1
|
Clemente G, De Rose AM, Panettieri E, Ardito F, Murazio M, Nuzzo G, Giuliante F. Pancreatico-Jejunostomy On Isolated Loop After Pancreatico-Duodenectomy: Is It Worthwhile? J Gastrointest Surg 2022; 26:1205-1212. [PMID: 35296957 PMCID: PMC9184425 DOI: 10.1007/s11605-022-05296-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative morbidity remains a significant problem after pancreatico-duodenectomy. The management of pancreatic stump continues to be a challenge, and many technical solutions have been developed over the years. In this study, we report the results obtained with the use of an isolated loop for pancreatico-jejunostomy in patients with soft pancreas and small pancreatic duct diameter. METHODS Clinical data of patients submitted to pancreatico-duodenectomy in a period of sixteen years (2005-2020) were extracted from a prospective database. Patients with soft pancreas, main duct diameter < 2 mm and reconstruction by pancreatico-jejunostomy on single loop or isolated loop were selected. Primary end-point was the incidence of clinically relevant fistulas in the two groups of patients. Secondary endpoint was the length of postoperative hospital stay. A propensity score matching analysis was used for the statistics. RESULTS Two hundred and twenty-one patients with the above characteristics were found in the database. One hundred and twelve of these received a single-loop reconstruction and 109 an isolated loop reconstruction. Incidence of clinically relevant fistulas was higher in the first group (41% vs 27%; p = 0.023). Postoperative hospital stay was significantly shorter in the second group (21 days vs 15; p < 0.001). These results were confirmed at the propensity score matching. CONCLUSION In patients with soft pancreatic texture and small main duct diameter, pancreatico-jejunostomy on isolated loop is associated with a lower incidence of clinically relevant fistulas than after classic reconstruction. The duration of postoperative hospital stay was significantly reduced, with consequent reduction of cost.
Collapse
Affiliation(s)
- Gennaro Clemente
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Agostino Maria De Rose
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Elena Panettieri
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marino Murazio
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro Nuzzo
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
2
|
Zimmitti G, Coppola A, Ardito F, Meniconi R, Ettorre GM, Rosso E, Manzoni A, Colasanti M, Clemente G, Murazio M, Giuliante F. Outcomes comparison of Pancreato-Gastrostomy and Isolated Jejunal Loop Pancreato-Jejunostomy following Pancreato-Duodenectomy in patients with soft pancreas and at moderate-high risk for POPF: a retrospective multicenter experience-based analysis. Updates Surg 2021; 74:223-234. [PMID: 34761349 DOI: 10.1007/s13304-021-01203-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
Following pancreatoduodenectomy (PD), the modality of pancreato-enteric continuity restoration may impact on postoperative pancreatic fistula (POPF) risk. The aim of this study is to compare, among patients with soft pancreas and at moderate/high risk for POPF, the outcomes of PD with Pancreato-Gastrostomy (PG), versus Isolated Jejunal Loop Pancreato-Jejunostomy (IJL-PJ). 193 patients with a Callery Fistula Risk Score (C-FRS) ≥ 3 operated at 3 HPB Units, two performing PG and one IJL-PJ as their preferred anastomotic technique following PD (2009-2019) were included in this study (PG = 123, IJL-PJ = 70). Primary outcomes were POPF, clinically relevant (cr-)postoperative pancreatic hemorrhage (cr-PPH), delayed gastric emptying (cr-DGE), and postoperative major complications and mortality. POPF, cr-PPH, and cr-DGE occurred in 21.8%, 17.6%, and 11.4% of patients, and did not differ significantly between PG (26%, 19.5%, and 10.6%, respectively) and IJL-PJ (17.1%, 14.3%, and 12.9%, respectively; all p > 0.05) patients. Major (Dindo ≥ 3) complication and mortality rates were 26.4% and 3.3%, respectively, and did not differ significantly between PG (29.3% and 3.8%) and IJL-PJ (21.4% and 2.9) patients (p > 0.05). A faster surgical drain and nasogastric tube removal matched a significantly shorter hospitalization among IJL-PJ patients (median LOS: 18 days versus 25 days among PG patients, p < 0.001). In conclusion, IJL-PJ and PG, when performed by surgeons specialized with the concerned anastomotic technique in patients with soft pancreas and moderate/high risk for POPF, have similar results in terms of perioperative mortality and postoperative complications both overall and specific for PD.
Collapse
Affiliation(s)
- Giuseppe Zimmitti
- Dipartimento Di Chirurgia Generale, Istituto Ospedaliero Fondazione Poliambulanza, via Bissolati n.57, Brescia, Italy
| | - Alessandro Coppola
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy
| | - Francesco Ardito
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy
| | - Roberto Meniconi
- Dipartimento Di Chirurgia Generale E Trapianti, Ospedale S. Camillo-Forlanini Spallanzani, via G. Folchi n.6a, Roma, Italy
| | - Giuseppe Maria Ettorre
- Dipartimento Di Chirurgia Generale E Trapianti, Ospedale S. Camillo-Forlanini Spallanzani, via G. Folchi n.6a, Roma, Italy
| | - Edoardo Rosso
- Dipartimento Di Chirurgia Generale, Istituto Ospedaliero Fondazione Poliambulanza, via Bissolati n.57, Brescia, Italy
| | - Alberto Manzoni
- Dipartimento Di Chirurgia Generale, Istituto Ospedaliero Fondazione Poliambulanza, via Bissolati n.57, Brescia, Italy
| | - Marco Colasanti
- Dipartimento Di Chirurgia Generale E Trapianti, Ospedale S. Camillo-Forlanini Spallanzani, via G. Folchi n.6a, Roma, Italy
| | - Gennaro Clemente
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy
| | - Marino Murazio
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy
| | - Felice Giuliante
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy.
| |
Collapse
|
3
|
Morandi E, Corbellini C, Castoldi M, de Vuono A, Pisoni L, Vignati G. Comparison between two different reconstruction techniques after pancreatic head resection. Technical feasibility and clinical benefits. Minerva Surg 2020; 76:90-96. [PMID: 32456401 DOI: 10.23736/s2724-5691.20.08338-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The study aim was to evaluate if diverting drainage of bile and pancreatic secretions with an isolated Roux loop technique helps to decrease the rate of postoperative morbidity and mortality, in particular postoperative pancreatic fistula (POPF). METHODS A prospectively maintained database between 2006 and 2018 was reviewed. Patients who underwent primary elective pancreaticoduodenectomy were included. Two types of reconstruction methods were compared: single loop (SJL) reconstruction (28 patients) and isolated Roux-en-Y (DJL) reconstruction (36 patients). Demographic characteristics and perioperative results were compared between the two groups. RESULTS This study includes 64 patients. The average duration of surgery was 308 mins; it was longer for DJL (P<0.0001). Major postoperative complications were seen in 24 patients (9 in SJL; 15 in DJL) without statistically significant difference. The most frequent complication that occurred was PJ anastomosis failure (4 in SJL; 6 in DJL). The choice of postoperative complication management was not related to surgical reconstruction technique (P=0.389). Length of hospital stay in DJL was significantly longer than in SJL (P=0.04). CONCLUSIONS No significant advantage of one technique over the other was found. In our opinion, surgeons should choose the approach with which they have the most experience and ease.
