performed a retrospective chart review for all patients who underwent PD from 2007-2016 to identify incidence and risk factors associated with PMUs. Second, we analyzed follow up gastroscopies in all patients undergoing PD from 2007-2011 to identify the overall incidence of marginal ulcers.

Results

A total of 725 patients underwent PD in the retrospective study period. 17 patients (2.3%) suffered from PMU at a median postoperative time of 13 months. These patients were significantly younger (median age: 49 vs. 62 years; P=0.02) and suffered most often from chronic pancreatitis (P<0.001). Smoking and alcohol consumption were significantly more common (P=0.01 and P=0.023). An elevated level of carcinoembryonic antigen and chronic pancreatitis were identified as independent risk factors. Overall, 373 patients were enrolled for prospective analysis. Marginal ulcers occurred in 5-5.9% over a postoperative period of 5 years.

Conclusions

Continuous treatment with proton-pump inhibitors for at least 5 years, immediate smoking cessation and follow-up gastroscopies are obligate for patients undergoing PD to avoid marginal ulcers and PMUs.

Effect of Flowable Thrombin-Containing Collagen-Based Hemostatic Matrix for Preventing Pancreatic Fistula after Pancreatectomy: A Randomized Clinical Trial

Background: The aim of this study was to evaluate the safety and efficacy of a flowable hemostatic matrix, and their effects for postoperative pancreatic fistula (POPF) after pancreatectomy. Methods: This was a randomized, clinical, single-center, single-blind (participant), non-inferiority, phase IV, and parallel-group trial. The primary endpoint was the incidence of POPF. The secondary endpoints were risk factors for POPF, drain removal days, incidence of complication, 90-day mortality, and length of hospital stay. Results: This study evaluated a total of 53 patients, of whom 26 patients were in the intervention group (flowable hemostatic matrix) and 27 patients were in the control group (thrombin-coated collagen patch). POPF was more common in the control group than in the intervention group (59.3% vs. 30.8%, p = 0.037). Among participants who underwent distal pancreatectomy, POPF (33.3% vs. 92.3%, p = 0.004), and clinically relevant POPF (8.3% vs. 46.2%, p = 0.027) was more common in the control group. A multivariate logistic regression model identified flowable hemostatic matrix use as an independent negative risk factor for POPF, especially in cases of distal pancreatectomy (DP) (odds ratio 17.379, 95% confidential interval 1.453–207.870, p = 0.024). Conclusion: Flowable hemostatic matrix application is a simple, feasible, and effective method of preventing POPF after pancreatectomy, especially for patients with DP. Non-inferiority was demonstrated in the efficacy of preventing POPF in the intervention group compared to the control group.

Perforation of anastomotic peptic ulcer following pancreaticoduodenectomy: a report of three cases

BACKGROUND

Perforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention.

CASE PRESENTATION

Marginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65-79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients.

CONCLUSIONS

Lack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.

Symptomatic marginal ulcer after pancreatoduodenectomy

BACKGROUND

Marginal ulcer is a well-known complication after pancreatoduodenectomy. In light of increasing long-term survival after pancreatoduodenectomy, the identification of risk factors and preventive strategies are of utmost importance. We assessed the incidence, clinical impact, and potential risk factors of marginal ulcer after pancreatoduodenectomy.

METHODS

A prospectively maintained database of patients undergoing pancreatoduodenectomy was analyzed retrospectively. Univariate and bivariate competing-risk Cox regression analyses were performed to identify risk factors for marginal ulcer.

RESULTS

Two hundred and fifty-five consecutive patients underwent pancreatoduodenectomy. The median follow-up was 35.7 months. Marginal ulcer was diagnosed in 19 patients (7.5%), and the median time from pancreatoduodenectomy to marginal ulcer diagnosis was 450 days. Thirteen of these 19 patients presented with abdominal pain, melena, or anemia. In all these 13 patients, marginal ulcer resolved with proton pump inhibitor therapy and endoscopic surveillance. Six patients with marginal ulcer presented with an acute abdomen and underwent emergency laparotomy for marginal ulcer perforation and peritonitis. There was no marginal ulcer-related mortality. Univariate and bivariate competing-risk analyses showed an increased risk for marginal ulcer with discontinuation of proton pump inhibitor therapy, smoking, alcohol intake, and the use of non-steroidal anti-inflammatory drugs. Discontinuation of proton pump inhibitor therapy was an independent risk factor for marginal ulcer development.

