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Okui N, Furukawa K, Shirai Y, Onda S, Haruki K, Chiba M, Kato M, Torisu Y, Gocho T, Ikegami T. Safe and beneficial outcomes of pancreaticogastrostomy with endoscopic transgastric drainage for pancreatic fistula after pancreaticoduodenectomy. Surg Oncol 2024; 57:102141. [PMID: 39326127 DOI: 10.1016/j.suronc.2024.102141] [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: 07/08/2024] [Revised: 08/26/2024] [Accepted: 09/18/2024] [Indexed: 09/28/2024]
Abstract
PURPOSES The optimal surgical technique and perioperative management to prevent postoperative pancreatic fistula (POPF) formation after pancreaticoduodenectomy have not yet been established. This study examined the perioperative outcomes of pancreaticogastrostomy with endoscopic transgastric drainage. METHODS We performed a retrospective analysis of 191 patients who underwent pancreaticoduodenectomy between 2016 and 2023. They were divided into two groups: pancreaticojejunostomy group (n = 135) and pancreaticogastrostomy group (n = 56). We compared preoperative factors and postoperative outcomes. We performed endoscopic drainage only in the pancreaticogastrostomy group. RESULTS Preoperative factors were similar between the two groups. Operative time [480 (404-542) vs. 382 (346-458) minutes], blood loss [505 (270-850) vs. 315 (145-535) g], pseudoaneurysm formation (7 % vs. 0 %), and postoperative hospital stay [28 (22-38) vs. 19 (17-24) days] were significantly lower in the pancreaticogastrostomy group. In the analysis of 41 patients with POPF, postoperative hospital stay [40 (23-108) vs. 27 (18-54) days] and hospital stay after POPF diagnosis [30 (10-99) vs. 15 (5-35) days] were significantly shorter in the pancreaticogastrostomy group. Endoscopic transgastric drainage was performed in 77 % of patients in the pancreaticogastrostomy group, and drainage was successfully completed in all patients. CONCLUSION Pancreaticogastrostomy with endoscopic transgastric drainage could be effective for the safe management of pancreaticoduodenectomy.
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Affiliation(s)
- Norimitsu Okui
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masafumi Chiba
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Masayuki Kato
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Torisu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Gocho
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Yu HH, Wang SE, Shyr BS, Chen SC, Shyr YM, Shyr BU. Impact of hepatic artery variation on surgical and oncological outcomes in robotic pancreaticoduodenectomy. Surg Endosc 2024; 38:3728-3737. [PMID: 38780631 DOI: 10.1007/s00464-024-10887-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/29/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND In patients with hepatic artery variation (HAV), feasibility and justification of robotic pancreatoduodenectomy (RPD) for periampullary lesions have been not been well established. METHODS A total of 600 patients with periampullary lesions receiving RPD or open pancreaticoduodenectomy (OPD) were identified from our prospectively collected computer database. Surgical outcomes, oncological radicality, and survival outcomes after RPD in HAV ( +) and (-) patients were compared. RESULTS The incidence of HAV was 16%, including 12.7% in patients with RPD and 23.0% in those with OPD. In the HAV ( +) group, vascular injury rate had no statistical difference between the RPD (3.7%) and OPD (9.1%) patients, P = 0.404. Among the RPD patients, those with HAV ( +) had longer operation time (8.5 ± 2.5 vs. 7.7 ± 2.0 h, P = 0.013) and higher vascular injury (3.8% vs. 0.6%, P = 0.024) when compared with the HAV (-) patients. There was no significant difference between the HAV ( +) and (-) patients with RPD regarding blood loss, open conversion, vascular resection, and surgical mortality and morbidity. There was no survival difference between the HAV ( +) and (-) patients with pancreatic head adenocarcinoma after RPD. There was no survival difference between RPD and OPD in the HAV ( +) group. CONCLUSIONS When compared with OPD, RPD is feasible and justifiable without increasing vascular injury rate for patients with HAV ( +). Hepatic artery variation has no negative impact on surgical, oncological, and survival outcomes following an RPD, if it is accurately identified pre-operatively and appropriately managed intraoperatively.
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Affiliation(s)
- Hsuan-Hsuan Yu
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Bor-Shiuan Shyr
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shih-Chin Chen
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Bor-Uei Shyr
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
- Therapeutic and Research Center of Pancreatic Cancer, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
- National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University, 10 Floor 201 Section 2 Shipai Road, Taipei, 112, Taiwan, ROC.
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Shyr BS, Wang SE, Chen SC, Shyr YM, Shyr BU. Survival and surgical outcomes of robotic versus open pancreatoduodenectomy for ampullary cancer: A propensity score-matching comparison. Asian J Surg 2024; 47:899-904. [PMID: 37925285 DOI: 10.1016/j.asjsur.2023.10.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 09/06/2023] [Accepted: 10/20/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND/OBJECTIVE Robotic pancreaticoduodenectomy in ampullary cancer has never been studied. This study aimed to clarify the feasibility and justification of robotic pancreaticoduodenectomy in ampullary cancer in terms of surgical risks, and oncologic and survival outcomes. METHODS A propensity score-matching comparison of robotic and open pancreaticoduodenectomy based on seven factors commonly used to predict the survival outcomes in ampullary cancer patients. RESULTS A total of 147 patients were enrolled, of which 101 and 46 underwent robotic and open pancreaticoduodenectomies, respectively. After propensity score-matching with a 2:1 ratio, 88 and 44 patients in the robotic and open pancreaticoduodenectomy groups were included. The operation time was of no significant difference after matching. The median intraoperative blood loss was much less in those who underwent robotic pancreaticoduodenectomy, both before (median, 120 vs. 320 c.c. P < 0.001) and after (100 vs. 335 mL P < 0.001) score-matching. There were no significant differences in terms of surgical risks, including surgical mortality, surgical morbidity, Clavien-Dindo severity classification, postoperative pancreatic fistula, delayed gastric emptying, post-pancreatectomy hemorrhage, chyle leak, bile leak, and wound infection, both before or after score-matching. The survival outcomes were also similar between the two groups, regardless of matching. CONCLUSIONS Robotic pancreaticoduodenectomy for ampullary cancer is not only technically feasible and safe without increasing surgical risks, but also oncologically justifiable without compromising surgical radicality and survival outcomes.
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Affiliation(s)
- Bor-Shiuan Shyr
- Division of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taiwan, ROC; National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shin-E Wang
- Division of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taiwan, ROC; National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shih-Chin Chen
- Division of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taiwan, ROC; National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yi-Ming Shyr
- Division of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taiwan, ROC; National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Bor-Uei Shyr
- Division of General Surgery, Departments of Surgery, Taipei Veterans General Hospital, Taiwan, ROC; National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.
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Shyr BS, Shyr YM, Chen SC, Wang SE, Shyr BU. Reappraisal of surgical and survival outcomes of 500 consecutive cases of robotic pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:99-109. [PMID: 37881144 DOI: 10.1002/jhbp.1383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
BACKGROUND The role of the robotic approach for pancreaticoduodenectomy has not been well established with robust data. This study aimed to reappraise feasibility and justification of robotic pancreaticoduodenectomy (RPD) over time. METHODS A total of 500 patients undergoing RPD were enrolled and divided into early (first 250 patients) and late (last 250 patients) groups for a comparative study. RESULTS The conversion rate was 8.8% overall and was significantly lower in the late group (5.6% vs. 12.0%; p = .012). The overall median intraoperative blood loss was 130 mL. Radicality of resection was similar between early and late groups. The overall surgical mortality after RPD was 1.3%. The overall surgical morbidity and major complication was 44.1% and 13.2%, respectively, and similar between early and late groups. Chyle leakage was the most common complication after RPD (25.0%), followed by postoperative pancreatic fistula (POPF). The POPF rate was 8.6% overall, with 5.9% in the early group and 11.0% in the late group, p = .051. The overall delayed gastric emptying rate was 3.5%. The late group had better survival outcomes than those of the early group after RPD for ampullary adenocarcinoma (p = .027) but not for pancreatic head adenocarcinoma. CONCLUSIONS Reappraisal of this study has confirmed that RPD is not only technically feasible without increasing surgical risks but also oncologically justified without compromising survival outcomes for both pancreatic head and other periampullary cancers over time. Moreover, RPD is associated with the benefits of low surgical mortality, blood loss, and delayed gastric emptying.
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Affiliation(s)
- Bor-Shiuan Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Bor-Uei Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Zhou B, Gao Z, Tian Y, Yan S. A modified Blumgart method using a homemade crochet needle facilitates pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy: a retrospective cohort study. BMC Surg 2024; 24:22. [PMID: 38218837 PMCID: PMC10787960 DOI: 10.1186/s12893-023-02308-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/29/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Among the safest procedures for anastomosis in pancreaticoduodenectomy, Blumgart pancreaticojejunostomy is associated with low rates of postoperative pancreatic fistula (POPF) and postoperative complications. However, this technique is difficult to perform during laparoscopic pancreaticoduodenectomy (LPD). This study presents a modified Blumgart method using a homemade crochet needle to facilitate laparoscopic pancreaticojejunostomy and evaluates its safety and reliability. METHODS From February 2019 to October 2022, 96 LPD surgeries with the new technique were performed by the same surgeons in the Second Affiliated Hospital of Zhejiang University School of Medicine. The operative details (operative time, pancreaticojejunostomy time, POPF rate, postoperative complication rate, mortality rate) were analyzed along with clinical and pathological indicators (pancreatic duct diameter, pancreatic texture, and histopathological findings). RESULTS There were 54 men and 42 women with a mean age of 63.38 ± 10.41 years. The intraoperative bleeding volume, operative time and postoperative length of hospital stay were 198.43 ± 132.97 mL, 445.30 ± 87.05 min and 13.68 ± 4.02 days, respectively. The operation time of pancreaticojejunostomy was 66.28 ± 10.17 min. Clinically relevant POPFs (grades B and C) occurred in 14.6% of patients. Only one patient had postoperative abdominal hemorrhage and was cured after reoperation. There were no operative or in-hospital deaths. With our proposed modification, the pancreatic duct and jejunal orifice are aligned correctly during duct-to-mucosa (DTM) after the application of external traction through the homemade crochet needle. The space between the posterior wall of pancreatic remnant and jejunal loop can be exposed by adjusting the tension of the external threads, which can facilitate DTM. CONCLUSIONS A modified Blumgart method using a homemade crochet needle could be technically feasible and safe during LPD. A randomized control trial is needed to confirm these findings.