Collapse
Affiliation(s)
- Eugenio Morandi
- Department of General Surgery, ASST - Rhodense, Rho Hospital, Rho, Milan, Italy
| | - Carlo Corbellini
- Department of General Surgery, ASST - Rhodense, Rho Hospital, Rho, Milan, Italy -
| | - Marco Castoldi
- Department of General Surgery, ASST - Rhodense, Rho Hospital, Rho, Milan, Italy
| | - Andrea de Vuono
- Department of Statistics, ASST - Rhodense, Rho Hospital, Rho, Milan, Italy
| | - Laura Pisoni
- Department of General Surgery, ASST - Rhodense, Rho Hospital, Rho, Milan, Italy
| | - Gianandrea Vignati
- Department of General Surgery, ASST - Rhodense, Rho Hospital, Rho, Milan, Italy
| |
Collapse
|
4
|
Chhaidar A, Mabrouk MB, Ali AB. Isolated Roux loop pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: A case-control study. Int J Surg Case Rep 2018; 53:223-227. [PMID: 30428436 PMCID: PMC6232583 DOI: 10.1016/j.ijscr.2018.10.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/05/2018] [Accepted: 10/13/2018] [Indexed: 12/22/2022] Open
Abstract
Pancreaticojejunostomy is commonly used in the reconstruction after pancreaticoduodenectomy, but the incidence of POPF remains high. There are a number of theoretical advantages to the isolated Roux loop pancreaticojejunostomy reconstruction, mainly related to the physical separation of bile acids and the pancreaticojejunostomy. The use of an isolated Roux loop pancreaticojejunostomy seems to be associated with decrease in the rate of postoperative PF in patients undergoing PD.
Objectives The aim of this study was to compare the postoperative outcomes of isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD). Methods Data of patients who underwent IPJ were compared with those of a pair-matched equal number of patients undergoing CPJ. The matching was performed according to age, gender, nature of the lesion indicating PD and the texture of the pancreas. The primary outcome was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality. Results Seventy patients treated by PD (35 patients in each group) were included in the study. The two groups were comparable with regards to the pre-operative and intra-operative parameters. Postoperative pancreatic fistula developed in 10 out of 35 patients in the CPJ group and 3 out of 35 patients in the IPJ group (p = 0.031). Nine CPJ patients and one IPJ patient had POPF of type B or C (p = 0.006). Re-laparotomy was significantly more frequent in the CPJ group (11.1% versus 34.6%; p = 0.04). Time to resumption of oral feeding was shorter in the IPJ group (p = 0.001). Conclusions The use of IPJ is associated with decrease in the rate of postoperative PF in patients undergoing PD. In addition, patients with IPJ reconstruction have lesser need for re-laparotomy and early resumption of oral feeding.
Collapse
Affiliation(s)
- Amine Chhaidar
- Department of Surgery, Sahloul Hospital, Sousse, Tunisia.
| | | | - Ali Ben Ali
- Department of Surgery, Sahloul Hospital, Sousse, Tunisia.
| |
Collapse
|
5
|
Aghalarov I, Herzog T, Uhl W, Belyaev O. A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients. HPB (Oxford) 2018; 20:676-683. [PMID: 29456198 DOI: 10.1016/j.hpb.2018.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/17/2017] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Double-loop (DL) reconstruction after pancreaticoduodenectomy (PD), diverting pancreatic from biliary secretions, has been reported to reduce rates and severity of postoperative pancreatic fistula (POPF) compared to single loop (SL) reconstruction at the price of prolonged operative duration. This study investigated the feasibility of a new reconstruction method combining the advantages of DL with the simplicity of SL in patients with high-risk pancreas. METHODS A modified single-loop (mSL) reconstruction was used in patients undergoing PD with a soft pancreatic remnant and a pancreatic duct smaller than 3 mm (n = 50). The loop between the pancreatic and the biliary anastomoses was left longer and a side-to-side jejunojejunal anastomosis was performed between them at the lowest point to promote isolated flow of pancreatic and biliary secretions. Rate and severity of POPF, mortality, duration of surgery, and POPF-associated morbidity were compared to those of 50 matched patients with SL and 25 patients with DL reconstruction. RESULTS Duration of surgery was 57 min longer for DL, but equal for mSL and SL. The POPF rate did not differ between the three groups. The severity of POPF was more pronounced in the SL group (62% grade C: p = 0.011). Mortality and major morbidity were lower and hospital stay shorter in the mSL and DL groups compared to the SL group. CONCLUSIONS The new mSL reconstruction was safer than conventional SL and faster to perform than DL reconstruction in patients with a high-risk pancreas. It did not influence the rate of POPF, but reduced its severity, leading to less major morbidity and mortality.
Collapse
Affiliation(s)
- Ilgar Aghalarov
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Orlin Belyaev
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany.
| |
Collapse
|
6
|
Deng LH, Xiong JJ, Xia Q. Isolated Roux-en-Y pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis. J Evid Based Med 2017; 10:37-45. [PMID: 27314553 DOI: 10.1111/jebm.12202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/07/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the advantage between isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD). METHODS Comparative studies on this topic published between January 1976 and April 2015 in PubMed, EMbase, EBSCO, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched, and selected based on specific inclusion and exclusion criteria. Perioperative outcomes such as postoperative pancreatic fistula, delayed gastric emptying, operation time, intraoperative blood loss, intraoperative blood transfusion, postoperative bleeding, intra-abdominal abscess, bile leakage, wound infection, morbidity and mortality were compared. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence interval (CI) were calculated using either fixed- or random-effects model. RESULTS Six studies were included with two randomized controlled and four nonrandomized trials. A total of 712 patients (359 patients from the IPJ group and 353 patients from the CPJ group) were analyzed. The pooled results revealed that IPJ had longer operation time (WMD = 36.55, 95% CI 6.98 to 66.11, P = 0.02). However, there were no significant differences between both groups in postoperative pancreatic fistula, intraoperative blood loss, blood transfusion, delayed gastric emptying, postoperative bleeding, intra-abdominal abscess, bile leakage, wound infection, morbidity, mortality and postoperative hospital stay. CONCLUSIONS PD with IPJ was comparable to CPJ in intraoperative outcomes and postoperative complications. However, further randomized controlled trials should be undertaken to ascertain these findings.
Collapse
Affiliation(s)
- Li Hui Deng
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Jie Xiong
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
7
|
Li DB, Chai C, Cao L, Zhou YM. Isolated Roux-en-Y reconstruction versus conventional reconstruction after pancreaticoduodenectomy. Surgeon 2017; 15:18-23. [DOI: 10.1016/j.surge.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
|
8
|
Zhang H, Tan C, Wang X, Kang D, Chen Y, Xiong J, Tian B, Li K, Hu W, Chen X, Ke N, Li A, Liu X. Preventive effects of ulinastatin on complications related to pancreaticoduodenectomy: A Consort-prospective, randomized, double-blind, placebo-controlled trial. Medicine (Baltimore) 2016; 95:e3731. [PMID: 27310952 PMCID: PMC4998438 DOI: 10.1097/md.0000000000003731] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is one of the most common major complications after pancreaticoduodenectomy (PD). Ulinastatin is an intrinsic trypsin inhibitor and mainly used to treat acute pancreatitis, chronic recurrent pancreatitis, and acute circulatory failure. The study aims to investigate the efficacy of ulinastatin on pancreatic fistula and other complications after PD. This prospective, randomized, double-blind, placebo-controlled trial was conducted in West China Hospital of Sichuan University from December 2012 to December 2014. A total of 106 consecutive patients undergoing PD were randomly assigned to receive ulinastatin or placebo during and after the surgery for 5 days. Baseline clinical characteristics and outcomes of patients were recorded and analyzed. Ninety-two patients including 42 in the ulinastatin group and 50 in the placebo group were available for outcome assessment. The POPF rates were comparable between ulinastatin group (43%) and placebo group (26%), whereas the severe pancreatic fistula rate (grade B + C) was significantly less in ulinastatin group than that in placebo group (7% vs 24%, P = 0.045). For patients with small pancreatic duct diameter (≤3 mm), ulinastatin could significantly reduce the risk of POPF (P = 0.022). Ulinastatin had protective effects for patients undergoing PD on the prevention of severe postoperative pancreatic fistula.