CONCLUSION

Marginal ulcer is a relevant long-term complication after pancreatoduodenectomy that occurs more frequently after proton pump inhibitor therapy is discontinued. Based on our data, permanent use of proton pump inhibitor after pancreatoduodenectomy is strongly recommended especially for those patients who smoke, consume alcohol, or use non-steroidal anti-inflammatory drugs.

Analysis of Symptomatic Marginal Ulcers in Patients Who Underwent Pancreaticoduodenectomy for Periampullary Tumors

OBJECT

The objectives are to investigate the incidence and risk factors associated with symptomatic marginal ulcer (sMU) and analyze their relationship with the use of prophylactic proton pump inhibitors (PPIs) after pancreaticoduodenectomy.

METHODS

Clinical postoperative outcomes of 72 sMU and 1266 non-sMU were compared and analyzed. We performed a subanalysis of 72 patients with sMU diagnosed within (n = 18) and after 4 months (n = 54). The risk factors associated with sMU incidence were analyzed.

RESULTS

Of the 1338 patients, 72 (5.4%) were diagnosed as having sMU. Eighteen patients (25.0%) were diagnosed during the first 4 months, and 48 (66.7%), within 16 months. Cumulative sMU incidence differed according to the duration of prophylactic PPI use (≥4 months: 7.1% vs <4 months: 10.1%, P < 0.001). The duration of prophylactic PPI use was identified as a risk factor in the multivariable analysis (hazard ratio, 2.294; 95% confidence interval, 1.436-3.664; P = 0.001).

CONCLUSIONS

Two-thirds or more of the patients were diagnosed as having sMU within 16 months after surgery. The duration of the prophylactic PPI use was an independent risk factor. We recommend the use of prophylactic PPI for more than 16 months after pancreaticoduodenectomy for periampullary tumors.

Is antisecretory therapy after pancreatoduodenectomy necessary? Meta-analysis and contemporary practices of pancreatic surgeons

BACKGROUND

Marginal ulcer (MU) is a well-described complication of pancreatoduodenectomy (PD) whose incidence remains unclear. Gastric antisecretory medications likely attenuate the risk of marginal ulceration after PD; however, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known. The aims of this study were to document the incidence of MU after PD, identify any relationship between MU and gastric antisecretory medication, and survey current practice of MU prophylaxis among experienced pancreatic surgeons.

METHODS

the MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials, and Cochrane Database of Systematic Reviews databases were searched from their inception to May 2014 for abstracts documenting ulceration after pancreatoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Contemporary practice was assessed through a four-question survey distributed globally to 200 established pancreatic surgeons.

RESULTS

After a review of 208 abstracts, 54 studies were graded as relevant. These represented a cohort of 212 patients with marginal ulcer after PD (n = 4794). A meta-analysis of the included references shows mean incidence of ulceration after PD of 2.5% (confidence interval (CI) 1.8-3.2%) with a median time to diagnosis of 15.5 months. Pylorus preservation was associated with a MU rate of 2.0% (CI 1.0-2.9%), while "classic" PD procedures report an overall rate of 2.6% (CI 1.6-3.6%). Documented use of postoperative antisecretory medication was associated with a reduced rate of 1.4% (CI 0.1-1.7%). One hundred forty-four of 200 (72%) surveys were returned, from which it was determined that 92% of pancreatic surgeons have dealt with this complication, and 86% routinely prescribe prophylactic antisecretory medication after PD.

CONCLUSIONS

The incidence of MU after PD is 2.5% with a median time to occurrence of 15.5 months postoperatively. Gastric antisecretory medication prescription may affect the incidence of MU. The majority of pancreatic surgeons surveyed have encountered MU after PD; most (86%) routinely prescribe prophylactic gastric antisecretory medication.

Morbidity among long-term survivors after pancreatoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

Because pancreatoduodenectomy for pancreatic adenocarcinoma is focused on disease-free and overall survival, morbidity among long-term survivors is not well described. This study sought to evaluate outcomes for long-term survivors of pancreatic cancer after pancreatoduodenectomy.

METHODS

The authors identified 29 patients from their prospectively collected database of patients with pancreatic adenocarcinoma who had undergone pancreatoduodenectomy and were without evidence of disease during at least 3 years of follow-up evaluation. Demographics, treatment, and pathologic characteristics were collected for review. Data with regard to long-term sequelae also were collected, focusing on those complications requiring additional procedures and on the development of metachronous cancers.

