Permeability and functionality of pancreaticogastrostomy after pancreaticoduodenectomy with dynamic magnetic resonance pancreatography after secretin stimulation

Feasibility of Percutaneous Pancreatic Stent Placement in Postoperative Pancreaticojejunostomy Stenosis

OBJECTIVE

To evaluate the role of percutaneous pancreatic stent placement in postoperative pancreaticojejunostomy stenosis (PJS).

MATERIALS AND METHODS

This retrospective single-center study included seven procedures in five patients (four males and one female; median age, 63 years) who underwent percutaneous pancreatic stent placement for postoperative PJS between January 2005 and December 2021. The patients were referred to interventional radiology because of unfavorable anatomy or bowel abnormalities. The pancreatic duct was accessed under ultrasound and/or computed tomography guidance. A stent was placed after balloon dilatation of the PJS. Moreover, plastic stents were placed for the first two procedures, whereas bare-metal stents were used for the remaining five procedures. Technical success was defined as the successful placement of stents for the PJS, meanwhile, clinical success was defined as the normalization of pancreatic enzymes without recurrence of pancreatitis.

RESULTS

Pancreatic duct access and stent placement were successfully performed in all patients (technical success rate: 100%). All the procedures initially yielded clinical success. However, recurrence of pancreatitis was observed after two procedures that used plastic stents because of stent migration at 0.3 and 3 months after the procedure. In contrast, no instances of recurrent pancreatitis were noted after metal stent placement for a follow-up duration of 1-36 months. No serious procedure-related adverse events were observed.

CONCLUSION

Percutaneous pancreatic stent placement may be a viable option for patients with postoperative PJS in whom an endoscopic approach is not feasible. Metal stents may be considered over plastic stents for the management of PJS, considering the possible lower stent migration and infeasibility of frequent endoscopic stent exchange due to the altered anatomy.

Surgical revision for pancreatojejunostomy stricture: a case series of 14 patients

Background

Pancreatojejunostomy stricture (PJS) is a rare long-term complication of pancreaticojejunal anastomosis. This study aimed to investigate the role of surgery in the management of pancreatojejunostomy strictures.

Methods

The database of the Pancreas Center of Nanjing Medical University was retrospectively screened for patients who underwent a surgical revision for PJS between June 2012 and August 2019, and their clinical characteristics and management modalities were reviewed.

Results

Fourteen consecutive cases were retrieved, the median age at index operation was 41.1 years (19–71). The average time between the two operations was 70.6 months (8–270 months). Index procedures included pancreaticoduodenectomy (PD) (7/14, 50%), pylorus-preserving PD (4/14, 28.6%), Berger procedure (2/14, 14.3%), and middle pancreatectomy (1/14, 7.1%). The diameter of the main pancreatic duct was < 4 mm in all 14 cases, and nine underwent pancreaticojejunostomy (PJ) stenting during the index operation. The most frequent complaints were abdominal pain (6/14, 42.9%), recurrent acute pancreatitis (6/14, 42.9%), pancreatic fistula (1/14, 7.1%), and abdominal distention (1/14, 7.1%). The diagnosis of PJ stricture was confirmed by computed tomography or magnetic resonance imaging in all cases. All patients had a main duct diameter > 5 mm before surgical revision. All patients underwent wedge excision with interrupted one-layer suturing with absorbable sutures and without stent placement. In this series, only one patient required reoperation. Upon follow-up, 11 of 12 patients had complete resolution of the PJ stricture.

Conclusion

PJS is a long-term complication of pancreatojejunostomy. Surgical revision of the anastomosis is a safe and effective treatment modality.

Pancreatic exocrine insufficiency occurs in most patients following pancreaticoduodenectomy

Background

Pancreatic exocrine insufficiency (PEI) is a well-defined complication of malignant diseases and pancreatic resection; however, study results of PEI are less consistent. Assessment of PEI by estimation of fecal elastase (FE)-1 in stool by enzyme-linked immunosorbent essay (ELISA) is a relatively inexpensive, noninvasive, and simple test. This study assessed exocrine function of pancreas following pancreaticoduodenectomy (PD) by estimating FE-1.

