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Yamamura K, Yamashita Y, Yamao T, Kitano Y, Arima K, Miyata T, Higashi T, Hayashi H, Beppu T, Baba H. Clinical impact of atrophic changes in remnant pancreas on the development of nonalcoholic fatty liver disease after pancreaticoduodenectomy. Ann Gastroenterol Surg 2022; 6:555-561. [PMID: 35847431 PMCID: PMC9271020 DOI: 10.1002/ags3.12554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/13/2022] [Accepted: 01/30/2022] [Indexed: 11/21/2022] Open
Abstract
Aim The aim of this study was to evaluate risk factors for nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD), with a special focus on remnant pancreatic volume (RPV) as assessed using computed tomography (CT). Methods From February 2004 to June 2017, 101 patients who underwent PD in our institution were enrolled. We defined a CT attenuation value of less than 40 HU as hepatic steatosis and measured RPV at 7 days, 3 months, and 1 year after PD using the SYNAPSE VINCENT system. The incidence of NAFLD and RPV were compared between the two groups according to reconstruction with pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ). Results The incidence of NAFLD at 3 months after PD was 39.6% (40/101). The RPV ratio (RPV at 3 months or 1 year divided by RPV at 7 days after PD) at both 3 months and 1 year was significantly smaller in the PG group than in the PJ group (59% vs 73%, P < .001 and 53% vs 67% P < .01, respectively). A positive correlation between the RPV ratio and liver CT value at 3 months was found. The multivariate analysis identified three independent risk factors for NAFLD: female sex (odds ratio [OR] 8.16, 95% confidence interval [95% CI] 2.27-35.9, P < .001), PG reconstruction (OR 3.87, 95% CI 1.04-15.6, P = .04), and RPV ratio ≤60% (OR 3.44, 95% CI 1.06-11.8, P = .001). Conclusion Atrophic change in the remnant pancreas is significantly associated with the development of NAFLD, and PJ reconstruction may be superior to PG from the viewpoint of NAFLD development.
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Affiliation(s)
- Kensuke Yamamura
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
- Department of SurgeryYamaga City Medical CenterKumamotoJapan
| | - Yo‐ichi Yamashita
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Takanobu Yamao
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Yuki Kitano
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Kota Arima
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Tatsunori Miyata
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Takaaki Higashi
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Hiromitsu Hayashi
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
| | - Toru Beppu
- Department of SurgeryYamaga City Medical CenterKumamotoJapan
| | - Hideo Baba
- Department of Gastroenterological SurgeryGraduate School of Medical ScienceKumamoto UniversityKumamotoJapan
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Ferencz S, Bíró Z, Vereczkei A, Kelemen D. Innovations in pancreatic anastomosis technique during pancreatoduodenectomies. Langenbecks Arch Surg 2020; 405:1039-1044. [PMID: 32737588 PMCID: PMC7541374 DOI: 10.1007/s00423-020-01942-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/21/2020] [Indexed: 12/22/2022]
Abstract
Purpose Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem. Methods A total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23–81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days. Results Mean postoperative hospital stay was 13 days (range: 7–75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2–6). In the other group, the drain was left in situ protractedly or reinserted later on. Conclusion A single center’s experience proves that the refinement of the technique can improve the results of pancreatic surgery.
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Affiliation(s)
- S Ferencz
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
| | - Zs Bíró
- Division of Surgery, County Hospital, Szombathely, Hungary
| | - A Vereczkei
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
| | - D Kelemen
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary.
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Olakowski M, Grudzińska E, Mrowiec S. Pancreaticojejunostomy-a review of modern techniques. Langenbecks Arch Surg 2020; 405:13-22. [PMID: 31975148 PMCID: PMC7036071 DOI: 10.1007/s00423-020-01855-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
Background Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared to the other methods. Purpose The aim of this review was to provide a concise and illustrated description of the most recent methods of pancreaticojejunostomy. Their development was directly related to the still ongoing search by surgeons for such a technique of anastomosis that would eliminate the problem of POPF. Conclusions Knowledge of various techniques of anastomosis may help the surgeon to find the most suitable and optimal method of pancreatic-intestinal anastomosis for the patient.