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Affiliation(s)
- Bo Zhou
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Zhenzhen Gao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Yang Tian
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Sheng Yan
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China.
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Wang ML, Shyr BS, Chen SC, Wang SE, Shyr YM, Shyr BU. Comparison of robotic and open central pancreatectomy. Int J Med Robot 2023:e2562. [PMID: 37574857 DOI: 10.1002/rcs.2562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/01/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Central pancreatectomy (CP) is an ideal parenchyma-sparing procedure. The experience of r robotic central pancreatectomy (RCP) is very limited. MATERIALS AND METHODS Patients undergoing CP were included. Comparisons were made between RCP and open central pancreatectomy (OCP) groups. RESULTS The most common lesion in patients undergoing CP was serous cystadenoma (35.5%). The median operation time was 4.2 h for RCP versus 5.5 h for OCP. The median blood loss was significantly lower in RCP, 20 c.c. versus 170 c.c., p = 0.001. Postoperative pancreatic fistula occurred in 19.4% of all patients, with 22.1% in RCP and 15.4% in OCP. There was no significant difference regarding other surgical complications between the RCP and OCP groups. Only one patient in the OCP group developed de novo diabetes mellitus (DM), and no steatorrhoea/diarrhoea occurred after either RCP or OCP. CONCLUSIONS RCP is feasible and safe without compromising surgical outcomes and pancreatic functions.
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Affiliation(s)
- Man-Ling Wang
- Departments of Surgery, Division of General Surgery, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Bor-Shiuan Shyr
- Departments of Surgery, Division of General Surgery, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Chin Chen
- Departments of Surgery, Division of General Surgery, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shin-E Wang
- Departments of Surgery, Division of General Surgery, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Departments of Surgery, Division of General Surgery, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Bor-Uei Shyr
- Departments of Surgery, Division of General Surgery, Taipei Veterans General Hospital, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Sun Q, Peng P, Gong X, Wu J, Zhang Q, Hu Z, Chang X, Hu Z. A Blumgart Anastomosis-Based Half-Invagination Pancreaticoenterostomy with Better Applicability to Laparoscopy and Lower Incidence of Pancreatic Leakage. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2023; 2023:6304047. [PMID: 36873788 PMCID: PMC9981301 DOI: 10.1155/2023/6304047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 02/25/2023]
Abstract
Background The Blumgart anastomosis (BA) is one of the safest anastomoses for pancreatic stump reconstruction. The incidence of postoperative pancreatic fistula (POPF) and postoperative complications is low. However, how to make laparoscopic pancreaticoenterostomy easier and safer is still a topic to be discussed. Methods The data of patients who underwent laparoscopic pancreaticoduodenectomy (PD) from April 2014 to December 2019 were analyzed retrospectively. Results Half-invagination anastomosis was performed in 20 cases (HI group), and the Cattell-Warren anastomosis was carried out in 26 cases (CW group). The amount of intraoperative bleeding, operation time, and postoperative catheterization time in the HI group was significantly less than those in the CW group. Besides, the number of patients at the Clavien-Dindo grade III and above in the HI group was significantly less than that in the control group. Moreover, the incidence of POPF in the HI group was significantly lower than that in the CW group. Furthermore, fistula risk score (FRS) analysis showed that there was no high-risk group, and the highest risk in the medium-risk group was pancreatic leakage. In addition, the incidence of pancreatic leakage in the HI group and CW group was 7.7% and 46.67%, respectively, while the incidence of pancreatic leakage in the HI group was significantly lower than that in the CW group. Conclusions The half-invagination pancreaticoenterostomy based on the Blumgart anastomosis should have good applicability under laparoscopy and could effectively reduce the incidence of postoperative pancreatic leakage.
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Affiliation(s)
- Qiang Sun
- General Surgery Department 1, Zhongshan People's Hospital, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
| | - Peng Peng
- General Surgery Department 1, Zhongshan People's Hospital, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
| | - Xueyi Gong
- General Surgery Department 1, Zhongshan People's Hospital, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
| | - Jianlong Wu
- General Surgery Department 1, Zhongshan People's Hospital, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
| | - Qiao Zhang
- General Surgery Department 1, Zhongshan People's Hospital, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
| | - Zhipeng Hu
- General Surgery Department 1, Zhongshan People's Hospital, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
| | - Xiaojian Chang
- General Surgery Department 1, Zhongshan People's Hospital, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
| | - Zemin Hu
- General Surgery Department 1, Zhongshan People's Hospital, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
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Teres ligamentum wrap covering the pancreaticojejunostomy following pancreatoduodenectomy is associated with a lower rate of postoperative pancreas fistula: a prospective cohort study. HPB (Oxford) 2023; 25:116-123. [PMID: 36280427 DOI: 10.1016/j.hpb.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/26/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreas fistula (POPF) is a common complication after pancreatoduodenectomy (PD). A Teres Ligamentum (TL)-wrap covering the pancreaticojejunostomy (PJ) is suggested as a potential solution to reduce POPF. The aim of this study was to compare POPF incidence (grade B/C) in patients with or without a TL-wrap. METHODS A prospective cohort study was performed between January 2019-December 2021. All consecutive patients were included. Patient, tumor and surgical characteristics and postoperative complications were compared in both open and robot-assisted surgery. RESULTS A total of 118 consecutive patients were included. The first 57 patients were treated without and the following 61 patients with a TL-wrap. There were no statistically significant differences between both groups regarding patient, pre-operative treatment and surgical characteristics. The occurrence of POPF was strongly reduced in the TL-wrap group compared to patients without a TL-wrap (3.3% vs 28.1%, P < 0.001). Also mean length of hospital stay was reduced (11.5 vs 18.8 days, P = 0.030). CONCLUSION The use of a TL-wrap covering the PJ as addition to the modified Blumgart anastomosis technique is associated with a significantly reduced POPF rate and a reduced length of hospital stay. A TL-wrap is a simple addition to a PJ that may be considered to improve postoperative outcome. This association must be studied more definitively in a randomized controlled trial.
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Risk factors for delayed gastric emptying in pancreaticoduodenectomy. Sci Rep 2022; 12:22270. [PMID: 36564517 PMCID: PMC9789159 DOI: 10.1038/s41598-022-26814-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022] Open
Abstract
The study of robotic pancreaticouodenectomy (RPD) focusing on delayed gastric emptying (DGE) is seldom reported. This study explored the incidence of DGE in RPD with extracorporeal hand-sewn gastrojejunostomy involving downward positioning of the stomach. Patients with periampullary lesions undergoing RPD or open pancreaticouodenectomy (OPD) were included for comparison. A variety of clinical factors were evaluated for the risk of developing DGE. There were 409 (68.2%) RPD and 191 (31.8%) OPD in this study. DGE occurred in 7.7% of patients after pancreaticoduodenectomy, with 4.4% in RPD and 14.7% in OPD, p < 0.001. Nausea/vomiting (12.6% vs. 6.3%) and jaundice (9.9% vs. 5.2%) were significant preoperative risk factors for DGE, while malignancy (8.7% vs. 2.2%) and lymph node involvement (9.8% vs. 5.6%) were significant pathological risk factors. Intraoperative blood loss > 200 c.c. was the other factor related to DGE (11.2% vs. 4.4% in those with blood loss ≤ 200 c.c.). None of the postoperative complications was significantly associated with DGE. Hospital stay was significantly longer in the group with DGE (median, 37 vs. 20 days in the group without DGE). After multivariate analysis by binary logistic regression, compared with OPD, RPD was the only independent factor associated with a lower incidence of DGE. RPD with extracorporeal hand-sewn antecolic, antiperistaltic, and inframesocolic gastrojejunostomy via a small umbilical wound involving careful downward positioning of the stomach was associated with a low incidence of DGE and presented as the most powerful independent predictor of this condition.
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Jalil O, Muhammad QR, Farrugia A, Ali M, Gavriilidis P, Marangoni G, Ahmad J. Initial Experience of Consecutive Robotic Pancreatoduodenectomies With Patient Reported Outcomes From a Single Center in the UK. J Clin Med Res 2021; 13:435-437. [PMID: 34527100 PMCID: PMC8425791 DOI: 10.14740/jocmr4574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/07/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Omar Jalil
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Qazi Rahim Muhammad
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Alexia Farrugia
- Walsall Healthcare NHS Trust, Walsall Manor Hospital, Moat Road, Walsall WS2 9PS, UK.,Warwick Medical School, University of Warwick, Medical School Building, Coventry CV4 7AL, UK
| | - Majid Ali
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Paschalis Gavriilidis
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - Gabriele Marangoni
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK.,Warwick Medical School, University of Warwick, Medical School Building, Coventry CV4 7AL, UK
| | - Jawad Ahmad
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK.,Warwick Medical School, University of Warwick, Medical School Building, Coventry CV4 7AL, UK
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Shyr Y, Wang S, Chen S, Shyr B, Shyr B. Robotic pancreaticoduodenectomy for pancreatic head cancer and periampullary lesions. Ann Gastroenterol Surg 2021; 5:589-596. [PMID: 34585043 PMCID: PMC8452471 DOI: 10.1002/ags3.12457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/03/2021] [Accepted: 03/08/2021] [Indexed: 12/23/2022] Open
Abstract
Pancreaticoduodenectomy, so-called "Whipple operation," is a time-consuming and technically demanding complex operation. Traditionally, this procedure has been performed most usually by open approach, which results in a large and painful wound. With the introduction of laparoscopic and robotic surgery, minimally invasive surgery (MIS) has emerged as a worldwide trend to improve wound cosmesis and to minimize wound pain. Although MIS for pancreaticoduodenectomy has also been attempted at some centers, the role of MIS, either robotic or laparoscopic approach, has not been well-established for complex pancreaticoduodenectomy. Given that laparoscopic pancreaticoduodenectomy has been limited by its technical complexity and the high level of advanced laparoscopic skills required for pancreatic reconstruction, a robotic surgical system is introduced to overcome several limitations related to the laparoscopic approach. Providing high-quality three-dimensional (3-D) vision, high optical magnification, articulation of robotic instruments, greater precision with suture targeting, and elimination of surgeon tremor, robotic surgical systems innovatively perform more delicate and complex procedures involving extensive dissection and suturing techniques such as pancreaticoduodenectomy. Although associated with longer operative time, robotic pancreaticoduodenectomy (RPD) has been claimed to have the benefits of less delayed gastric emptying, less blood loss, shorter length of postoperative stay, and lower wound infection rate, as compared with the traditional open pancreaticoduodenectomy (OPD). Moreover, RPD seems to be not only technically feasible but also justified without compromising the survival outcomes for pancreatic head and ampullary adenocarcinomas. Therefore, RPD could be recommended not only to surgeons but also to patients in terms of surgical feasibility, surgical outcomes, and patient satisfaction.