Collapse
Affiliation(s)
| | | | | | - Deying Kang
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | | | | | | | | | | | | | | | - Ang Li
- Department of Pancreatic Surgery
| | | |
Collapse
|
9
|
Machado MCC, Machado MAC. Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: Five years of experience with zero mortality. Eur J Surg Oncol 2016; 42:1584-90. [PMID: 27266408 DOI: 10.1016/j.ejso.2016.05.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/01/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The aim of this study is to perform a comprehensive evaluation of 5 years of experience with the technique of isolated pancreatic anastomosis reconstruction after pancreatoduodenectomy from the perspective of safety and surgical efficacy using a prospective database. METHODS The study included all consecutive patients undergoing pancreatoduodenectomy from April 2009 to April 2014 at a single referral center for hepato-pancreato-biliary diseases. The primary endpoint was the safety of the procedures, which was assessed as the occurrence of complications during hospitalization. Ninety-day mortality was also assessed. Postoperative pancreatic fistulas were classified as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification. RESULTS The study group included 214 consecutive patients with a median age of 60 years who underwent pancreatoduodenectomy. Portal vein resection was performed on 41 patients. Indications for resection were 165 pancreatic head tumors, 33 ampullary tumors, 7 chronic pancreatitis, 3 distal bile duct tumors, and 6 duodenal tumors. There was no perioperative or 90-day mortality in this series. Complications occurred in 68 patients (32%), and 42 patients presented with pancreatic fistulas (19.6%). Grade A fistulas were present in 38 patients. Three patients presented persistent pancreatic fistula and were treated with percutaneous drainage. One patient developed combined pancreatic and biliary fistulas and was reoperated on for pancreatic abscess drainage. CONCLUSIONS The technique of isolated pancreatic anastomosis by diverting the pancreatic from biliary secretion may contribute to reducing the severity of pancreatic fistulas and therefore the severity of this complication.
Collapse
Affiliation(s)
- M C C Machado
- Department of Surgery, University of São Paulo, Brazil
| | - M A C Machado
- Department of Surgery, University of São Paulo, Brazil.
| |
Collapse
|
10
|
Limongelli P, D'Alessandro A, Parisi S, Pirozzi R, Bondanese M, Colella C, Docimo G, Del Genio G, Del Genio A, Docimo L. Double loop reconstruction following pancreaticoduodenectomy for malignant tumor: Short-term outcome. Int J Surg Case Rep 2016; 20S:16-20. [PMID: 26872635 DOI: 10.1016/j.ijscr.2016.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To evaluate the use of a double loop reconstruction following pylorus preserving proximal pancreaticoduodenectomy (PPPPD). METHODS Morbidity and mortality were evaluated in 55 patients undergoing PPPPD for malignant tumors, followed by a double loop reconstruction. RESULTS The mean intra-operative blood loss was 908mL±531. In-hospital mortality was 5.4% (3/55 pts). The mean length of hospital stay was 17±5 days (range 12-45 days). Postoperative complications occurred in 25 patients (46.2%). Five patients developed an anastomotic leak, one biliary and four pancreatic (4/55; 7%). Delayed gastric emptying occurred in 8 patients (14.5%). Reoperation was required in two patients for hemorrhage. CONCLUSIONS A double loop alimentary reconstruction following PPPPD led to a low incidence of DGE and pancreatic fistula. Although mortality rate was higher than that reported by referral centres, this technique has been performed in a not specialized unit attaining acceptable results.
Collapse
Affiliation(s)
- Paolo Limongelli
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy.
| | - A D'Alessandro
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - S Parisi
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - R Pirozzi
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - M Bondanese
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - C Colella
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - Giovanni Docimo
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - Gianmattia Del Genio
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - Alberto Del Genio
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - Ludovico Docimo
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| |
Collapse
|
11
|
The Preoperative CT-Scan Can Help to Predict Postoperative Complications after Pancreatoduodenectomy. BIOMED RESEARCH INTERNATIONAL 2015; 2015:824525. [PMID: 26605340 PMCID: PMC4641955 DOI: 10.1155/2015/824525] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/15/2015] [Indexed: 02/08/2023]
Abstract
After pancreatoduodenectomy, complication rates are up to 40%. To predict the risk of developing postoperative pancreatic fistula or severe complications, various factors were evaluated. 110 consecutive patients undergoing pancreatoduodenectomy at our institute between January 2012 and September 2014 with complete CT scan were retrospectively identified. Pre-, per-, and postoperative patients and pathological information were gathered. The CT-scans were analysed for the diameter of the pancreatic duct, attenuation of the pancreas, and the visceral fat area. All data was statistically analysed for predicting POPF and severe complications by univariate and multivariate logistic regression analyses. The POPF rate was 18%. The VFA measured at umbilicus (OR 1.01; 95% CI = 1.00–1.02; P = 0.011) was an independent predictor for POPF. The severe complications rate was 33%. Independent predictors were BMI (OR 1.24; 95% CI = 1.10–1.42; P = 0.001), ASA class III (OR 17.10; 95% CI = 1.60–182.88; P = 0.019), and mean HU (OR 0.98; 95% CI = 0.96–1.00; P = 0.024). In conclusion, VFA measured at the umbilicus seems to be the best predictor for POPF. BMI, ASA III, and the mean HU of the pancreatic body are independent predictors for severe complications following PD.
Collapse
|
12
|
Mitra A, D'Souza A, Goel M, Shrikhande SV. Surgery for Pancreatic and Periampullary Carcinoma. Indian J Surg 2015; 77:371-80. [PMID: 26722199 DOI: 10.1007/s12262-015-1358-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
Surgical resection for pancreatic and periampullary cancer has evolved over several decades. The postoperative mortality for these resections has declined to less than 5 %. However, morbidity associated with these resections is still considerable. Various technical modifications like pylorus preservation, reconstruction techniques and methods to perform pancreaticoenteric anastomosis have been suggested to improve postoperative outcomes after pancreaticoduodenectomy. Surgical modifications to improve oncological clearance and decrease fistula rates after distal pancreatic resections have also been suggested. Dilemma still exists whether interventions like pancreatic duct stents, octreotide and drains help to improve postoperative outcomes. The role of extended lymph node dissection and extended resections for pancreatic and periampullary cancer is still controversial, as is the management of borderline resectable pancreatic cancer. In this review, we discuss the literature pertaining to various surgical aspects of pancreatic and periampullary carcinoma.