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Affiliation(s)
- Marek Olakowski
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
| | - Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland.
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
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Sun YL, Zhao YL, Li WQ, Zhu RT, Wang WJ, Li J, Huang S, Ma XX. Total closure of pancreatic section for end-to-side pancreaticojejunostomy decreases incidence of pancreatic fistula in pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2017; 16:310-314. [PMID: 28603100 DOI: 10.1016/s1499-3872(17)60010-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a serious complication and results in prolonged hospitalization and high mortality. The present study aimed to evaluate the safety and effectiveness of total closure of pancreatic section for end-to-side pancreaticojejunostomy in pancreaticoduodenectomy (PD). METHODS This was a prospective randomized clinical trial comparing the outcomes of PD between patients who underwent total closure of pancreatic section for end-to-side pancreaticojejunostomy (Group A) vs those who underwent conventional pancreaticojejunostomy (Group B). The primary endpoint was the incidence of pancreatic fistula. Secondary endpoints were morbidity and mortality rates. RESULTS One hundred twenty-three patients were included in this study. The POPF rate was significantly lower in Group A than that in Group B (4.8% vs 16.7%, P<0.05). About 38.3% patients in Group B developed one or more complications; this rate was 14.3% in Group A (P<0.01). The wound/abdominal infection rate was also much higher in Group B than that in Group A (20.0% vs 6.3%, P<0.05). Furthermore, the average hospital stays of the two groups were 18 days in Group A, and 24 days in Group B, respectively (P<0.001). However, there was no difference in the probability of mortality, biliary leakage, delayed gastric emptying, and pulmonary infection between the two groups. CONCLUSION Total closure of pancreatic section for end-to-side pancreaticojejunostomy is a safe and effective method for pancreaticojejunostomy in PD.
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Affiliation(s)
- Yu-Ling Sun
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital of Zhengzhou University; Institute of Hepatobiliary and Pancreatic Diseases, Zhengzhou University, Zhengzhou 450052, China.
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Intraoperative Fluid Excess Is a Risk Factor for Pancreatic Fistula after Partial Pancreaticoduodenectomy. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2016; 2016:1601340. [PMID: 27738384 PMCID: PMC5050351 DOI: 10.1155/2016/1601340] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/28/2016] [Indexed: 12/31/2022]
Abstract
Background. After pancreaticoduodenectomy (PD), pancreatic fistulas (PF) are a frequent complication. Infusions may compromise anastomotic integrity. This retrospective analysis evaluated associations between intraoperative fluid excess and PF. Methods. Data on perioperative parameters including age, sex, laboratory findings, histology, infusions, surgery time, and occurrence of grade B/C PF was collected from all PD with pancreaticojejunostomy (PJ) performed in our department from 12/2011 till 02/2015. The glomerular filtration rate (GFR), infusion rate, and the ratio of both and its association with PF were calculated. ROC analysis was employed to identify a threshold. Results. Complete datasets were available for 83 of 86 consecutive cases. Median age was 66 years (34–84; 60% male), GFR was 93 mL/min (IQR 78–113), and surgery time was 259 min (IQR 217–307). Intraoperatively, 13.6 mL/min (7–31) was infused. In total, n = 18 (21%) PF occurred. When the infusion : GFR ratio exceeded 0.15, PF increased from 11% to 34% (p = 0.0157). No significant association was detected for any of the other parameters. Conclusions. This analysis demonstrates for the first time an association between intraoperative fluid excess and PF after PD with PJ even in patients with normal renal function. A carefully patient-adopted fluid management with due regard to renal function may help to prevent postoperative PF.