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Affiliation(s)
- Yi‐Ming Shyr
- Division of General SurgeryDepartment of SurgeryTaipei Veterans General Hospital and School of MedicineNational Yang Ming UniversityTaipeiTaiwan
| | - Shin‐E Wang
- Division of General SurgeryDepartment of SurgeryTaipei Veterans General Hospital and School of MedicineNational Yang Ming UniversityTaipeiTaiwan
| | - Shih‐Chin Chen
- Division of General SurgeryDepartment of SurgeryTaipei Veterans General Hospital and School of MedicineNational Yang Ming UniversityTaipeiTaiwan
| | - Bor‐Uei Shyr
- Division of General SurgeryDepartment of SurgeryTaipei Veterans General Hospital and School of MedicineNational Yang Ming UniversityTaipeiTaiwan
| | - Bor‐Shiuan Shyr
- Division of General SurgeryDepartment of SurgeryTaipei Veterans General Hospital and School of MedicineNational Yang Ming UniversityTaipeiTaiwan
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12
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Lee PY, Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Surgical and survival outcomes after robotic and open pancreaticoduodenectomy with positive margins. J Chin Med Assoc 2021; 84:698-703. [PMID: 34050108 DOI: 10.1097/jcma.0000000000000558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Though nowadays a palliative pancreaticoduodenectomy (PD) can be performed safely with relatively low mortality and acceptable morbidity rates in experienced centers, there have been no studies on the routine use of a palliative PD or on the advantages of performing surgical resection as a debulking procedure. Furthermore, the impact of resection margins on survival outcomes has been a matter of controversy. Therefore, this study aimed to clarify the role of robotic PD (RPD) in pancreatic and periampullary adenocarcinomas with positive resection margins. METHODS Patients undergoing RPDs and open PDs (OPDs) were included in this study. Based on the resection margins, the patients were divided into the R0, R1, and R2 PD groups. Surgical risks and survival outcomes were analyzed. RESULTS There were 348 PDs, including 29 (8.3%) palliative and 319 (91.7%) curative. Primary tumor origin, tumor sizes, perineural invasions, and abnormal serum carcinoembryonic antigen (CEA) levels were factors leading to palliative resection. The multivariate analysis showed that only pancreatic head adenocarcinomas and abnormal serum CEA levels (>5 ng/mL) were independent predictors. The surgical risks between curative and palliative PD were similar. There were no significant differences in the surgical risks and other surgical parameters between palliative RPDs and OPDs. For curative resection, RPDs resulted in less blood loss, greater harvested lymph nodes yield, less postoperative complications, less delayed gastric emptying, and shorter hospital stays than OPDs. The survival outcome was significantly better following R0 resection in overall periampullary adenocarcinomas, whereas a significant survival difference was shown only between the R0 and R2 resections for pancreatic head adenocarcinomas. CONCLUSION Compared with R0 PDs, palliative R1 PDs could benefit patients with pancreatic head adenocarcinomas when considering survival outcomes without increasing surgical risks. RPD can be considered for curative purposes and as an alternative for palliative management.
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Affiliation(s)
- Po-Ying Lee
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, and National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Wongta K, Tangsirapat V. Surgical outcomes of combined modified Blumgart pancreaticojejunostomy and long internal pancreatic duct stent for pancreaticoduodenectomy. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Circulating Cell-Free DNA as a Prognostic Biomarker in Resectable Ampullary Cancer. Cancers (Basel) 2021; 13:cancers13102313. [PMID: 34065893 PMCID: PMC8151754 DOI: 10.3390/cancers13102313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 01/05/2023] Open
Abstract
Simple Summary Circulating cell-free DNA (cfDNA) in patients with ampullary cancer was measured to clarify the correlation between cfDNA and clinicopathological factors and the impact of cfDNA on survival outcomes. The level of cfDNA was significantly higher in patients with lymph node involvement, lymphovascular invasion, abnormal serum carcinoembryonic antigen level, and stage II and III cancer. The 1- and 5-year survival rates were 92.0% and 66.5%, respectively, for patients with low cfDNA levels ≤ 6687 copies/mL as compared with 84.0% and 49.9%, respectively, for patients with high cfDNA levels > 6687 copies/mL (p < 0.001). After multivariate analysis, only the cfDNA level and cancer stage were independent factors in determining the prognosis of the ampullary cancer. The cfDNA level could act as a surrogate marker of both disease extent and biological aggressiveness of ampullary cancer. Moreover, cfDNA plays a significant role in determining the prognosis of resectable ampullary cancer. Abstract Circulating cell-free DNA (cfDNA) in ampullary cancer patients was measured to clarify the correlation between cfDNA and clinicopathological factors and the impact of cfDNA on survival outcomes. Patients with ampullary cancer undergoing pancreaticoduodenectomy were included. Correlations between cfDNA and clinicopathological and prognostic factors were determined. The cfDNA levels in patients ranged from 1282 to 21,674 copies/mL, with a median of 6687 copies/mL. The cfDNA level was significantly higher in patients with lymph node involvement, lymphovascular invasion, abnormal serum carcinoembryonic antigen (CEA) level, and stage II and III cancer. Poor prognostic factors for ampullary cancer included high cfDNA > 6687 copies/mL, lymph node involvement, abnormal serum CEA > 5 ng/mL, and advanced stage II and III cancer. The 1- and 5-year survival rates were 92.0% and 66.5%, respectively, for patients with low cfDNA < 6687 copies/mL and 84.0% and 49.9%, respectively, for patients with high cfDNA > 6687 copies/mL (p < 0.001). After multivariate analysis, only the cfDNA level and stage were independent prognostic factors of ampullary cancer. Thus, the cfDNA level could act as a surrogate marker of both disease extent and biological aggressiveness of ampullary cancer. Moreover, cfDNA plays a significant role in the prognosis of resectable ampullary cancer.
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Endo Y, Kitago M, Shinoda M, Yagi H, Abe Y, Oshima G, Hori S, Yokose T, Abe K, Takemura R, Ishi R, Kitagawa Y. Clinical Impact of Portal Vein Distance on Computed Tomography for Postoperative Pancreatic Fistula after Pancreatoduodenectomy. World J Surg 2021; 45:2200-2209. [PMID: 33791854 DOI: 10.1007/s00268-021-06076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pancreatic fistulas remain a significant concern after pancreatectomy owing to the associated high risk of mortality and high costs. It is not possible to perform preoperative risk stratification for all patients. This study aimed to evaluate the usefulness of the measurement of portal vein (PV) distance as a predictive indicator of pancreatic fistula development after pancreatoduodenectomy and compare it with the usefulness of other indicators such as body mass index (BMI), and abdominal fat area. METHODS Patient characteristics, preoperative laboratory data, radiographic findings, and their association with pancreatic fistula development after pancreatoduodenectomy were analyzed for 157 patients who underwent resection during 2011-2017. Clinically relevant postoperative pancreatic fistulas (CR-POPF) were defined as Grade B or C fistulas based on the International Study Group of Pancreatic Surgery (ISGPS) 2016 consensus. RESULTS CR-POPF developed in 38 patients (24.2%). Multivariate logistic regression indicated that PV distance and BMI were potential candidates for predictive models for pancreatic fistula development, and small pancreatic duct diameter, diabetes mellitus development, and pathology of non-pancreatic cancers were independent factors for CR-POPF. When comparing the two risk models (PV distance- and BMI-based models), the PV distance-derived risk model was compatible to the BMI-based stratification models (area under the curve 0.831 vs. 0.830). CONCLUSIONS PV distance was confirmed to be a useful risk predictor for CR-POPF. This research highlighted the efficacy of abdominal thickness measurement, which is simple and easily applicable in the clinical setting.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan.
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Go Oshima
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Takahiro Yokose
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Kodai Abe
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Ryo Takemura
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Ryota Ishi
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku, Tokyo, 160-8582, Japan
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Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Propensity score-matched comparison of the oncological feasibility and survival outcomes for pancreatic adenocarcinoma with robotic and open pancreatoduodenectomy. Surg Endosc 2021; 36:1507-1514. [PMID: 33770276 DOI: 10.1007/s00464-021-08437-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study is to clarify the feasibility of and justification for robotic pancreaticoduodenectomy (RPD) in patients with pancreatic adenocarcinoma. METHODS A 1-to-1 propensity score-matched comparison of RPD and open pancreaticoduodenectomy (OPD) was performed based on six covariates commonly used to predict the survival outcome for pancreatic adenocarcinoma. RESULTS A total of 130 patients were enrolled, with 65 in each study group after propensity score matching. The median operating time was longer for RPD (8.3 h vs. 7.0 h, P = 0.002). However, RPD was associated with less blood loss, lower overall surgical complication rate, and lower incidence of delayed gastric emptying. The resection radicality was oncologically similar between these two groups, but the median lymph node yield was higher for RPD (18 vs. 16, P = 0.038). Before propensity score matching, the 5-year survival was better in RPD (27.0% vs. 17.6%, P = 0.006). After matching, there was still a trend towards improved overall survival in the RPD group; however, the difference in 5-year survival between RPD and OPD was not significant (24.5% vs. 19.7%, P = 0.088). CONCLUSION RPD is not only technically feasible with no increase in surgical risk but also oncologically justifiable without compromising survival outcome. However, unlike randomized control trials, the limitations in this propensity score-matched analysis only accounted for 6 observed covariates commonly used to predict the survival outcome in patients with pancreatic adenocarcinoma, and confounders not included in this study could also affect our results.