Collapse
Affiliation(s)
- Abhishek Mitra
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Ashwin D'Souza
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Mahesh Goel
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| | - Shailesh V Shrikhande
- GI and HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012 India
| |
Collapse
|
13
|
Ke FY, Wu XS, Zhang Y, Zhang HC, Weng MZ, Liu YB, Wolfgang C, Gong W. Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis. Chin J Cancer Res 2015; 27:397-407. [PMID: 26361409 DOI: 10.3978/j.issn.1000-9604.2015.07.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 06/16/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis. The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy (PD). METHODS We searched PubMed, EMBASE, the Cochrane Library and Web of Science databases until the end of December, 2014. Studies comparing outcomes of external vs. internal stent placement in PD were eligible for inclusion. Included literature was extracted and assessed by two independent reviewers. RESULTS Seven articles were identified for inclusion: three randomized controlled trials (RCTs) and four observational clinical studies (OCS). The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula (PF) in total [odds ratio (OR) =0.69; 95% confidence interval (CI), 0.48-0.99; P=0.04], PF in soft pancreas (OR =0.30; 95% CI, 0.16-0.56; P=0.0002) and delayed gastric emptying (DGE) (OR =0.58; 95% CI, 0.38-0.89; P=0.01) compared with internal stents. There were no significant differences in other postoperative outcomes between two stenting methods, including postoperative morbidity (OR =0.93; 95% CI, 0.39-2.23; P=0.88), overall mortality (OR =0.70; 95% CI, 0.22-2.25; P=0.55), and intra-abdominal collections (OR =0.67; 95% CI, 0.26-1.71; P=0.40). CONCLUSIONS Based upon this meta-analysis, the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE. Due to the limited number of original studies, more RCTs are needed to further support our result and clarify the issue.
Collapse
Affiliation(s)
- Fa-Yong Ke
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Xiang-Song Wu
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Yong Zhang
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hong-Cheng Zhang
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ming-Zhe Weng
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ying-Bin Liu
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christopher Wolfgang
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Wei Gong
- 1 Department of General Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China ; 2 Department of Hepatobiliary and Pancreatic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| |
Collapse
|
14
|
Klaiber U, Probst P, Knebel P, Contin P, Diener MK, Büchler MW, Hackert T. Meta-analysis of complication rates for single-loop versus dual-loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after pancreaticoduodenectomy. Br J Surg 2015; 102:331-40. [DOI: 10.1002/bjs.9703] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 08/19/2014] [Accepted: 10/13/2014] [Indexed: 12/16/2022]
Abstract
Abstract
Background
Postoperative pancreatic fistula is one of the most important and potentially severe complications after partial pancreaticoduodenectomy. In this context, the reduction of postoperative pancreatic fistula by means of a dual-loop (Roux-en-Y) reconstruction with isolation of the pancreaticojejunostomy from biliary drainage has been evaluated in several studies. This systematic review and meta-analysis summarizes evidence of effectiveness and safety of the isolation of the pancreaticojejunostomy compared with conventional single-loop reconstruction.
Methods
Randomized clinical trials (RCTs) and controlled clinical trials (CCTs) comparing outcomes of dual-loop reconstruction with isolated pancreaticojejunostomy and single-loop reconstruction were searched according to PRISMA guidelines. Random-effects meta-analyses were performed and the results presented as weighted risk ratios or mean differences with their corresponding 95 per cent c.i.
Results
Of 83 trials screened for eligibility, three RCTs and four CCTs including a total of 802 patients were finally included. Quantitative synthesis showed no significant statistical difference between the two procedures regarding postoperative pancreatic fistula, delayed gastric emptying, haemorrhage, intra-abdominal fluid collection or abscess, bile leakage, wound infection, pneumonia, overall morbidity, mortality, reinterventions, reoperations, perioperative blood loss and length of hospital stay. Duration of surgery was significantly longer in patients undergoing dual-loop reconstruction.
Conclusion
Dual-loop (Roux-en-Y) reconstruction with isolated pancreaticojejunostomy after partial pancreaticoduodenectomy is not superior to single-loop reconstruction regarding pancreatic fistula rate or other relevant outcomes. Additional superiority trials are therefore not warranted, although a high-quality trial may be justified to prove equivalence or non-inferiority.
Collapse
Affiliation(s)
- U Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - P Knebel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - P Contin
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
15
|
Single Versus Double Roux-en-Y Reconstruction Techniques in Pancreaticoduodenectomy: A Comparative Single-Center Study. World J Surg 2014; 38:3228-34. [DOI: 10.1007/s00268-014-2742-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
16
|
El Nakeeb A, Hamdy E, Sultan AM, Salah T, Askr W, Ezzat H, Said M, Zeied MA, Abdallah T. Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study. HPB (Oxford) 2014; 16:713-22. [PMID: 24467711 PMCID: PMC4113253 DOI: 10.1111/hpb.12210] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 11/20/2013] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The optimal strategy for the reconstruction of the pancreas following pancreaticoduodenectomy (PD) is still debated. The aim of this study was to compare the outcomes of isolated Roux loop pancreaticojejunostomy (IRPJ) with those of pancreaticogastrostomy (PG) after PD. METHODS Consecutive patients submitted to PD were randomized to either method of reconstruction. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality, and exocrine and endocrine pancreatic functions. RESULTS Ninety patients treated by PD were included in the study. The median total operative time was significantly longer in the IRPJ group (320 min versus 300 min; P = 0.047). Postoperative pancreatic fistula developed in nine of 45 patients in the IRPJ group and 10 of 45 patients in the PG group (P = 0.796). Seven IRPJ patients and four PG patients had POPF of type B or C (P = 0.710). Time to resumption of oral feeding was shorter in the IRPJ group (P = 0.03). Steatorrhea at 1 year was reported in nine of 42 IRPJ patients and 18 of 41 PG patients (P = 0.029). Albumin levels at 1 year were 3.6 g/dl in the IRPJ group and 3.3 g/dl in the PG group (P = 0.001). CONCLUSIONS Isolated Roux loop PJ was not associated with a lower rate of POPF, but was associated with a decrease in the incidence of postoperative steatorrhea. The technique allowed for early oral feeding and the maintenance of oral feeding even if POPF developed.
Collapse
Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology Surgical Centre, Mansoura University, Mansoura, Egypt
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Tani M, Kawai M, Hirono S, Okada KI, Miyazawa M, Shimizu A, Kitahata Y, Yamaue H. Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy. Br J Surg 2014; 101:1084-91. [PMID: 24975853 DOI: 10.1002/bjs.9544] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 04/02/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is associated with a high incidence of postoperative complications including pancreatic fistula. This randomized clinical trial compared the incidence of pancreatic fistula between the isolated Roux-en-Y (IsoRY) and conventional reconstruction (CR) methods. METHODS Patients admitted for PD between June 2009 and September 2012 in a single centre were assigned randomly to CR or IsoRY. The primary endpoint was the incidence of pancreatic fistula (grade A-C) defined according to the International Study Group on Pancreatic Fistula. Secondary endpoints were complication rates, mortality and hospital stay. Multiple logistic regression analysis was performed to identify factors associated with pancreatic fistula. RESULTS Some 153 patients were randomized, 76 to CR and 77 to IsoRY; two patients from the IsoRY group were excluded after randomization. Pancreatic fistula occurred in 26 patients (34 per cent) in the CR group and 25 (33 per cent) in the IsoRY group (P = 0·909). The number of patients with a clinically relevant pancreatic fistula (grade B or C) was similar in the two groups (10 and 11 patients respectively; P = 0·789), as were complication rates (42 versus 40 per cent; P = 0·793) and mortality (none in either group; P = 0·999). Soft pancreas was the only independent risk factor for pancreatic fistula (odds ratio 4·42, 95 per cent confidence interval 1·85 to 10·53; P <0·001). CONCLUSION This study showed that IsoRY reconstruction does not reduce the incidence of pancreatic fistula compared with CR. REGISTRATION NUMBER NCT00915863 (http://www.clinicaltrials.gov/) and UMIN000001967 (http://www.umin.ac.jp/).