RESULTS

The median follow-up period was 83 months, with 62 % of patients still alive. All patients received an R0 resection, and 34 % of the patients had N1 disease. For 42 % of the patients, no significant subsequent sequelae occurred. In the four remaining patients (14 %), ascites developed, requiring repeated paracentesis or Denver shunt, with a median time to development (MTD) of 63 months. Six patients (21 %) experienced a biliary stricture requiring stent placement (MTD, 56 months). One patient experienced portal venous thrombosis requiring a venous stent (MTD, 52 months), and four patients (14 %) experienced clinically significant ulcers (MTD, 52 months). With regard to metachronous cancers, two patients experienced subsequent lymphomas (MTD, 92 months).

CONCLUSIONS

Long-term survivors among patients who undergo pancreatoduodenectomy for pancreatic adenocarcinoma can experience significant late sequelae, which often manifest more than 3 years after surgery. As such, continued follow-up evaluation and counseling are warranted.

Does modified Braun enteroenterostomy improve alkaline reflux gastritis and marginal ulcer after pancreaticoduodenectomy?

BACKGROUND

The safety of pancreaticoduodenectomy has improved significantly. However, alkaline reflux gastritis and marginal ulcer are two substantial problems after pancreaticoduodenectomy.

AIMS

To identify whether Child reconstruction with a modified Braun enteroenterostomy decreases the incidence of alkaline reflux gastritis and marginal ulcer after pancreaticoduodenectomy better than Roux-en-Y reconstruction.

METHODS

Data on 57 consecutive patients who underwent standard pancreaticoduodenectomy between January 1, 2008 and January 31, 2012 were collected prospectively. Data on early and late complications of the Child reconstruction with a modified Braun enteroenterostomy and Roux-en-Y were gathered. The risk factors of alkaline reflux gastritis and marginal ulcer were also investigated by using univariate and multivariate analyses.

RESULTS

Twenty-five patients received Roux-en-Y and 32 underwent Child reconstruction with a modified Braun enteroenterostomy. Early complications after the two reconstruction methods were insignificant. Significant differences in terms of later postoperative morbidity (P = 0.01) and change in body mass index (P = 0.03) were found 12 months after pancreaticoduodenectomy. No significant difference for alkaline reflux gastritis was observed between the two methods (14.8 vs. 28.6 %, P = 0.24). Marginal ulcer occurred significantly lower in patients with the modified reconstruction than in those with Roux-en-Y reconstruction (11.1 vs. 47.6 %, P = 0.01). Peptic ulcer history, diabetes mellitus, and reconstruction type had a significant effect on marginal ulcer formation.

CONCLUSIONS

Child reconstruction with a modified Braun enteroenterostomy offers an advantage with respect to marginal ulcer after standard pancreaticoduodenectomy, potentially decreasing the incidence of alkaline reflux gastritis as effectively as Roux-en-Y reconstruction.

Preservation of the pyloric ring has little value in surgery for pancreatic head cancer: a comparative study comparing three surgical procedures

BACKGROUND

Pylorus-preserving pancreatoduodenectomy (PPPD) has replaced conventional pancreatoduodenectomy with a distal gastrectomy (cPD) as the most commonly performed procedure. However, there has been no evidence from prospective studies to indicate the overwhelming superiority of PPPD over cPD. A recent report revealed that resection of the pyloric ring reduced the incidence of delayed gastric emptying (DGE) in a randomized controlled trial.

METHODS

In 158 patients with pancreatic head cancer, the perioperative outcomes and long-term nutritional consequences were retrospectively compared among three types of pancreatoduodenectomy: cPD; PPPD; and subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pyloric ring and duodenum were removed and more than 90% of the stomach was preserved.

RESULTS

The incidence of DGE was significantly higher in the PPPD group than in the cPD and SSPPD groups (27.3 vs. 5.8 and 5.4%, respectively; P = 0.0012). The serum albumin concentration and total lymphocyte count at 1 year postoperatively were significantly higher in the SSPPD group than in the PPPD group (P = 0.0303 and P = 0.0203, respectively). The patients in the SSPPD group showed longer survival times than the patients in the cPD and PPPD groups (median survival times, 21.3, 17.1, and 17.7 months, respectively), although the differences did not reach statistical significance.