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Affiliation(s)
- Bor-Uei Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Bor-Shiuan Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
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Wang SE, Shyr BU, Shyr BS, Chen SC, Chang SC, Shyr YM. Circulating Cell-Free DNA in Pancreatic Head Adenocarcinoma Undergoing Pancreaticoduodenectomy. Pancreas 2021; 50:214-218. [PMID: 33565798 DOI: 10.1097/mpa.0000000000001730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Circulating cell-free DNA (cfDNA) analysis is recently reported as a promising prognostic biomarker in various types of cancer. This study aimed to evaluate the role of cfDNA in pancreatic head adenocarcinoma. METHODS Data for pancreatic head adenocarcinoma undergoing pancreaticoduodenectomy were studied for cfDNA. Prognostic factors were determined, and their correlation with cfDNA level was evaluated. RESULTS The median of cfDNA for 97 cases was 7724 copies/mL, with a mean of 10,467, and ranging from 1856 to 44,203. Cell-free DNA was significantly higher in positive lymph node involvement and advanced stage III. Poor prognostic factors included high cfDNA level (>7724 copies/mL), abnormal carbohydrate antigen 19-9, abnormal carcinoembryonic antigen, and advanced stage. The 1- and 5-year survivals for those with high cfDNA were poorer, 70.2% and 21.2%, respectively, as compared with 93.4% and 23.7% for those with low cfDNA level. Only cfDNA level and stage were independent prognostic factors after multivariate analysis. CONCLUSIONS The level of cfDNA was correlated with tumor burden. Therefore, it could be an emerging survival predictor for resectable pancreatic head adenocarcinoma, and its detection might be a promising liquid biopsy to monitor both tumor progression and treatment response.
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Affiliation(s)
- Shin-E Wang
- From the Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
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Furbetta N, Gianardi D, Guadagni S, Di Franco G, Palmeri M, Bianchini M, Pisani K, Di Candio G, Morelli L. Somatostatin administration following pancreatoduodenectomy: a case-matched comparison according to surgical technique, body mass index, American Society of Anesthesiologists' score and Fistula Risk Score. Surg Today 2020; 51:1044-1053. [PMID: 33270148 PMCID: PMC8141487 DOI: 10.1007/s00595-020-02189-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE This study evaluated the controversial role of somatostatin after pancreatoduodenectomy (PD), stratifying patients for the main risk factors using the most recent postoperative pancreatic fistula (POPF) classification and including only patients who had undergone PD with the same technique of pancreatojejunostomy. METHODS Between November 2010 and February 2020, 218 PD procedures were carried out via personal modified pancreatojejunostomy (mPJ-PD). Somatostatin was routinely administered between 2010 and 2016, while from 2017, 97 mPJ-PD procedures without somatostatin (WS) were performed. The WS group was retrospectively compared with a control (C) group obtained with one-to-one case-control matching according to the body mass index, American Society of Anesthesiologists' score, and Fistula Risk Score (FRS). RESULTS A total of 144 patients (72 WS group versus 72 C group) were compared. In the WS group. 6 patients (8.3%) developed clinically relevant POPF, compared with 8 patients (11.1%) in the C group (p = 0.656). In addition, on analyzing the subgroup of high-risk patients according to the FRS, we did not note any significant differences in POPF occurrence. Furthermore, no marked differences in the morbidity or mortality were found. Digestive bleeding and diabetes onset rates were higher in the WS group than in the control group, but not significantly so. CONCLUSIONS The results of the present study confirm no benefit with the routine administration of somatostatin after PD to prevent POPF, even in high-risk patients. However, a possible role in the prevention of postoperative digestive bleeding and diabetes was observed.
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Affiliation(s)
- Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Kevin Pisani
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
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Andrianello S, Marchegiani G, Malleo G, Masini G, Balduzzi A, Paiella S, Esposito A, Landoni L, Casetti L, Tuveri M, Salvia R, Bassi C. Pancreaticojejunostomy With Externalized Stent vs Pancreaticogastrostomy With Externalized Stent for Patients With High-Risk Pancreatic Anastomosis: A Single-Center, Phase 3, Randomized Clinical Trial. JAMA Surg 2020; 155:313-321. [PMID: 32101272 DOI: 10.1001/jamasurg.2019.6035] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance The operative scenarios with the highest postoperative pancreatic fistula (POPF) risk represent situations in which fistula prevention and mitigation strategies have the strongest potential to affect surgical outcomes after pancreaticoduodenectomy. Evidence from studies providing risk stratification is lacking. Objective To investigate whether pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG), both with externalized transanastomotic stent, is the best reconstruction method for patients at high risk of POPF after pancreaticoduodenectomy. Design, Setting, and Participants A single-center, phase 3, randomized clinical trial was conducted at the Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy, from July 12, 2017, through March 15, 2019, among adults undergoing elective pancreaticoduodenectomy and considered at high risk for pancreatic fistula after intraoperative assessment of the fistula risk score, some of whom were randomized to undergo PG or PJ. All analyses were performed on an intention-to-treat basis. Interventions Intervention consisted of PJ or PG, both with externalized transanastomotic stent and octreotide omission. Main Outcomes and Measures The primary end point was POPF. The secondary end points were Clavien-Dindo grade 3 or higher morbidity, postpancreatectomy hemorrhage, delayed gastric emptying, and average complication burden. Results A total of 604 patients were screened for eligibility; 82 were at high risk for POPF (fistula risk score, 7-10), and 72 were randomized undergo PG (n = 36; 20 men and 16 women; median age, 65 years [interquartile range, 23-82]) or PJ (n = 36; 26 men and 10 women; median age, 63 years [interquartile range, 35-79]). There was no significant difference in the incidence of POPF between patients who underwent PG and patients who underwent PJ (18 [50.0%] vs 14 [38.9%]; P = .48), but for patients who developed a POPF, the mean (SD) average complication burden was lower for those who underwent PJ than for those who underwent PG (0.25 [0.13] vs 0.39 [0.17]; P = .04). The rates of postpancreatectomy hemorrhage (14 [38.9%] in the PG group vs 9 [25.0%] in the PJ group; P = .31) and delayed gastric emptying (16 [44.4%] in the PG group vs 18 [50.0%] in the PJ group; P = .81) were similar, but patients who underwent PG presented with a significantly higher incidence of Clavien-Dindo grade 3 or higher morbidity than those who underwent PJ (17 [47.2%] vs 8 [22.2%]; P = .047). Conclusions and Relevance Among patients at the highest risk for POPF, those who underwent PG or PJ experienced similar rates of POPF. However, PG was associated with an increased incidence of Clavien-Dindo grade 3 or higher morbidity and with an increased average complication burden for the patients who developed a POPF. For patients at high risk for pancreatic fistula, PJ with the use of externalized stent and octreotide omission should be considered the most appropriate technical strategy. Trial Registration ClinicalTrials.gov Identifier: NCT03212196.
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Affiliation(s)
- Stefano Andrianello
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Gaia Masini
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Alberto Balduzzi
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
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Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis. Sci Rep 2020; 10:17896. [PMID: 33087777 PMCID: PMC7578105 DOI: 10.1038/s41598-020-74812-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/07/2020] [Indexed: 02/05/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.
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Liu Q, Zhao Z, Gao Y, Zhao G, Jiang N, Lau WY, Liu R. Novel Technique for Single-Layer Pancreatojejunostomy is Not Inferior to Modified Blumgart Anastomosis in Robotic Pancreatoduodenectomy: Results of a Randomized Controlled Trial. Ann Surg Oncol 2020; 28:2346-2355. [PMID: 33079303 DOI: 10.1245/s10434-020-09204-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/20/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND A novel technique of single-layer continuous suturing (SCS) for pancreaticojejunostomy (PJ) during robotic pancreaticoduodenectomy (RPD), a technically straightforward procedure, has been shown to produce promising results in a previous study. The present RCT aims to show that SCS during RPD does not increase the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) when compared with modified Blumgart anastomosis (MBA). PATIENTS AND METHODS Between January 2019 and September 2019, consecutive patients (ASA score ≤ 2) who underwent RPD were enrolled and randomized to the SCS or the MBA group. The primary endpoint was the rate of CR-POPF. A noninferiority margin of 10% was chosen. RESULTS Of the 186 patients, 4 were excluded because PJ was not performed. The remaining 182 patients were randomized to the SCS group (n = 89) or MBA group (n = 93). CR-POPF rate was not inferior in the SCS group [SCS: 6.7%, MBA: 11.8%; 95% confidence interval (- 0.76, - 0.06), P = 0.0002]. PJ duration was significantly lower in the SCS group (P < 0.01). No significant differences were found between the two groups in operative time, estimated blood loss, postoperative hospital stay, or rates of conversion to laparotomy, morbidity, reoperation, or mortality. On subgroup analysis of patients with a soft pancreas and small main pancreatic duct, SCS significantly reduced the duration of PJ. CONCLUSIONS This study showed that SCS was not inferior to MBA in terms of the CR-POPF rate during RPD. Registration number: ChiCTR1800020086 ( www.Chictr.org.cn ).
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Affiliation(s)
- Qu Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhiming Zhao
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yuanxing Gao
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Guodong Zhao
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Nan Jiang
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, SAR, China
| | - Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China.