Collapse
Affiliation(s)
- M Tani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera,, Wakayama, 641-8510, Japan
| | | | | | | | | | | | | | | |
Collapse
|
18
|
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.
Collapse
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.
| |
Collapse
|
19
|
Machado MAC, Makdissi FF, Surjan RCT, Machado MCC. Laparoscopic pylorus-preserving pancreatoduodenectomy with double jejunal loop reconstruction: an old trick for a new dog. J Laparoendosc Adv Surg Tech A 2012; 23:146-9. [PMID: 23157325 DOI: 10.1089/lap.2012.0338] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Pancreatoduodenectomy is an established procedure for the treatment of benign and malignant diseases located at the pancreatic head and periampullary region. In order to decrease morbidity and mortality, we devised a unique technique using two different jejunal loops to avoid activation of pancreatic juice by biliary secretion and therefore reduce the severity of pancreatic fistula. This technique has been used for open pancreatoduodenectomy worldwide but to date has never been described for laparoscopic pancreatoduodenectomy. This article reports the technique of laparoscopic pylorus-preserving pancreatoduodenectomy with two jejunal loops for reconstruction of the alimentary tract. MATERIALS AND METHODS After pancreatic head resection, retrocolic end-to-side pancreaticojejunostomy with duct-to-mucosa anastomosis is performed. The jejunal loop is divided with a stapler, and side-to-side jejunojejunostomy is performed with the stapler, leaving a 40-cm jejunal loop for retrocolic hepaticojejunostomy. Finally, end-to-side duodenojejunostomy is performed in an antecolic fashion. RESULTS This technique has been successfully used in 3 consecutive patients with pancreatic head tumors: 2 patients underwent hand-assisted laparoscopic pylorus-preserving pancreatoduodenectomy, and 1 patient underwent totally laparoscopic pylorus-preserving pancreatoduodenectomy. One patient presented a Grade A pancreatic fistula that was managed conservatively. One patient received blood transfusion. Mean operative time was 9 hours. Mean hospital stay was 7 days. No postoperative mortality was observed. CONCLUSIONS Laparoscopic pylorus-preserving pancreatoduodenectomy with double jejunal loop reconstruction is feasible and may be useful to decrease morbidity and mortality after pancreatoduodenectomy. This operation is challenging and may be reserved for highly skilled laparoscopic surgeons.
Collapse
|
20
|
Pancreatic fistula after pancreatectomy: definitions, risk factors, preventive measures, and management-review. Int J Surg Oncol 2012; 2012:602478. [PMID: 22611494 PMCID: PMC3348641 DOI: 10.1155/2012/602478] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 01/24/2012] [Indexed: 01/09/2023] Open
Abstract
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.
Collapse
|
21
|
Zhou Y, Yang C, Wang S, Chen J, Li B. Does external pancreatic duct stent decrease pancreatic fistula rate after pancreatic resection?: a meta-analysis. Pancreatology 2011; 11:362-70. [PMID: 21876365 DOI: 10.1159/000330222] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 06/08/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The use of an external pancreatic duct stent to prevent fistula formation of pancreatic anastomosis remains a matter of debate. This study is a meta-analysis of the available evidence. METHODS Articles published until the end of March 2011 comparing external stenting and non-stenting in pancreatic anastomosis were included. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model. RESULTS Six articles were identified for inclusion: 3 randomized controlled trials and 3 observational clinical studies. The meta-analysis revealed that the use of an external pancreatic duct stent was associated with a statistically significant reduction in overall postoperative morbidity (OR 0.56; 95% CI 0.39-0.81; p = 0.002), pancreatic fistula (OR 0.34; 95% CI 0.23-0.15; p < 0.001), severity of pancreatic fistula (OR 0.70; 95% CI 0.32-1.57; p = 0.04), delayed gastric emptying (OR 0.44; 95% CI 0.25-0.80; p = 0.007), and length of hospital stay (WMD -3.95; 95% CI -6.38 to -1.52; p = 0.001). CONCLUSIONS The current literature suggests that the use of an external pancreatic duct stent reduced the leakage rate of pancreatic anastomosis after pancreatic resection. and IAP.
Collapse
Affiliation(s)
- Yanming Zhou
- Department of Hepato-Biliary-Pancreato-Vascular Surgery, First Affiliated Hospital of Xiamen University, China
| | | | | | | | | |
Collapse
|
22
|
The effect of somatostatin and its analogs in the prevention of pancreatic fistula after elective pancreatic surgery. Eur Surg 2011. [DOI: 10.1007/s10353-011-0612-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
23
|
|
24
|
Ball CG, Howard TJ. Does the type of pancreaticojejunostomy after Whipple alter the leak rate? Adv Surg 2010; 44:131-48. [PMID: 20919519 DOI: 10.1016/j.yasu.2010.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.
Collapse
Affiliation(s)
- Chad G Ball
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis 46202, USA
| | | |
Collapse
|
25
|
Ballas K, Symeonidis N, Rafailidis S, Pavlidis T, Marakis G, Mavroudis N, Sakantamis A. Use of isolated Roux loop for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy. World J Gastroenterol 2010; 16:3178-82. [PMID: 20593503 PMCID: PMC2896755 DOI: 10.3748/wjg.v16.i25.3178] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the efficacy of the isolated Roux loop technique in decreasing the frequency of pancreaticojejunal anastomosis failure. METHODS We retrospectively reviewed 88 consecutive patients who underwent pancreaticoduodenectomy (standard or pylorus-preserving). Single jejunal loop was used in 42 patients (SL group) while isolated Roux loop was used in 46 patients (RL group). Demographic characteristics (age, gender) and perioperative results (major/minor complications, mortality, hospital stay) were compared between the two groups. RESULTS Mortality was almost equal in both groups and overall mortality was 2.27%. Leak rate from the pancreaticojejunal anastomosis and hospital stay were lower in the RL group without significant difference. Morbidity was 39.1% in the RL group, insignificantly higher than the SL group. Operative time was almost 30 min longer in the RL group. CONCLUSION The isolated Roux loop, although an equally safe alternative, does not present advantages over the traditional use of a single jejunal loop. Randomized controlled studies are required to further clarify its efficacy.