CONCLUSIONS

Our results suggest that preservation of the pyloric ring without vagal innervation has little significance, and that SSPPD with better perioperative and long-term outcomes is more suitable as a standard procedure for patients with pancreatic head cancer.

Reflux esophagitis and marginal ulcer after pancreaticoduodenectomy

BACKGROUND

Reflux esophagitis is a common complication following a distal gastrectomy. Increasingly, Roux-en-Y reconstruction has been used to prevent reflux esophagitis; however, marginal ulcer is a concern in patients with a Roux-en-Y reconstruction after distal gastrectomy. The effect of Roux-en-Y reconstruction on the development of reflux esophagitis and marginal ulcer after pancreaticoduodenectomy (PD) has not been studied.

METHODS

We retrospectively studied both reflux esophagitis and marginal ulcer after 371 PDs and analyzed the association with different methods of gastrointestinal reconstruction.

RESULTS

In a median follow-up time of 20 months, 40 (10.8%) of the 371 patients developed reflux esophagitis, 15 after 158 standard PD, and 25 after 213 pylorus-preserving pancreaticoduodenectomy (PPPD; P = 0.62). Cox regression model showed Roux-en-Y reconstruction was significantly inversely related to occurrence of reflux esophagitis in 158 patients after standard PD (P = 0.04) but not in 213 patients after PPPD (P = 0.24). Thirty-five of 371 studied patients developed marginal ulcer, 15 after standard PD and 20 after PPPD (P = 0.45). Multivariate analysis showed that Roux-en-Y reconstruction was the only significant predictor for marginal ulcer after PD (P = 0.02).

CONCLUSIONS

Our data support the use of Roux-en-Y reconstruction after standard PD but not after PPPD.

[Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation. A systematic review with meta-analysis]

BACKGROUND

Two surgical procedures are mainly performed for the treatment of pancreatic head cancer and periampullary carcinoma: the classical Whipple operation and the pylorus-preserving Whipple operation.

METHODS

This manuscript represents an extension of a systematic review and meta-analysis previously published in the Annals of Surgery. A systematic literature search was performed in MEDLINE, EMBASE and the Cochrane Library (central) to identify randomized controlled trials (RCTs) and observational studies. A meta-analysis based on a random-effects model was performed for the hazard ratios (HR) of survival and the odds ratios (OR) of postoperative mortality. The results of the different studies on quality of life (QoL) could not be summarized quantitatively in a meta-analysis and were therefore summarized qualitatively. Subgroup analyses were performed by study type, RCTs, prospective cohort studies (PSs), retrospective cohort studies (RSs), study quality and tumor localization (pancreatic head cancer versus periampullary carcinoma).

RESULTS

The systematic literature search retrieved 4,503 studies of which 4,460 did not fulfill the inclusion criteria. The remaining 43 studies (6 RCTs, 12 PSs and 25 RSs) representing 3,893 patients were finally included in the review. There was neither a significant survival difference for patients with pancreatic head cancer in the pooled estimate of the RCTs (HR 0.80; 95% CI 0.53-1.22; p=0.16) nor in the pooled estimate of the PSs (HR 0.84; 95% CI 0.7-1.0; p=0.95) or the RSs (HR 0.84; 95% CI 0.7-1.01; p=0.21). Survival of patients with periampullary carcinoma was not significantly different in the RCTs (HR 1.02; 95% CI 0.49-2.13; p=0.3), the PSs (HR 1.26; 95% CI 0.46-3.42; p=0.65) or the RSs (HR 0.86; 95% CI 0.6-1.24; p=0.33). Postoperative mortality was not significantly different after both types of operations (RCTs: HR 0.49; 95% CI 0.17-1.4; p=0.18; PSs: HR 0.63; 95% CI 0.34-1.18; p=0.15; RSs: HR 0.7; 95% CI 0.37-1.31; p=0.27). QoL was reported as either the same in both groups or in favor of the pylorus-preserving Whipple operation.

CONCLUSIONS

Mortality, survival and QoL were not significantly different between the classical Whipple and the pylorus-preserving Whipple operations. Given the poor quality of the underlying trials a pragmatic RCT is recommended to prove the findings of this systematic review.

Pylorus preserving pancreaticoduodenectomy for peri-ampullary carcinoma, is it a good option?