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22
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Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Robotic and open pancreaticoduodenectomy: results from Taipei Veterans General Hospital in Taiwan. Updates Surg 2020; 73:939-946. [PMID: 33068270 DOI: 10.1007/s13304-020-00899-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/08/2020] [Indexed: 12/13/2022]
Abstract
This study is to clarify the feasibility and justification of robotic pancreaticoduodenectomy (RPD) by comparing the outcomes between RPD and open pancreaticoduodenectomy (OPD) groups. All perioperative data and outcomes were prospectively collected. There were 304 (63.9%) RPD and 172 (36.1%) OPD. The median operation time was longer in RPD group than OPD (7.5 vs 7.0 h). The blood loss was much lower in RPD group, with a median of 130 vs. 400 c.c. in OPD group. Based on Clavien-Dindo classification, grade 0 (no complication) was 51.8% in RPD group, higher than 43.2% in OPD. Delayed gastric emptying was only 3.5% in RPD group, much lower than 13.6% in OPD. Wound infection rate was also lower in RPD group, 3.2% vs. 7.7% in OPD. The postoperative hospital stay was shorter in RPD group, with a median of 20 days, vs. 24 days in OPD. There was no significant difference regarding the lymph node yield, surgical mortality, postoperative pancreatic fistula, postpancreatectomy hemorrhage, chyle leakage and bile leakage between RPD and OPD groups. For pancreatic head adenocarcinoma, the survival outcome was better in RPD group, with 1-year, 3-year, and 5-year survival of 82.9%, 45.3%, and 26.8% respectively, as compared with 63.8%, 26.2%, and 17.4% in OPD. RPD is not only feasible but also justified without increasing the surgical risks and compromising the survival outcomes. Moreover, RPD might provide benefits of less blood loss, less delayed gastric emptying, lower wound infection rate and shorter length of postoperative stay, as compared with OPD.
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Affiliation(s)
- Bor-Uei Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Bor-Shiuan Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
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The 1-year outcomes after pancreaticogastrostomy using vertical versus horizontal mattress suturing for gastric wrapping. Surg Today 2020; 51:511-519. [PMID: 32968859 DOI: 10.1007/s00595-020-02134-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate the differences in nutritional status 1 year after pancreaticogastrostomy (PG) using vertical suturing (VS) vs. twin square horizontal mattress (HMS) suturing in patients undergoing pancreaticoduodenectomy (PD). METHODS The subjects of this study were 134 patients who underwent PD, followed by PG, which was closed by VS in 52 and by HMS in 82. We evaluated the peri- and postoperative factors, nutritional parameters, diameter of the remnant main pancreatic duct, and glucose intolerance 1 year postoperatively. RESULTS Forty-five (87%) patients from the VS group and 75 (91%) patients from the HMS group survived for more than 1 year. The incidences of intraabdominal abscess and pancreatic fistula were significantly lower in the HMS group than in the VS group (19.2% vs. 6.6% and19.2% vs. 2.6%, respectively). There were no significant changes in the total protein, serum albumin, and HbA1c levels 1 year postoperatively. The postoperative expansion ratio of the main pancreatic duct diameter was significantly smaller in the HMS group than in the VS group. The strongest risk factor for body weight loss 1 year postoperatively was a non-soft pancreas texture. CONCLUSION HMS was superior to VS for preventing early postoperative complications and did not affect pancreatic function.
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Menonna F, Napoli N, Kauffmann EF, Iacopi S, Gianfaldoni C, Martinelli C, Amorese G, Vistoli F, Boggi U. Additional modifications to the Blumgart pancreaticojejunostomy: Results of a propensity score-matched analysis versus Cattel-Warren pancreaticojejunostomy. Surgery 2020; 169:954-962. [PMID: 32958267 DOI: 10.1016/j.surg.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula continues to occur frequently after pancreatoduodenectomy. METHODS We have described a modification of the Blumgart pancreaticojejunostomy. The modification of the Blumgart pancreaticojejunostomy was compared to the Cattel-Warren pancreaticojejunostomy in cohorts of patients matched by propensity scores based on factors predictive of clinically relevant postoperative pancreatic fistula, which was the primary endpoint of this study. Based on a noninferiority study design, 95 open pancreatoduodenectomies per group were needed. Feasibility of the modification of the Blumgart pancreaticojejunostomy in robotic pancreatoduodenectomy was also shown. All pancreaticojejunostomies were performed by a single surgeon. RESULTS Between October 2011 and May 2019, there were 415 pancreatoduodenectomies with either a Cattel-Warren pancreaticojejunostomy (n = 225) or a modification of the Blumgart pancreaticojejunostomy (n = 190). There was 1 grade C postoperative pancreatic fistula in 190 consecutive modification of the Blumgart pancreaticojejunostomies (0.5%). Logistic regression analysis showed that the rate of clinically relevant postoperative pancreatic fistula was not affected by consecutive case number. After exclusion of robotic pancreatoduodenectomies (the Cattel-Warren pancreaticojejunostomy: 82; modification of the Blumgart pancreaticojejunostomy: 66), 267 open pancreatoduodenectomies were left, among which the matching process identified 109 pairs. The modification of the Blumgart pancreaticojejunostomy was shown to be noninferior to the Cattel-Warren pancreaticojejunostomy with respect to clinically relevant postoperative pancreatic fistula (11.9% vs 22.9%; odds ratio: 0.46 [0.21-0.93]; P = .03), grade B postoperative pancreatic fistula (11.9% vs 18.3%; P = .18), and grade C postoperative pancreatic fistula (0 vs 4.6%; P = .05) as well as to all secondary study endpoints. The modification of the Blumgart pancreaticojejunostomy was feasible in 66 robotic pancreatoduodenectomies. In this subgroup with 1 conversion to open surgery (1.5%), a clinically relevant postoperative pancreatic fistula occurred after 9 procedures (13.6%) with no case of grade C postoperative pancreatic fistula and a 90-day mortality of 3%. CONCLUSION The modification of the Blumgart pancreaticojejunostomy described herein is noninferior to the Cattel-Warren pancreaticojejunostomy in open pancreatoduodenectomy. This technique is also feasible in robotic pancreatoduodenectomy.
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Affiliation(s)
- Francesca Menonna
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Emanuele F Kauffmann
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Sara Iacopi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Caterina Martinelli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy.
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Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy. Surgery 2020; 169:362-368. [PMID: 32896373 DOI: 10.1016/j.surg.2020.07.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/28/2020] [Accepted: 07/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are no reports of performing mesopancreas dissections in robotic pancreaticoduodenectomy. This study evaluated the feasibility and justification for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy. METHODS Surgical outcomes after robotic pancreaticoduodenectomy and open pancreaticoduodenectomy were evaluated and compared. RESULTS There were 289 robotic pancreaticoduodenectomy and 162 open pancreaticoduodenectomy patients included in the study. Postoperative diarrhea occurred in 34.5% of mesopancreas level 3 dissection cases and was higher than in levels 2 and 1 dissection cases, P < .001. Blood loss in the robotic pancreaticoduodenectomy group was higher for mesopancreas level 3 dissection, with a median loss of 263 mL (P = .015). The rate of R0 resection with margin >1 mm was higher for mesopancreas level 3 dissection (93.8%) than for level 2 dissection (72.2%) (P < .001). The lymph node yield was higher for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy; the median lymph node yield was 21 for level 3, 18 for level 2, and 14 for level 1 (P < .001). Compared with mesopancreas levels 1 and 2 dissections in the robotic pancreaticoduodenectomy groups, level 3 dissection did not show increased surgical mortality or postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, chyle leakage, bile leakage, or wound infection. Compared with open pancreaticoduodenectomy, mesopancreas level 3 dissection in robotic pancreaticoduodenectomy had less blood loss, no delayed gastric emptying, and lower chyle leakage. CONCLUSION Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy is feasible without compromising surgical safety. Therefore, robotic pancreaticoduodenectomy can be recommended as a safe alternative to open pancreaticoduodenectomy for mesopancreas level 3 dissection.
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Affiliation(s)
- Bor-Uei Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Bor-Shiuan Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shin-E Wang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan.
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Di Martino M, de la Hoz Rodríguez Á, Martín-Pérez E. Blumgart pancreaticojejunostomy: does it reduce postoperative pancreatic fistula in comparison to other pancreatic anastomoses? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:736. [PMID: 32647661 PMCID: PMC7333131 DOI: 10.21037/atm.2020.03.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Marcello Di Martino
- Department of Surgery, HPB Unit, University Hospital La Princesa, Madrid, Spain
| | | | - Elena Martín-Pérez
- Department of Surgery, HPB Unit, University Hospital La Princesa, Madrid, Spain
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Shyr YM, Wang SE, Chen SC, Shyr BU. Robotic pancreaticoduodenectomy in the era of minimally invasive surgery. J Chin Med Assoc 2020; 83:639-643. [PMID: 32332518 DOI: 10.1097/jcma.0000000000000333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Minimally invasive surgery has become a worldwide trend to reduce the wound and mitigate pain. However, the role of robotic pancreaticoduodenectomy (RPD) has not been well established in the era of minimally invasive surgery. It would be nearly impossible to apply minimally invasive surgery in the tedious and complicated Whipple operation without an experienced and dedicated pancreas team. The pancreatic team led by Shyr YM and Wang SE at Taipei Veterans General Hospital have already been highly accredited with a Copper Award of Symbol of National Quality (SNQ award), entitled with "Minimally Invasive Robotic Pancreatic Surgery-Small Wound for Major Pancreatic Surgery" in Taiwan in 2019. RPD was claimed to be associated with less blood loss, less delayed gastric emptying, shorter length of postoperative stay, and lower wound infection rate, but longer operative time, as compared with the traditional open pancreaticoduodenectomy (OPD). More than 99% of the patients undergoing minimally invasive RPD are satisfied with the surgical outcomes and would like to recommend RPD to those with periampullary lesions. RPD could be recommended not only to surgeons but also to patients in terms of surgical outcomes and patient satisfaction. Moreover, our study showed a survival benefit for pancreatic head adenocarcinoma in RPD group, with 1-year, 3-year, and 5-year survival of 82.9%, 45.3%, and 26.8%, respectively, as compared with 63.8%, 26.2%, and 17.4% in OPD.