Collapse
Affiliation(s)
- Konstantinos Ballas
- Second Propedeutical Department of Surgery, Ippokratio General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos str, Thessaloniki, 54642, Thessaloniki, Greece
| | | | | | | | | | | | | |
Collapse
|
26
|
Tewari M, Hazrah P, Kumar V, Shukla HS. Options of restorative pancreaticoenteric anastomosis following pancreaticoduodenectomy: A review. Surg Oncol 2010; 19:17-26. [DOI: 10.1016/j.suronc.2009.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 12/21/2008] [Accepted: 01/20/2009] [Indexed: 01/15/2023]
|
27
|
Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump. Pancreas 2009; 38:e177-82. [PMID: 19730152 DOI: 10.1097/mpa.0b013e3181b57705] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the impact of the length of the isolated jejunal loop and the type of pancreaticojejunostomy on pancreatic leakage after pancreaticoduodenectomy. METHODS One hundred thirty-two consecutive patients who underwent a pancreaticoduodenectomy were studied according to the length of the isolated jejunal loop (short loop, 20-25 cm vs long loop, 40-50 cm) and the type of pancreaticojejunostomy (invagination vs duct to mucosa). RESULTS The use of the long isolated jejunal loop was associated with a significantly lower pancreatic leakage rate compared with the use of a short isolated jejunal loop (4.34% vs 14.2%, P < 0.05). In addition, the use of duct-to-mucosa technique was associated with significantly lower incidence of postoperative pancreatic fistula compared with the invagination technique (4.2% vs 14.5%, P < 0.05). Finally, patients with a short isolated jejunal loop compared with patients with a long loop had increased morbidity (50.7% vs 27.5%, P < 0.05) and prolonged hospital stay (16.3 +/- 1.9 days vs 10.2 +/- 2.3 days, P < 0.05). Overall mortality rate was 1.5%. CONCLUSIONS The use of a long isolated jejunal loop and a duct-to-mucosa pancreaticojejunostomy is associated with decreased pancreatic leakage rate after pancreaticoduodenectomy.
Collapse
|
28
|
Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, Praveen Raj P. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. ACTA ACUST UNITED AC 2009; 16:731-40. [PMID: 19652900 DOI: 10.1007/s00534-009-0157-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 03/31/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy is a technically demanding surgery performed only at few centers in the world. This article aims to describe the evolution of the technique and summarizes the results in our institute over the years. METHODS Prospective data of patients undergoing laparoscopic pancreaticoduodenectomy from March 1998 to January 2009 was retrospectively reviewed. RESULTS There were a total of 75 patients (22 females and 53 males) with a mean age of 62 (range, 28-76) years. Conversion rate was 0%, overall postoperative morbidity was 26.7% and mortality rate was 1. 33%. Pancreatic fistula was seen in 6.67%. The mean operating time was 357 min (range 270-650), and the mean blood loss was 74 ml (range 35-410). The average time to the first bowel movement was 3 days and mean hospital stay was 8.2 days (range 6-42). Resected margins were positive in 2.6% of cases. The mean number of retrieved lymph nodes for the malignant lesions was 14 (range 8-22). CONCLUSION Laparoscopic pancreaticoduodenectomy can be safely performed by highly skilled laparoscopic surgeons. This technique can achieve adequate margins and follow oncological principles. Randomized comparative trials are needed to establish the superiority of laparoscopy versus open surgery.
Collapse
Affiliation(s)
- C Palanivelu
- GEM Hospital, 45-A, Pankaja Mill Road, Ramnathapuram, Coimbatore, 641045, India.
| | | | | | | | | | | | | |
Collapse
|
29
|
Price LH, Brandabur JJ, Kozarek RA, Gluck M, Traverso WL, Irani S. Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents. Gastrointest Endosc 2009; 70:174-9. [PMID: 19559842 DOI: 10.1016/j.gie.2008.12.051] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 12/06/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic duct stents are used for a variety of endoscopic pancreatic manipulations, and small surgical stents are used prophylactically to bridge pancreatic-enteric anastomoses. With increasing use of pancreatic stents, many complications have been recognized. OBJECTIVE To determine the complications and outcomes of pancreatic stent migration. DESIGN Case series from a retrospective review of all cases of upstream or proximally migrated pancreatic duct stents, placed either endoscopically or surgically, identified between 2000 and 2007. SETTING Tertiary referral center. PATIENTS This study involved 33 patients; 23 postendoscopic and 10 postsurgical stents. MAIN OUTCOME MEASUREMENTS Retrieval rates, minor/major complications. RESULTS Endoscopic stents had a successful retrieval rate of 78%. Most patients were asymptomatic. The most common procedure was balloon extraction (8 of 18; 44%). Nine patients required multiple procedures (3 patients, 2 attempts; 5 patients, 3 attempts; 1 patient, 4 attempts). Five stents could not be retrieved. Of these, 4 were associated with downstream stenosis. Four patients underwent surgery, and 1 patient was treated with observation. Complications included pancreatic duct disruption (1 of 23), stent fragmentation (1 of 23), and postprocedure pancreatitis (1 of 23). Surgically placed stents had a successful retrieval rate of 80%. Most surgical stents had migrated into the biliary tree (8 of 10). All of these patients were symptomatic with pain or fever. Two stents could not be retrieved; 1 of those patients underwent surgery. LIMITATION Retrospective study. CONCLUSION The majority of upstream-migrated stents can be endoscopically removed. Despite manipulation of the pancreatic duct, pancreatitis was infrequent. Surgically placed pancreatic stents migrate downstream and into the open biliary anastomosis and are associated with pain, cholangitis, or liver abscesses.
Collapse
Affiliation(s)
- Leslie H Price
- Virginia Mason Medical Center, Seattle, Washington 98101, USA
| | | | | | | | | | | |
Collapse
|
30
|
Perwaiz A, Singhal D, Singh A, Chaudhary A. Is isolated Roux loop pancreaticojejunostomy superior to conventional reconstruction in pancreaticoduodenectomy? HPB (Oxford) 2009; 11:326-31. [PMID: 19718360 PMCID: PMC2727086 DOI: 10.1111/j.1477-2574.2009.00051.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Accepted: 02/16/2009] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Pancreatic fistula (PF) predicts mortality and morbidity in patients undergoing pancreaticoduodenectomy (PD). This study aimed to assess whether isolated Roux loop pancreaticojejunostomy (IPJ) is superior to conventional pancreaticojejunostomy (CPJ). METHODS Between September 2003 and July 2007, we performed 108 PDs. All patients underwent classical Kausch-Whipple PD with pancreaticojejunostomy (PJ). Patients were divided into two groups based on the type of PJ. Patients in group 1 underwent IPJ and those in group 2 underwent CPJ. A retrospective analysis of prospectively maintained data was performed to compare outcomes in the two groups. RESULTS There were 53 patients in group 1 and 55 in group 2. The two groups were comparable in both pre- and intraoperative parameters. The overall incidence of PF was 10.1% (five cases in group 1 vs. six in group 2). The course of clinically significant PF was similar in both groups in terms of fistula behaviour, management and the duration of spontaneous closure. Two patients in each group died. Overall complications, mortality and length of hospital stay were also similar; however, duration of surgery was significantly higher in group 1 vs. group 2 (442 min and 370 min, respectively; P= 0.005). CONCLUSIONS Isolated Roux loop pancreaticojejunostomy is not superior to conventional PJ; instead, it increases the duration of surgery.