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A comparative study on the complications of conventional and end-to-side inserting pancreatojejunostomy after pancreaticoduodenectomy. Surg Today 2016; 47:238-244. [DOI: 10.1007/s00595-016-1364-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/15/2016] [Indexed: 12/19/2022]
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Hsu CW, Lin LF, Law MK. Purse-string suture without pancreatic parenchymal stitches in pancreaticojejunostomy during laparoscopic pancreaticoduodenectomy. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Chih-Wei Hsu
- Division of General Surgery, Department of Surgery; Tungs' Taichung MetroHarbor Hospital; Taichung Taiwan
| | - Lien-Fu Lin
- Division of Gastroenterology, Department of Internal Medicine; Tungs' Taichung MetroHarbor Hospital; Taichung Taiwan
| | - Ming-Ko Law
- Division of General Surgery, Department of Surgery; Tungs' Taichung MetroHarbor Hospital; Taichung Taiwan
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Kelemen D, Papp R, Kaszás B, Bíró Z, Vereczkei A. Pancreatojejunostomy with modified purse-string suture technique. Langenbecks Arch Surg 2016; 401:403-7. [PMID: 26856591 DOI: 10.1007/s00423-015-1371-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/28/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE Despite many efforts, pancreatic fistula remains the most troublesome complication following pancreatic resections, especially in case of anastomosis made with soft pancreatic tissue. The purpose of the authors was to show their modification of purse-string pancreatodigestive anastomosis and the results obtained. METHODS Between January 2013 and June 2015, the technique was applied in 49 patients; one purse-string suture and two U-shaped mattress sutures were used to create the pancreatojejunal anastomosis. In case of soft pancreatic parenchyma, an external stent was temporarily left in the main pancreatic duct. The most frequent pathology was pancreatic cancer, and a pylorus-preserving Whipple procedure was mostly done. RESULTS Postoperative early morbidity rate was 35 %. There were two fistulas, one grade A fistula from a fibrotic pancreas (4.2 %) and one grade B in case of a soft pancreas (4 %). However, there was no reoperation and mortality. CONCLUSIONS According to favorable results, the modification of the purse-string suture technique makes this method even safer.
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Affiliation(s)
- Dezső Kelemen
- Department of Surgery, Clinical Centre, University of Pécs, Ifjúság útja 13., 7624, Pécs, Hungary.
| | - Róbert Papp
- Department of Surgery, Clinical Centre, University of Pécs, Ifjúság útja 13., 7624, Pécs, Hungary
| | - Bálint Kaszás
- Department of Surgery, Clinical Centre, University of Pécs, Ifjúság útja 13., 7624, Pécs, Hungary
| | - Zsanett Bíró
- Department of Surgery, Clinical Centre, University of Pécs, Ifjúság útja 13., 7624, Pécs, Hungary
| | - András Vereczkei
- Department of Surgery, Clinical Centre, University of Pécs, Ifjúság útja 13., 7624, Pécs, Hungary
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Toihata T, Hashimoto D, Hayashi H, Chikamoto A, Beppu T, Baba H. Intraoperative gastrojejunoscopy-assisted fistulojejunostomy for postoperative pancreatic fistula. Asian J Endosc Surg 2014; 7:311-3. [PMID: 25354375 DOI: 10.1111/ases.12130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 07/06/2014] [Accepted: 07/07/2014] [Indexed: 01/17/2023]
Abstract
Postoperative pancreatic fistula is a known complication after pancreaticojejunostomy. When an anastomosis collapses completely, two-stage reconstruction is necessary. Herein, we describe the case of a 70-year-old woman who underwent subtotal stomach-preserving pancreaticoduodenectomy with pancreaticojejunostomy after she had developed a severe postoperative pancreatic fistula. The pancreaticojejunostomy was divided, and an external pancreatic drainage tube was placed. Four months later, fistulojejunostomy between the pancreas and the stump of the jejunum was performed successfully using intraoperative gastrojejunoscopy.