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Affiliation(s)
- Yi-Ming Shyr
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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28
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Paik KY. Implication of pancreaticoenterostomy regarding postoperative pancreatic fistula. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:597. [PMID: 32568270 PMCID: PMC7290525 DOI: 10.21037/atm-2020-77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Kwang Yeol Paik
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Cao F, Tong X, Li A, Li J, Li F. Meta-analysis of modified Blumgart anastomosis and interrupted transpancreatic suture in pancreaticojejunostomy after pancreaticoduodenectomy. Asian J Surg 2020; 43:1056-1061. [PMID: 32169516 DOI: 10.1016/j.asjsur.2020.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/12/2019] [Accepted: 01/13/2020] [Indexed: 12/21/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) remains the main cause of surgery related mortality after pancreaticoduodenectomy. Various pancreatoenteric anastomosis methods have been developed to reduce the POPF rate. However, the optimum choice has not been clarified. A literature search is performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing modified Blumgart anastomosis with interrupted transpancreatic suture are included in this meta-analysis. Grade B/C POPF, overall POPF rate and overall sever complication rate (Clavien-Dindo classification IIIa or more) are measured as primary outcomes. Revman 5.3 was used to perform the analysis. Five retrospective comparative studies and 1 randomized controlled trial with a total number of 1409 patients are included in our analysis. Meta-analysis revealed that modified Blumgart anastomosis is associated with lower rate of grade B/C POPF [Odds Ratio (OR) 95% confidence interval (CI),0.32 (0.12-0.84); P = 0.02] and intra-abdominal abscess [OR 95%CI, 0.43 (0.29-0.65); P < 0.01] comparing with interrupted transpancreatic suture. However, this procedure could not reduce overall POPF [OR 95%CI,0.70 (0.34-1.44); P = 0.34] and overall sever complication rate [OR 95%CI,0.91 (0.48-1.72); P = 0.77]. At current level of evidence, modified Blumgart anastomosis is superior to interrupted transpancreatic suture in terms of grade B/C POPF and intra-abdominal abscess. However, high-grade evidence will be necessary to confirm these results.
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Affiliation(s)
- Feng Cao
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, PR China
| | - Xiaogang Tong
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, PR China
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, PR China
| | - Jia Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, PR China.
| | - Fei Li
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, PR China.
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Nagakawa Y, Takishita C, Hijikata Y, Osakabe H, Nishino H, Akashi M, Nakajima T, Shirota T, Sahara Y, Hosokawa Y, Ishizaki T, Katsumata K, Tsuchida A. Blumgart method using LAPRA-TY clips facilitates pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy. Medicine (Baltimore) 2020; 99:e19474. [PMID: 32150110 PMCID: PMC7478424 DOI: 10.1097/md.0000000000019474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The modified Blumgart method for pancreaticojejunostomy has been shown to reduce the rate of postoperative pancreatic fistula (POPF) in open surgery. We describe a modified Blumgart method using LAPRA-TY suture clips to facilitate laparoscopic pancreaticojejunostomy.We prepared a double-armed 4-0 nonabsorbable monofilament, which was ligated using the LAPRA-TY clip at the tail end, 12-cm in length. Next, the U-suture was placed through the pancreatic stump and the seromuscular layer of the jejunum. We performed duct-to-mucosa suturing with a 5-0 absorbable monofilament. After completing the duct-to-mucosa suturing, as a final step we placed the sutures through the seromuscular layer of the jejunum on the ventral side and tightly secured the thread with the LAPRA-TY clips. We performed laparoscopic Blumgart pancreaticojejunostomy during pancreaticoduodenectomy in 39 patients. We compared the surgical outcomes of 19 patients who underwent Blumgart pancreaticojejunostomy using the LAPRA-TY clips (LAPRA-TY group) with 20 patients undergoing surgery not using the LAPRA-TY clips (conventional group).The rate of clinically relevant postoperative pancreatic fistula in the LAPRA-TY group was 21.1%, which did not differ significantly from the rate of the conventional group. However, the mean time of pancreaticojejunostomy in the LAPRA-TY group was 56.2 min (range, 39-79 min), which was significantly shorter than that of the conventional group (69.7 min; range, 53-105 min, P < .001).Although the modified Blumgart pancreaticojejunostomy using LAPRA-TY suture clips did not improve the pancreatic fistula rate, it allowed for shorter operative times. Thus, this procedure lends itself to positive surgical and patient outcomes.
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Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Chyle leakage after robotic and open pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:273-279. [PMID: 31971351 DOI: 10.1002/jhbp.716] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/04/2020] [Accepted: 01/10/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Chyle leakage is a well-known but poorly characterized complication after pancreaticoduodenectomy (PD). No study examined the chyle leakage after robotic PD (RPD). METHODS Data regarding chyle leakage were prospectively collected and analyzed from patients undergoing RPD or open PD (OPD). RESULTS The study included 118 RPD and 165 OPD. Overall chyle leakage rate was 12.0%, with 13.6% for RPD and 10.9% for OPD. Chyle leakage was eventually resolved in all patients through conservative treatment. The drainage volumes were significantly higher in chyle leakage group from postoperative days (PODs) 1-7, with a median of 240 mL on POD 1 and POD 7, as compared to 160 mL on POD 1 and 70 mL on POD 7 for those without chyle leakage. The number of lymph nodes involved and resected and pancreatic head adenocarcinoma affected the risk of developing chyle leakage, whereas the surgical approach used (RPD or OPD) did not. CONCLUSIONS Chyle leakage after PD is not rare, and it can eventually be resolved through conservative treatment. The extent and radicality of the surgery probably have a significant effect on the risk of developing chyle leakage, but the surgical approach used does not.
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Affiliation(s)
- Bor-Uei Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Bor-Shiuan Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
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Kim SG, Paik KY, Oh JS. The vulnerable point of modified blumgart pancreaticojejunostomy regarding pancreatic fistula learned from 50 consecutive pancreaticoduodenectomy. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:630. [PMID: 31930031 DOI: 10.21037/atm.2019.10.89] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Blumgart anastomosis (BA) during pancreaticoduodenectomy (PD) had reduced postoperative pancreatic fistula (POPF) after PD in literatures. The aim of this study is to report surgical results from a consecutive series of operation using the modified BA method. Methods Data from 50 consecutive patients who underwent PD using modified BA between September 2011 and August 2018 were prospectively collected and retrospectively analyzed, regarding POPF, other morbidities, and mortality. Results Overall incidence of POPF was 10.0%, the rate of grade B POPF was 8.0% (4/50) and grade C was 2.0% (1/50). Among 50 patients, 5 post pancreatectomy hemorrhages (PPHs) (10.0%) including 2 POPF related bleeding, and 4 abscesses including 2 related to POPF occurred. Fistula risk grades were as follows: 0 negligible, 6 low, 36 intermediate, and 8 high. Except for one patient, fistulas improved over the clinical course after radiologic intervention drainage and angiography. The mortality occurred due to POPF followed by jejunal detachment from the remnant pancreas stump. In this case, jejunum was too thin, compared to the pancreatic thickness. Conclusions This retrospective single-center result demonstrated that the modified BA had an acceptable rate of POPF. Modified BA may be risky and potentially provoke fatal POPF, when joining a thin jejunum and thick pancreas.
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Affiliation(s)
- Sung Geun Kim
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kwang Yeol Paik
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ji Seon Oh
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Shyr BU, Shyr BS, Chen SC, Chang IW, Shyr YM, Wang SE. Operative results and patient satisfaction after robotic pancreaticoduodenectomy. Asian J Surg 2019; 43:519-525. [PMID: 31606357 DOI: 10.1016/j.asjsur.2019.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/20/2019] [Accepted: 08/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/OBJECTIVE There are no reports available on patient satisfaction and quality-of-life after robotic pancreaticoduodenectomy (RPD). This study aimed to evaluate not only surgical outcomes but also patient satisfaction after RPD. METHODS Prospectively collected data for RPD were analyzed for surgical outcomes. Questionnaires were sent to patients to assess patient satisfaction regarding RPD. RESULTS The study included 105 patients who underwent RPD, with 44 (41.9%) patients presenting with associated surgical complications. There were no significant differences between the without and with complication groups in median console time (390 min. Vs. 373 min.), blood loss (100 mL vs. 100 mL), and harvested lymph node number (14 vs. 15). There was no surgical mortality in this study. Major complications ≥ Clavien-Dindo III occurred in 7.6% of the total 105 RPD patients. The most common complication was chyle leakage (18.1%), followed by postoperative pancreatic fistula (5.7%), intra-abdominal abscess (4.8%), delayed gastric emptying (3.8%), and post pancreatectomy hemorrhage (3.8%). Almost all of the patients responded to this RPD-related survey with "fair" to "excellent" grades for all items, except 1 (<1%) poor grade for operation service and 2 (1.9%) "not good" grades for diet tolerance. CONCLUSIONS RPD is a feasible procedure with acceptable surgical outcomes. This patient survey with high patient satisfaction rates indicates that RPD provides acceptable satisfaction results, and the robotic approach for a major operation such as RPD has probably a higher priority than cost concerns. RPD could be recommended not only to surgeons but also to patients in terms of surgical outcomes and patient satisfaction.
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Affiliation(s)
- Bor-Uei Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Bor-Shiuan Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - I-Wen Chang
- Department of Nursing, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan.
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Piao S, Pan Z, Qian C, Jin X. The effect of bilateral U-sutures in pancreaticojejunostomy in 75 consecutive cases. Acta Chir Belg 2019; 119:201-204. [PMID: 31008700 DOI: 10.1080/00015458.2019.1610258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Various technical interventions have been suggested to decrease the frequency of postoperative pancreatic fistulas but the effect is not particularly satisfactory. We have analyzed our application of bilateral U-sutures in pancreaticojejunostomy. METHODS The pancreatic stump is freed over approximately 2 cm, an appropriate diameter silicone catheter with 2-4 lateral holes was inserted into the remnant pancreatic duct (>2 mm in diameter is required) over 2-3 cm as a stent in 69 patients. In six patients with soft pancreas and very small pancreatic duct (<2 mm in diameter), the silicone catheter was not used. An incision was made on the side of the distal section of the jejunum and end-to-side an invaginated pancreaticojejunostomy was performed using bilateral U-sutures. RESULTS Only two (2.67%) cases developed pancreatic 'biochemical leaks'. None of the 75 patients developed grade B and grade C pancreatic leakage. The overall morbidity was 29.33%. The anastomosis time was 14 minutes on average. There were no symptoms such as abdominal discomfort, dyspepsia and diarrhea, and no dilatation of pancreatic duct was found by CT in 75 patients after discharge from hospital. CONCLUSIONS Bilateral U-sutures are a safe, simple, and effective technique in pancreaticojejunostomy, preventing the primary complication of anastomotic leakage, and worthy of wide use.