Collapse
Affiliation(s)
- Azhar Perwaiz
- Department of Surgical Gastroenterology, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India
| | | | | | | |
Collapse
|
31
|
Poon RTP, Fan ST. Decreasing the pancreatic leak rate after pancreaticoduodenectomy. Adv Surg 2008; 42:33-48. [PMID: 18953808 DOI: 10.1016/j.yasu.2008.03.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ronnie T P Poon
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China.
| | | |
Collapse
|
32
|
Uchida K, Joseph JM, Gapany C, Chardot C. Modified digestive reconstruction with midgut transposition after pylorus-preserving pancreaticoduodenectomy for pancreatic head tumor in childhood. J Pediatr Surg 2008; 43:1932-4. [PMID: 18926236 DOI: 10.1016/j.jpedsurg.2008.03.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Revised: 02/06/2008] [Accepted: 03/21/2008] [Indexed: 11/29/2022]
Abstract
We describe a new procedure of digestive reconstruction after pylorus-preserving pancreaticoduodenectomy in a 13-year-old girl presenting with a large solid and papillary epithelial neoplasm of the pancreatic head. A midgut transposition (like in a cure of midgut malrotation) was easily performed after tumor removal with minimal additional dissection. Bilio- and pancreaticodigestive anastomoses were performed on 2 separate Roux-en-Y loops, placed behind the postpyloric jejunal loop. Separate biliary and pancreatic conduits prevented both activation of pancreatic enzymes at the pancreatic duct anastomosis and reflux of pancreatic juice in the bile ducts. Midgut transposition avoided any traction or twist of the 3 isoperistaltic intestinal loops. Postoperative course was uneventful. This technique may be useful after pancreatic head resections in children and adolescents.
Collapse
Affiliation(s)
- Keiichi Uchida
- Department of Paediatric Surgery, University Hospital of Geneva, CH 1205 Geneva, Switzerland
| | | | | | | |
Collapse
|
33
|
Kaman L, Sanyal S, Behera A, Singh R, Katariya RN. Isolated roux loop pancreaticojejunostomy vs single loop pancreaticojejunostomy after pancreaticoduodenectomy. Int J Surg 2008; 6:306-10. [PMID: 18556251 DOI: 10.1016/j.ijsu.2008.04.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Revised: 03/21/2008] [Accepted: 04/30/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreatic anastomotic leaks are a major cause of morbidity and mortality following pancreaticoduodenectomy, and no single technique of reconstruction has shown to be superior. The aim of this study was to review the experience of single loop versus isolated Roux loop pancreaticojejunostomy in a series of patients undergoing pancreatic head resection. METHODS A retrospective review involving 111 patients who underwent pancreatic head resections over 13year period (1994-2006) for malignant (n=106) and benign (n=5) disease was performed. Reconstruction of the pancreatic remnant was done using a single loop in 51 patients and by an isolated Roux loop in 60 patients. All pancreatic anastomosis were performed as a duct to mucosa anastomosis, in two layers, with pancreatic stent and closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50ml of amylase rich fluid for more than 7days postoperatively. RESULTS The two groups were comparable as regards to their demographic profiles, preoperative laboratory values and disease status in terms of pathology, pancreatic texture and pancreatic duct diameters. The overall incidence of pancreatic anastomotic leak was 11% (12) and was similar in both the groups; single loop 12% (6) and isolated Roux loop 10% (6). Isolated Roux loop pancreaticojejunostomy was associated with a significant prolongation of operative time (7.25+/-1.14h vs 6.07+/-1.12h) (p<0.05) and the need for more blood transfusion (2.25+/-0.84units vs 2.62+/-0.69units) (p<0.05). There was no significant difference in the morbidity or mortality between the two groups. Forty five percent (23) patients had complications in the single loop group and 48% (29) patients had complications in the isolated group. There were 8% (4) death in the single loop group and 8% (5) in the isolated group (p>0.05). CONCLUSION There does not appear to be a significant difference in the rates of pancreatic fistula following either method of reconstruction. However, performance of an isolated Roux loop pancreaticojejunostomy entails a prolongation of operative time and more intraoperative requirement of blood transfusions.
Collapse
Affiliation(s)
- Lileswar Kaman
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | | | | | | | | |
Collapse
|
34
|
Effect of BioGlue on the incidence of pancreatic fistula following pancreas resection. J Gastrointest Surg 2008; 12:882-90. [PMID: 18273671 DOI: 10.1007/s11605-008-0479-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 01/14/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite numerous modifications of surgical technique, pancreatic fistula remains a serious problem and occurs in about 10% of patients following pancreas resection. BioGlue is a new sealant that creates a flexible mechanical seal within minutes independent of the body's clotting mechanism. HYPOTHESIS Application of BioGlue sealant will reduce the incidence of pancreatic fistula following pancreas resection. METHODS A retrospective cohort study was performed with 64 patients undergoing pancreas resection. BioGlue sealant was applied to the pancreatic anastomosis (Whipple) or resection margin (distal pancreatectomy) in 32 cases. Factors that could affect the rate of postoperative pancreatic fistula were recorded. Pancreatic fistula was defined as greater than 50 ml of drain output with an amylase content greater than three times normal serum value after postoperative day 10. To improve the sensitivity of our study, we also examined pancreatic fistula with a strict definition of any drain output on or after postoperative day 3 with a high amylase content and graded the fistulas in terms of clinical severity. Grade A leaks were defined as subclinical. Grade B leaks required some response such as making the patient nil per os, parenteral nutrition, octreotide, antibiotics, or a prolonged hospital stay. Grade C leaks were defined as serious and life threatening. They were associated with hemorrhage, sepsis, resulted in deterioration of other organ systems, and mandated intensive care. Comparisons between the two groups were made using the chi-square test or Fisher's exact test for categorical variables and by the Wilcoxon rank-sum test for continuous variables. P values of 0.05 or less were deemed statistically significant. RESULTS There were no differences between the patients who received BioGlue and the control cohort in terms of comorbid conditions, tumor location, texture of the pancreas, size of the pancreatic duct, or surgical technique. By the common definition, pancreatic fistula occurred in 6% (control) vs. 22% (BioGlue). By the strict definition, a fistula occurred in 41% (control) vs. 60% (BioGlue). In the control group, ten were subclinical (grade A) and two were clinically apparent leaks (grade B). In the BioGlue group, seven were subclinical (grade A), five were clinically apparent (grade B), and three were severe (grade C). There were no statistically significant differences in the incidence or severity grades of postoperative pancreatic fistulas between the two groups. CONCLUSION Application of BioGlue sealant probably does not reduce the incidence of pancreatic fistula following pancreas resection.