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Affiliation(s)
- Tasuku Toihata
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Chen YJ, Lai ECH, Lau WY, Chen XP. Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature. Int J Surg 2014; 12:706-11. [PMID: 24851718 DOI: 10.1016/j.ijsu.2014.05.060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/11/2014] [Accepted: 05/14/2014] [Indexed: 01/15/2023]
Abstract
Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.
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Affiliation(s)
- Yong-jun Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
| | - Eric C H Lai
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chaiwan, Hong Kong, China.
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
| | - Xiao-ping Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
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Yu K, Li W, Ji Y, Wu W, Shen D, Zhu J. Wound healing after mesh inner embedding and outer binding pancreaticojejunostomy in piglets. Surg Innov 2013; 21:496-503. [PMID: 24368398 DOI: 10.1177/1553350613513513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this study was to introduce a novel technique of pancreaticojejunostomy, namely, mesh inner embedding and outer binding pancreaticojejunostomy, and to evaluate wound healing after this operation in piglets. METHODS Thirty-six domestic piglets were randomly divided into 2 groups after pancreaticoduodenectomy: the mesh inner embedding and outer binding pancreaticojejunostomy group (n = 18) and the conventional double-deck invaginated pancreaticojejunostomy group (n = 18). Bursting pressure and breaking strength were assessed on the operative day and on days 7 and 14 postoperatively. The pathologic findings and collagen content of the anastomotic site were evaluated on days 7 and 14 postoperatively. RESULTS Both the bursting pressure and breaking strength were significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 0, 7, and 14 (P < .01). The collagen content of the anastomotic site was significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 7 and 14 postoperatively (P < .01). The anastomotic site was more completely repaired by connective and granulation tissue in the mesh inner embedding and outer binding pancreaticojejunostomy group on day 7 than in the double-deck invaginated pancreaticojejunostomy group. CONCLUSION Mesh inner embedding and outer binding pancreaticojejunostomy significantly enhanced the anastomotic firmness and sped up the wound healing process compared with conventional mesh inner embedding and outer binding pancreaticojejunostomy. Therefore, it may decrease the risk of pancreatic fistulas after pancreaticoduodenectomy.
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Affiliation(s)
- Kai Yu
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Li
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Ji
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wanbo Wu
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Dijian Shen
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jinhui Zhu
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Abstract
INTRODUCTION Pancreatic fistula is one of the most relevant complications following pancreatoduodenectomies. Significant effort has been made to decrease it. The aim of the authors was to show a pancreatojejunal anastomosis combined with purse-string suture, and report the first experiences, as well. MATERIAL AND METHODS The implantation pancreatojejunostomy - which has been applied by the authors since 2003 - was modified, that the remnant of the pancreas was fixed in the jejunum with one purse-string and two mattress sutures. In case of a soft pancreas the Wirsungian duct was stented, then the vein canule was pulled out to the outside throught the afferent jejunal limb. The method was applied in seven patients during pylorus-preserving pancreatoduodenectomy performed for neoplasm. RESULTS In the postoperative period there were two complications in two patients noted (a bleeding ulcer developed in the region of the duodenojejunostomy and a transient confusion). However there was no pancreatic fistula, reoperation or early mortality detected. CONCLUSIONS While major conclusions can not be drawn due to the relatively small number of cases, this method seems promising and it is worth to carry out further trials.
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Affiliation(s)
- Dezső Kelemen
- Pécsi Tudományegyetem, Klinikai Központ Sebészeti Klinika 7623 Pécs Rákóczi út 2
| | - Róbert Papp
- Pécsi Tudományegyetem, Klinikai Központ Sebészeti Klinika 7623 Pécs Rákóczi út 2
| | - András Vereczkei
- Pécsi Tudományegyetem, Klinikai Központ Sebészeti Klinika 7623 Pécs Rákóczi út 2
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