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Affiliation(s)
- Shengjun Piao
- Department of General Surgery, Affiliated Hospital of Yanbian University, Yanji, China
| | - Zhijia Pan
- Department of General Surgery, Affiliated Hospital of Yanbian University, Yanji, China
| | - Changshi Qian
- Department of General Surgery, Affiliated Hospital of Yanbian University, Yanji, China
| | - Xinglin Jin
- Department of General Surgery, Affiliated Hospital of Yanbian University, Yanji, China
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Li R, Zhang W, Li Q. Modified Pancreatojejunostomy in Pancreaticoduodenectomy for the Treatment of Periampullary Tumor: 8 Years of Surgical Experience. Med Sci Monit 2019; 25:3788-3795. [PMID: 31112531 PMCID: PMC6540650 DOI: 10.12659/msm.916837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background We modified the anastomosis surgical method based on the Blumgart anastomosis in pancreaticoduodenectomy. This study aimed to compare patient outcomes with regards to clinically relevant postoperative pancreatic fistula (CR-POPF) and other postoperative complications among patients receiving traditional anastomosis, classical Blumgart anastomosis, and our modified-Blumgart anastomosis. Material/Methods Data were reviewed from 229 consecutive patients with periampullary tumors who underwent pancreaticoduodenectomy administered by a single surgeon at the Tianjin Medical University Cancer Institute and Hospital between January 2010 and December 2017. Subsequently, clinical factors potentially associated with CR-POPF were analyzed. Results During the study period, the incidence of overall CR-POPF was 31 out of 229 patients (13.5%). Using Blumgart anastomosis (BA), the incidence of CR-POPF was lower at 15 out of 148 patients (10.1%), significantly lower than that of traditional anastomosis (invagination technique or “duct-to-mucosa” anastomosis) (15 out of 148 patients versus 16 out of 81 patients, P=0.042). Compared with classical Blumgart anastomosis (c-B), our modified-Blumgart anastomosis (m-BA) method had similar outcomes in terms of CR-POPF (9 out of 73 patients versus 6 out of 75 patients, P=0.383), CR-POPF-related intra-abdominal hemorrhage rate (0 out of 73 patients versus 1 out of 75 patients, P=0.322), and median length of postoperative hospital stay (19 days versus 19 days, P=0.752). There were no fatalities as a result of CR-POPF in the BA group. Conclusions Upon review of a single surgeon’s experience over 8 years, Blumgart anastomosis might be more effective in the prevention of CR-POPF than traditional anastomosis. Our modified-Blumgart anastomosis method maintained a low rate of morbidity and mortality but with simplified procedures that can be easily put into practice. This technique can be used widely with excellent safety for pancreatojejunostomy as a part of pancreaticoduodenectomy.
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Affiliation(s)
- Rentao Li
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin, China (mainland)
| | - Wei Zhang
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin, China (mainland)
| | - Qiang Li
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin, China (mainland)
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Shyr BU, Chen SC, Shyr YM, Wang SE. Surgical, survival, and oncological outcomes after vascular resection in robotic and open pancreaticoduodenectomy. Surg Endosc 2019; 34:377-383. [PMID: 30963260 DOI: 10.1007/s00464-019-06779-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 04/04/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND To evaluate the surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV)/portal vein (PV) resection by either robotic PD (RPD) or open PD (OPD). METHODS Data of patients with periampullary lesions undergoing PD were retrieved from a prospectively collected computer database. Surgical risks as well as oncological and survival outcomes were compared between patients with (vein resection group) and without SMV/PV resection (without vein resection group). RESULTS A total of 391 patients undergoing pancreaticoduodenectomy were enrolled, including 43 (11.0%) and 384 (89.0%) patients with and without vein resection, respectively. Eleven (25.6%) of PDs with vein resection were performed using the robotic approach. Operation time in the vein resection group was significantly longer (median of 8 vs. 7 h). Blood loss, curative resection (R0) rate, and harvested lymph node number were similar between these two groups. Surgical outcomes including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), chyle leakage, wound infection, and hospital stay were not significantly different between the two groups. There was no survival difference between these groups, with 1- and 3-year survival rates of 92.6% and 26.5%, respectively, for vein resection group, vs. 70.3% and 37.2%, respectively, for the without vein resection group. CONCLUSIONS PD with vein resection is technically feasible by OPD and RPD in selected patients. Additional SMV/PV would not increase the surgical risks of PD and could achieve similar survival outcomes for pancreatic head adenocarcinoma when compared to PD without vein resection.
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Affiliation(s)
- Bor-Uei Shyr
- Departments of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Departments of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Departments of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shin-E Wang
- Departments of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan.
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, 201 Section 2 Shipai Road, Taipei, 112, Taiwan.
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Gupta V, Kumar S, Gupta V, Joshi P, Rahul R, Yadav RK, Dangi A, Chandra A. Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes. Hepatobiliary Pancreat Dis Int 2019; 18:181-187. [PMID: 30772208 DOI: 10.1016/j.hbpd.2019.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/25/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Blumgart's pancreaticojejunostomy (PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes. METHODS We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula (CR-POPF) and analysis of its risk factors. RESULTS The CR-POPF rate was 12.3%. Fistula risk score (FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay. CONCLUSION Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Vivek Gupta
- Department of Human Organ Transplant, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Pradeep Joshi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Rahul Rahul
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Rakesh Kumar Yadav
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Amit Dangi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
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Liu H, He A, Liu K, Jiang Z, Zhang F, Li X, He Y, Tao K, Wang L, Yue S. WITHDRAWN: A personal technical experience and results of a modified end-to-side technique of pancreatojejunostomy: A 350 patients retrospective cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018:S0748-7983(18)31994-2. [PMID: 30470530 DOI: 10.1016/j.ejso.2018.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/24/2018] [Accepted: 11/03/2018] [Indexed: 10/27/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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Affiliation(s)
- Huizhong Liu
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Anjiang He
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Kun Liu
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Zijian Jiang
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Fen Zhang
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Xiao Li
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Yong He
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Kaishan Tao
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lin Wang
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Shuqiang Yue
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
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Shyr BU, Chen SC, Shyr YM, Wang SE. Learning curves for robotic pancreatic surgery-from distal pancreatectomy to pancreaticoduodenectomy. Medicine (Baltimore) 2018; 97:e13000. [PMID: 30407289 PMCID: PMC6250552 DOI: 10.1097/md.0000000000013000] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This study sought to identify the learning curves of console time (CT) for robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP). Perioperative outcomes were compared between the early group of surgeries performed early in the learning curve and the late group of surgeries performed after the learning curve.Pancreaticoduodenectomy (PD) is a technically demanding and challenging procedure carrying a high morbidity.Data for RDP and RPD were prospectively collected for analysis. The learning curve was assessed by cumulative sum (CUSUM). Based on CUSUM analyses, patients were divided into the early group and the late group.There were 70 RDP and 61 RPD cases. It required 37 cases to overcome the learning curve for RDP and 20 cases for RPD. The median console time was significantly shorter in the late group for both RDP (112 minutes vs 225 minutes, P < .001) and RPD (360 minuntes vs 520 minutes, P < .001). Median blood loss was significantly less in the late group for both RDP (30 cc vs 100 cc, P = .003) and RPD (100 cc vs 200 cc, P < .001). No surgical mortality occurred in either group. Clinically relevant pancreatic fistula rate was 22.9% for RDP (32.4% in the early group vs 12.1% in the late group, P = .043), and 11.5% for RPD (0 in early group vs 17.1% in late group, P = .084).This study demonstrates that the RPD learning curve is 20 cases with prior experience of RDP and confirms the safety and feasibility of both RPD and RDP. Practice and familiarity with the robotic platform are likely to contribute to significant shortening of the learning curve in robotic pancreatic surgery, while knowledge and experience, in addition to practical skills, are also essential to minimize the potential surgical risks of RPD.
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Outcome of 150 Consecutive Blumgart's Pancreaticojejunostomy After Pancreaticoduodenectomy. Indian J Surg Oncol 2018; 10:65-71. [PMID: 30948875 DOI: 10.1007/s13193-018-0821-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/17/2018] [Indexed: 12/16/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) is the most feared complication after pancreaticoduodenectomy (PD) that leads to intra-abdominal abscess, sepsis, or bleeding and remains the single most important source of morbidity and mortality after PD. To minimize this dreaded complication, various surgical techniques and modifications of pancreaticoenteric reconstruction have been proposed. However, still POPF does occur even in experienced hands. We herein describe the outcome of 150 post PD patients who underwent duct-to-mucosa (DM) pancreaticojejunostomy (PJ) using a special technique, Blumgart's "through & through" U transpancreatic sutures. The technique is described in detail. Postoperative octreotide and metoclopramide were used in all patients for 3 days. An enhanced recovery (ERAS) protocol was followed in a subset of patients. All patients were ASA grade 1 and had adenocarcinoma of the periampullary region/pancreatic head and underwent standard pylorus resecting PD after due optimization. Eighty-eight (58.7%) patients had pancreatic duct < 3 mm and pancreatic texture was soft to very soft in 112 (74.6%) patients. There was only one International Study Group of Pancreatic Surgery (ISGPS) grade C POPF with concomitant hemorrhage. Five patients developed ISGPS grade B and two grade C, delayed gastric emptying (DGE). There was no 30-day mortality. The average length of hospital stay was 7.3 ± 4.2 days with a median of 6 days in the ERAS subset of patients. Blumgart's "through & through" DMPJ technique is very helpful in reducing the POPF and other complications even in high-risk pancreas (i.e., soft with a small pancreatic duct) and is easy to learn and perform.