Pancreaticoduodenectomy (PD) is the standard surgical treatment for resectable peri-ampullary tumors. It can be performed with or without pylorus preservation. Many surgeons have a negative opinion of pylorus preserving PD (PPPD) and consider it an inferior operation, especially from an oncological point of view. This article reviews the various aspects of PD in the context of operative factors like blood loss and operation time, complications such as delayed gastric emptying and anastomotic leaks, and the impact on quality of life and survival. We aim to show that PPPD is at least as good as classic PD, if not better in some aspects.

Improvement of early delayed gastric emptying in patients with Billroth I type of reconstruction after pylorus preserving pancreatoduodenectomy

BACKGROUND

Early delayed gastric emptying (DGE) is the most common complication after pylorus-preserving pancreatoduodenectomy (PpPD). Recently, a vertical antecolic reconstruction for duodenojejunostomy was recommended to decrease the incidence of early DGE in patients with Billroth II-type reconstruction after PpPD. However, Billroth I-type reconstruction (B-I) after PpPD is still favored in Japan.

METHODS

Twelve consecutive patients with B-I were prospectively enrolled. Our technique includes an end-to-side duodenojejunostomy and alignment of the stomach contours with fixation of the greater omentum to the abdominal wall in order to promote passage from the stomach through the jejunal loop. DGE was evaluated according to the consensus definition of the International Study Group of Pancreatic Surgery (ISGPS).

RESULTS

DGE was absent, with the nasogastric tube removed within 3 days in all patients. Mean duration of nasogastric tube placement was 1.5 +/- 0.4 days. Mean maximum suction volume was 85 +/- 32 ml/day.

CONCLUSION

Preliminary results were encouraging simply with relief of the outflow disturbance around the duodenojejunostomy in patients with B-I after PpPD. These findings warrant further prospective randomized trials at either multiple or high-volume centers.

Middle segmental pancreatic resection: An option to treat benign pancreatic body lesions

OBJECTIVE

To clarify whether middle segmental pancreatic resection can be performed with comparable morbidity and mortality to classic pancreatic resections for lesions in the mid-portion of the pancreas.

SUMMARY BACKGROUND DATA

Pancreaticoduodenectomies or distal pancreatectomy, traditionally used to treat lesions of the pancreatic body, sacrifice a significant amount of normal pancreatic tissue. Middle segmental pancreatic resection has therefore been introduced to minimize loss of functioning pancreatic tissue.

PATIENTS AND METHODS

In a prospective 4-year single-center study, 40 consecutive patients with lesions of the neck or the body of the pancreas underwent a middle segmental pancreatic resection. A matched-pairs analysis comparing middle segmental pancreatic resection with pp-Whipple and distal pancreatectomy was included.

RESULTS

Seventeen patients had neoplastic lesions (4 solid malignancies, 9 cystic lesions, 4 neuroendocrine tumors) and 23 patients had focal chronic pancreatitis. Postoperative surgical morbidity was 27.5% and mortality 2.5%. The reoperation rate was 5.0%. Three patients (7.5%) developed pancreatic fistula. Median postoperative hospital stay was 11 days (range, 6-62 days). After a median follow-up of 29 months, 97.4% (38 patients) of the patients were satisfied with the operation. The mean quality of life status (EORTC QLQ-C30) was comparable to a normal control population. Matched-pairs analysis revealed no differences of perioperative parameters (except operation time), morbidity, and mortality. However, endocrine pancreatic function was better preserved (P < 0.05) in patients with middle segmental pancreatic resection.

CONCLUSIONS

Middle segmental pancreatic resection is an appropriate procedure for selected patients with tumorous lesions in the mid-portion of the pancreas. It preserves pancreatic parenchyma and function and has a mortality and morbidity rate comparable to other pancreatic resection procedures.

Type of gastrointestinal reconstruction affects postoperative recovery after pancreatic head resection

BACKGROUND/PURPOSE

The postoperative recovery of gastric motility with various reconstructions after pancreatic head resection has been reported. However, little is known about this recovery after pancreatic head resection with segmental duodenectomy (PHRSD). Some have attributed gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD) to tube gastrostomy, but its effect on gastric motility has not been investigated. In this study, the postoperative recovery after PHRSD and PPPD, and gastric motility with and without gastrostomy after PPPD were investigated.

METHODS

We analyzed the first appearance of gastric phase III motility, postoperative systemic status, and body weight (BW; n = 32). The Imanaga PPPD and PHRSD were compared because the procedures differ only in the length of the remaining duodenum. Traverso and Roux-en-Y PPPDs were compared because the two procedures are similar except for the creation of gastrostomy.