Collapse
|
35
|
Kleespies A, Albertsmeier M, Obeidat F, Seeliger H, Jauch KW, Bruns CJ. The challenge of pancreatic anastomosis. Langenbecks Arch Surg 2008; 393:459-71. [PMID: 18379817 DOI: 10.1007/s00423-008-0324-4] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Accepted: 02/21/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Significant progress in surgical technique and perioperative management has substantially reduced the mortality rate of pancreatic surgery. However, morbidity remains considerably high, even in expert hands and leakage from the pancreatic stump still accounts for the majority of surgical complications after pancreatic head resection. For that reason, management of the pancreatic remnant after partial pancreatoduodenectomy remains a challenge. This review will focus on technique, pitfalls, and complication management of pancreaticoenteric anastomoses. MATERIALS AND METHODS A medline search for surgical guidelines, prospective randomized controlled trials, systematic metaanalysis, and clinical reports was performed with regard to surgical technique and complication management of pancreatic anastomoses. RESULTS Pancreaticojejunostomy appears to be most widely performed, but pancreaticogastrostomy is a reasonable alternative. Postoperative treatment with octreotide can be recommended only for patients with soft pancreatic tissue, and neither stents of the pancreatic duct nor drainages have proven to effectively reduce anastomotic complications. Gastroparesis remains the most common complication after pancreatic surgery and should be treated conservatively. However, it may be a symptom of other local complications, such as anastomotic leakage, pancreatic fistula or abscess. All septic complications may finally result in late postoperative hemorrhage, which requires immediate diagnostic workup and therapy. Today, interventional radiology has emerged as a standard tool in the management of local septic complications and bleeding. Therefore, relaparotomy has become less frequent and salvage pancreatectomy is now a rare procedure in case of local complications. CONCLUSION The surgeon's experience with one or the other technique of pancreatic anastomosis appears to be more important than the technique itself.
Collapse
Affiliation(s)
- Axel Kleespies
- Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilian-University of Munich, Munich, Germany.
| | | | | | | | | | | |
Collapse
|
36
|
Horiguchi A, Ishihara S, Ito M, Nagata H, Shimizu T, Furusawa K, Kato R, Katada K, Miyakawa S. Pancreatoduodenectomy in which dissection of the efferent arteries of the head of the pancreas is performed first. ACTA ACUST UNITED AC 2007; 14:575-8. [DOI: 10.1007/s00534-006-1198-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Accepted: 11/14/2006] [Indexed: 11/25/2022]
|
37
|
Rezvani M, O'Moore PV, Pezzi CM. Late pancreaticojejunostomy stent migration and hepatic abscess after Whipple procedure. JOURNAL OF SURGICAL EDUCATION 2007; 64:220-3. [PMID: 17706575 DOI: 10.1016/j.jsurg.2007.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 02/22/2007] [Accepted: 03/11/2007] [Indexed: 05/16/2023]
Abstract
A previously unreported late complication of a transanastomotic stent across a pancreaticotojejunostomy is described. The stent migrated distally into the jejunal lumen, through the biliary anastomis into the bile duct and proximally into the liver where it served as a nidus for infection with abscess formation. A percutaneous transhepatic interventional radiologic approach both drained the abscess and pushed the stent out of the liver and biliary tree and into the bowel, with complete recovery. The decision by the surgeon to use a stent in these patients is discussed, and the complications associated with stenting a pancreaticojejunostomy are reviewed.
Collapse
Affiliation(s)
- Masoud Rezvani
- Department of Surgery, Abington Memorial Hospital, Abington, Pennsylvania 19001, USA
| | | | | |
Collapse
|
38
|
Crippa S, Salvia R, Falconi M, Butturini G, Landoni L, Bassi C. Anastomotic leakage in pancreatic surgery. HPB (Oxford) 2007; 9:8-15. [PMID: 18333107 PMCID: PMC2020778 DOI: 10.1080/13651820600641357] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Stefano Crippa
- Department of Surgery, Policlinico ‘GB Rossi’, University of VeronaVeronaItaly
| | - Roberto Salvia
- Department of Surgery, Policlinico ‘GB Rossi’, University of VeronaVeronaItaly
| | - Massimo Falconi
- Department of Surgery, Policlinico ‘GB Rossi’, University of VeronaVeronaItaly
| | - Giovanni Butturini
- Department of Surgery, Policlinico ‘GB Rossi’, University of VeronaVeronaItaly
| | - Luca Landoni
- Department of Surgery, Policlinico ‘GB Rossi’, University of VeronaVeronaItaly
| | - Claudio Bassi
- Department of Surgery, Policlinico ‘GB Rossi’, University of VeronaVeronaItaly
| |
Collapse
|
39
|
Butturini G, Marcucci S, Molinari E, Mascetta G, Landoni L, Crippa S, Bassi C. Complications after pancreaticoduodenectomy: the problem of current definitions. ACTA ACUST UNITED AC 2006; 13:207-11. [PMID: 16708296 DOI: 10.1007/s00534-005-1035-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2005] [Accepted: 03/30/2005] [Indexed: 01/26/2023]
Abstract
Pancreaticoduodenectomy nowadays represents a complex procedure and a challenge for the surgeon. Even though mortality is reported to be below 5% for experienced surgeons, morbidity is still around 30%-50%, often leading to prolongation of hospital stay, demanding postoperative investigations and procedures, and outpatient monitoring of the patients with complications. In the literature there is no agreement on the definitions of postoperative complications following pancreaticoduodenectomy, leading to a wide range of complication rates in different specialist units, particularly regarding the source of every complication, postoperative pancreatic fistula, and others such as delayed gastric emptying. Some authors have demonstrated that applying different definitions in homogeneous, single-center series, the incidence of a complication varied with statistical significance, implying the impossibility of correctly comparing different experiences. It seems essential to organize a Consensus Meeting among expert surgeons to prepare world-wide accepted definitions. The aim of this article is to review the current controversial definitions and to suggest a new clinical-based approach to the problem of the feasibility and reliability of the definitions themselves.
Collapse
Affiliation(s)
- Giovanni Butturini
- Surgical and Gastroenterological Department, University of Verona, Policlinico GB Rossi, Piazzale LA Scuro 10, 37134, Verona, Italy
| | | | | | | | | | | | | |
Collapse
|
40
|
Cheng TY, Sheth K, White RR, Ueno T, Hung CF, Clary BM, Pappas TN, Tyler DS. Effect of neoadjuvant chemoradiation on operative mortality and morbidity for pancreaticoduodenectomy. Ann Surg Oncol 2006; 13:66-74. [PMID: 16372154 DOI: 10.1245/aso.2006.02.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 08/01/2005] [Indexed: 01/11/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (neo-CRT) is being used with increasing frequency for periampullary tumors, but how it alters the complication rate of pancreaticoduodenectomy (PD) is unclear. METHODS A retrospective analysis was conducted of 79 patients with periampullary malignancies who received 5-fluorouracil-based neo-CRT followed by PD. RESULTS There was no difference in mortality between PD after neo-CRT (3.8%) and conventional PD for either malignant (4.5%) or benign (2.2%) disease. Focusing only on patients with malignancy, the neo-CRT group had a significantly lower pancreatic leak rate than the conventional group (10% vs. 43%; P < .001). Intra-abdominal abscesses were less common in the neo-CRT group (8.8% vs. 21%; P = .019), and there was one (1.2%) amylase-rich abscess in neo-CRT group, compared with eight (12%) in the conventional group. In addition, two patients in the conventional group died of leak-associated sepsis, compared with none in the neo-CRT group. Multivariate analysis revealed that neoadjuvant chemoradiation (odds ratio, .15) was the most significant factor associated with a reduced risk of pancreatic leak. CONCLUSIONS Neo-CRT does not increase the mortality or morbidity of PD. In contrast, neo-CRT was associated with a marked reduction in the incidence of pancreatic leak, as well as leak-associated morbidity and mortality.
Collapse
Affiliation(s)
- Tsung-Yen Cheng
- Department of Surgery, Duke University Medical Center, Box 3118, Durham, North Carolina 27710, USA
| | | | | | | | | | | | | | | |
Collapse
|