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Kawakatsu S, Inoue Y, Mise Y, Ishizawa T, Ito H, Takahashi Y, Saiura A. Comparison of pancreatojejunostomy techniques in patients with a soft pancreas: Kakita anastomosis and Blumgart anastomosis. BMC Surg 2018; 18:88. [PMID: 30355352 PMCID: PMC6201584 DOI: 10.1186/s12893-018-0420-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/02/2018] [Indexed: 12/15/2022] Open
Abstract
Background Postoperative pancreatic fistula (PF) is the main cause of operative mortality in patients who undergo pancreatoduodenectomy. Various pancreatoenteric anastomosis techniques have been reported to minimize the postoperative PF rate. However, the optimal method remains unknown. This study was performed to clarify the impact of pancreatojejunostomy on clinically relevant PF (CR-PF) between Blumgart anastomosis and Kakita anastomosis in patients with a soft pancreas. Methods In total, 620 consecutive patients underwent pancreatoduodenectomy at our institute from January 2010 to December 2016, and 282 patients with a soft pancreas were analyzed (Blumgart anastomosis, n = 110; Kakita anastomosis, n = 176). Short-term outcomes were assessed, and univariate and multivariate analyses of several clinicopathological variables were performed to analyze factors affecting the incidence of CR-PF. Results The CR-PF rate was 42.7% (122/286). The CR-PF rate was not significantly different between the Blumgart and Kakita groups (42.7% and 42.6%, respectively; p = 0.985). The morbidity rate (Clavien–Dindo grade ≥ IIIa) was 24.5% (70/286), and the operation-related mortality rate was 0.7% (2/286). In the multivariate analysis, male sex (p = 0.0245) and a body mass index of ≥22 kg/m2 (p < 0.0001) were statistically significant risk factors for CR-PF. Conclusions The CR-PF rate was not significantly different between patients treated with Kakita versus Blumgart anastomosis.
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Affiliation(s)
- Shoji Kawakatsu
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Mise
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeaki Ishizawa
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
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Wang SE, Shyr BU, Chen SC, Shyr YM. Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy: A propensity score-matched study. Surgery 2018; 164:1162-1167. [PMID: 30093277 DOI: 10.1016/j.surg.2018.06.031] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 06/21/2018] [Accepted: 06/27/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study is to clarify the feasibility of robotic pancreaticoduodenectomy in terms of surgical risks, clinically relevant postoperative pancreatic fistula, and oncologic outcomes compared with open pancreaticoduodenectomy by using propensity score matching. Traditional open pancreaticoduodenectomy and robotic pancreaticoduodenectomy have been compared only in small, retrospective, and nonrandomized cohort studies with variable quality. METHODS Prospectively collected data for pancreaticoduodenectomy were evaluated. Comparison between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy was carried out after propensity-score matching. A total of 117 robotic pancreaticoduodenectomy and 128 open pancreaticoduodenectomy cases were performed during the study period. After propensity score matching, 87 cases were included for comparison in each cohort. RESULTS Longer operation time, less blood loss, more lymph nodes harvested, and less delayed gastric emptying were noted in the robotic pancreaticoduodenectomy cases. We found no significant difference regarding the overall postoperative complications by Clavien-Dindo classification, postpancreatectomy hemorrhage, wound infection rate, and postoperative hospital stay. Clinically relevant postoperative pancreatic fistula was not significantly different between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy, regardless of the Callery risk factor, with overall clinically relevant postoperative pancreatic fistula of 8.0% by robotic pancreaticoduodenectomy and 12.6% by open pancreaticoduodenectomy after propensity score matching. We found no survival difference between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy when the comparison was specifically performed for each primary periampullary malignancy. CONCLUSION Robotic pancreaticoduodenectomy is associated with less blood loss, less delayed gastric emptying, and more lymph node yield. Propensity scored-matched analysis revealed that robotic pancreaticoduodenectomy is not inferior to open pancreaticoduodenectomy in terms of clinically relevant postoperative pancreatic fistula, surgical risks, and survival outcomes.
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Affiliation(s)
- Shin-E Wang
- Departments of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Bor-Uei Shyr
- Departments of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Departments of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Departments of Surgery, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan.
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Satoi S, Yamamoto T, Yanagimoto H, Yamaki S, Kosaka H, Hirooka S, Kotsuka M, Ryota H, Michiura T, Inoue K, Matsui Y. Does modified Blumgart anastomosis without intra-pancreatic ductal stenting reduce post-operative pancreatic fistula after pancreaticojejunostomy? Asian J Surg 2018; 42:343-349. [PMID: 30087009 DOI: 10.1016/j.asjsur.2018.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/19/2018] [Accepted: 06/22/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). The aim of this study is to retrospectively compare clinically relevant (CR) POPF and other complications after pacreaticojejunostomy (PJ) after modified Kakita (m-Kakita) or modified Blumgart (m-Blumgart) anastomoses without stenting in a single institution. METHODS One hundred twenty-eight patients underwent PJ using m-Kakita anastomoses (two interrupted penetrating sutures) between January 2009 and December 2011. One hundred eighteen patients underwent m-Blumgart anastomoses (two transpancreatic/jejunal seromuscular sutures to cover the pancreatic stump with jejunal serosa) between January 2014 and December 2015. Demographics, clinical characteristics, and post-operative mortality and morbidity were retrospectively compared between the two groups. RESULTS There were no significant differences in demographics or clinical characteristics between the two groups except operative time. A significantly lower rate of CR-POPF was found in the m-Blumgart group relative to the m-Kakita group (10% vs. 19%, p = 0.038). Univariate and multivariate analyses revealed that the m-Blumgart anastomosis and fistula risk category (Negligible, Low) were independently protective against CR-POPF (p < 0.05). CONCLUSION This retrospective single-center study demonstrated that the modified Blumgart method without pancreatic duct stenting was associated with a lower rate of CR-POPF.
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Affiliation(s)
- Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan.
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Hisashi Kosaka
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Masaya Kotsuka
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Hironori Ryota
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Taku Michiura
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Yoichi Matsui
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
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De Pastena M, van Hilst J, de Rooij T, Busch OR, Gerhards MF, Festen S, Besselink MG. Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy. J Vis Exp 2018. [PMID: 29985364 PMCID: PMC6101760 DOI: 10.3791/56819] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis. The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index >35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers. The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy. The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.
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Affiliation(s)
- Matteo De Pastena
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center; General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center
| | | | | | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center;
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Watkins AA, Kent TS, Gooding WE, Boggi U, Chalikonda S, Kendrick ML, Walsh RM, Zeh HJ, Moser AJ. Multicenter outcomes of robotic reconstruction during the early learning curve for minimally-invasive pancreaticoduodenectomy. HPB (Oxford) 2018; 20:155-165. [PMID: 28966031 DOI: 10.1016/j.hpb.2017.08.032] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/15/2017] [Accepted: 08/31/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perceived excess morbidity during the early learning curve of minimally-invasive pancreaticoduodenectomy (MIPD) has limited widespread adoption. It was hypothesized that robot-assisted reconstruction (RA) after MIPD allows anastomotic outcomes equivalent to open pancreaticoduodenectomy (PD). METHODS Intent to treat analysis of centrally audited data accrued during early adoption of RA-MIPD at five centers. RESULTS CUSUM analysis of operating times at each center identified 92 RA-MIPD during the early learning curve. Mean age was 65 ± 12 years with body mass index 25.8 ± 5.0. Surgical indications included malignant (60%) and premalignant (38%) lesions. Median operating time was 504 min (interquartile range 133) with 242 ml median estimated blood loss (IQR 398) and twelve (13%) conversions to open PD. Major complication rate (Clavien-Dindo III/IV) was 24% with 2 (2.2%) deaths and ten (10.9%) reoperations. Nine (9.9%) clinically significant pancreatic fistulae were observed (4 grade B; 5 grade C). Margin negative resection rate for malignancy was 90% (75% for PDA) with mean harvest of 16 ± 8 lymph nodes. CONCLUSIONS These multicenter data during the early learning curve for RA-MIPD do not demonstrate excess anastomotic morbidity compared to open. Further studies are required to determine whether surgeon proficiency and evolving technique improve anastomotic outcomes compared to open.
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Affiliation(s)
- Ammara A Watkins
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tara S Kent
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - William E Gooding
- The University of Pittsburgh Cancer Institute Biostatistics Facility, Pittsburgh, PA, USA
| | | | - Sri Chalikonda
- Departments of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - R Matthew Walsh
- Departments of Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Herbert J Zeh
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - A James Moser
- Pancreas and Liver Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Technical Details and Results of a Modified End-to-Side Technique of Pancreatojejunostomy: a Personal Series of 100 Patients. J Gastrointest Surg 2017; 21:2090-2099. [PMID: 28936588 DOI: 10.1007/s11605-017-3587-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/12/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The treatment of pancreatic stump is a critical step of pancreatoduodenectomy (PD) because leaks from this anastomosis incur major morbidity and mortality. We describe the technical details of a modified end-to-side pancreatojejunostomy (mPJ), and report on the outcome of the first 100 patients. METHODS From October 2008 to June 2017, 424 pancreatic resections were performed, of which 203 were PD. The mPJ was introduced in November 2010 and used in 100 consecutive patients, by a single surgeon. Data were retrieved from a prospectively collected Institutional database, and used for the present retrospective evaluation. Post-operative pancreatic fistulas (POPF) were stratified with the Fistula Risk Score (FRS), based on the 2005-International Study Group of Pancreatic Fistula classification (ISGPFc) and on the subsequent 2016-revised version (ISGPSc). RESULTS ISGPFc POPF occurred in 17/100 (17%): grade A in 10/100 (10%), grade B in 6/100 (6%) and grade C in 1/100 (1%). On the ISGPSc, POPF rate averaged 7%: grade B in 6/100 (6%) and grade C in 1/100 (1%). POPF rate associated with high FRS was 18.8%/6.3% (ISGPFc/ISGPSc). With low and intermediate FRS, POPFs were 5.3%/0% (ISGPFc/ISGPSc) and 21.3%/9.8% (ISGPFc/ISGPSc) respectively. Re-operation rate was 3%. In-hospital mortality rate was 2% and specific mortality rate for POPF was 1%. CONCLUSIONS The mPJ technique is associated with a POPF rate which was less than expected, especially for "difficult" pancreas with high FRS (soft gland texture and small duct). A larger prospective series is needed in addition to comparative studies with other techniques for robust assessment.
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