RESULTS

(1) Times to first appearance of gastric phase III motility and BW recovery were significantly better after PHRSD than after the Imanaga PPPD (P < 0.05). (2) Times to first gastric phase III motility and resumption of a regular diet as well as periods of gastric sump tube use and postoperative hospital stay were significantly shorter after the Roux-en-Y than after the Traverso PPPD (P < 0.05).

CONCLUSIONS

Preservation of as long a portion of the duodenum as possible, the choice of a Roux-en-Y duodenojejunostomy, and the avoidance of peritoneal fixation of the gastric wall may be factors that improve the recovery of gastric motility and BW after pancreatic head resection.

Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy

The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreatoduodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.

[Surgical treatment of gastric, enteric, and pancreatic endocrine tumors Part 1. Treatment of primary endocrine tumors]

Endocrine tumors (ET) of the digestive tract (formerly called neuroendocrine tumors) are rare. They are classified into two principal types: gastrointestinal ET's (formerly called carcinoid tumors) which are the most common, and pancreaticoduodenal ET's. Functioning ET's secrete polypeptide hormones which cause characteristic hormonal syndromes. The management of ET is multidisciplinary. Poorly-differentiated ET's have a poor prognosis and are treated by chemotherapy. Surgical excision is the only curative treatment of well-differentiated ET's. The surgical goals are to: 1. prolong survival by resecting the primary tumor and any nodal or hepatic metastases, 2. control the symptoms related to hormonal secretion, 3. prevent or treat local complications. The most common sites of gastrointestinal ET's ( carcinoids) are the appendix and the rectum; these are often small (<1 cm), benign, and discovered fortuitously at the time of appendectomy or colonoscopic removal. Ileal ET's, even if small, are malignant, frequently multiple, and complicated in 30-50% of cases by bowel obstruction, mesenteric invasion, or bleeding. The carcinoid syndrome (consisting of abdominal pain, flushing, diarrhea, hypertension, bronchospasm, and right sided cardiac vegetations) is caused by the hypersecretion of serotonin into the systemic circulation; it occurs in 10% of cases and is usually associated with hepatic metastases. More than half of the cases of pancreatic ET are non-functional. They are usually malignant and of advanced stage at diagnosis presenting as a palpable or obstructing mass or as liver metastases. Insulinoma and gastrinoma (cause of the Zollinger-Ellison syndrome) are the most common functional ET's. 80% are sporadic; in these cases, tumor size, location, and malignant potential determine the type of resection which may vary from a simple enucleation to a formal pancreatectomy. In 10-20% of cases, pancreaticoduodenal ET presents in the setting of multiple endocrine neoplasia (NEM type I), an autosomal-dominant genetic disease with multifocal endocrine involvement of the pituitary, parathyroid, pancreas, and adrenal glands. For insulinoma with NEM-I, enucleation of lesions in the pancreatic head plus a caudal pancreatectomy is the most appropriate procedure. For gastrinoma with NEM-I, the benefit of surgical resection for tumors less than 2-3 cm in size is not clear. The lesions are frequently small, multiple, and widespread and recurrence is frequent after excision. The long-term prognosis is nevertheless fairly good. But the eventual development of liver metastases which are the most common cause of mortality still argues for an aggressive surgical approach in the early stages of the disease.

Significance of perigastric lymph node involvement in periampullary malignant tumor

AIM: To determine the perigastric lymph node involvement in periampullar tumors, in an attempt to optimize the surgical treatment of pylorus-preserving pancreatoduodenectomy.

METHODS: We retrospectively investigated the frequence of lymph nodes involvement in perigastric regions. Distribution and number of involved lymph nodes were exambined from 112 patients with carcinoma of pancreas, 59 patients with distal bile duct carcinoma, and 41 patients with carcinoma of the papilla of Vater.

RESULTS: The frequency of lymphatic spread of carcinoma in pancreas; distal bile duct and papilla of Vater was 18.7%, 1.9%, 2.5% respectively. With regard to the mode of lymphatic spread in perigastric region, Infrapyloric nodes of carcinoma of the head of pancreas predominated over others, in carcinomas of the distal bile duct and the papilla of Vater, the left gastric artery, and the greater curvature lymph nodes was the only sole sites, respectively.

CONCLUSION: Understanding perigastric lymphatic involvement in periampullary tumors may be helpful for choosing the appropriate surgical approaches to pancreatoduodenectomy with preservation of pylorus.