Methods

This prospective hospital-based study involved 30 patients who had undergone PD for malignancy. All 30 patients had an uneventful postoperative period under the unit's enhanced recovery after surgery (ERAS) protocol with no Grade B, C postoperative pancreatic fistula/postpancreatectomy hemorrhage as per the International Study Group of Pancreatic Surgery (ISGPS) definitions. Stool samples were collected postoperatively 3 months after surgery from all patients irrespective of clinical symptoms. The analysis was based on a solid phase ELISA used for the quantitative determination of human elastase 1 in feces. Fecal elastase was considered normal if >200 μg/gm stool, moderately reduced if 100-200 μg/gm stool, and severely reduced if <100 μg/gm stool.

Results

Among 30 patients included, fecal elastase levels were moderately reduced in 10 (33.33%) and severely reduced in 20 (66.67%) patients (P <0.0001). Mean (± standard deviation) of fecal elastase was 87.12 ± 38.76 with median of 74.6 μg/gm stool. There was no significant difference in the fecal elastase levels between men and women (P = 0.057), age (P = 0.48), pancreatic duct diameter (P = 0.609), pancreatic texture (P = 0.286), and presence or absence of clinical symptoms (P = 0.181).

Conclusions

PD was frequently associated with PEI. Unfortunately PEI is an under recognized and under treated long-term sequel of PD. Fecal elastase 1 should be performed routinely in both symptomatic and asymptomatic patients. Pancreatic enzyme replacement therapy should be considered in every patient after PD.

Impact of age on the diagnostic performance of pancreatic ductal diameters in detecting chronic pancreatitis

PURPOSE

In the diagnosis of chronic pancreatitis (CP), definition of main pancreatic duct (MPD) dilation is challenging due to lack of commonly accepted normal values. This study assessed the diagnostic performance of MPD diameters to detect CP including the impact of age.

METHODS

274 patients with ERCP-verified CP and 262 healthy controls were included. All had magnetic resonance cholangiopancreatography (MRCP) with measurement of MPD diameters in the pancreatic head, body, and tail. CP disease stage was defined as patients with and without functional (exocrine and/or endocrine) impairment. Diagnostic performance of MPD diameter and corresponding cut-offs values to diagnose CP were determined, including an age-stratified analysis.

RESULTS

In healthy controls, an effect of age on MPD diameters was seen for the pancreatic head (P < 0.001), body (P = 0.006), and tail (P = 0.03). Patients with CP had increased MPD diameter compared to controls (all segments P < 0.001). Increased pancreatic head MPD diameter was seen in patients with functional pancreatic impairment compared to patients without (P = 0.03). The diagnostic performance of MPD diameter to detect CP was high (all segments ROC-AUC > 0.92). The optimal pancreatic MPD diameter cut-off values for diagnosing CP were: < 40 years: 2.0(head) and 1.8(body) mm; 40-60 years: 2.4(head) and 2.1(body) mm; > 60 years: 2.7(head) and 2.1(body) mm.

CONCLUSION

Age is an important factor when evaluating the diameter of the pancreatic ductal system. Our findings challenge the existing reported thresholds for defining an abnormal duct diameter and point at age-stratified assessments as an integrated part of future imaging-based diagnostic and grading systems for CP.

Pancreatic exocrine insufficiency after pancreaticoduodenectomy: Current evidence and management

Pancreaticoduodenectomy (PD) is the commonest procedure performed for pancreatic cancer. Pancreatic exocrine insufficiency (PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. The aim of this review was to ascertain the incidence of PEI, its consequences and management in the setting of PD for indications other than chronic pancreatitis. A literature search of databases (MEDLINE, EMBASE, Cochrane and Scopus) was carried out with the MeSH terms “pancreatic exocrine insufficiency” and “Pancreaticoduodenectomy”. Studies that analysed PEI and its complications in the setting of PD for malignant and benign disease were included. Studies reporting PEI in the setting of PD for chronic pancreatitis, conference abstracts and reviews were excluded. The incidence of PEI approached 100% following PD in some series. The pre-operative incidence varied depending on the characteristics of the patient cohort and it was higher (46%-93%) in series where pancreatic cancer was the predominant indication for surgery. Variability was also recorded with regards to the method used for the diagnosis and evaluation of pancreatic function and malabsorption. Pancreatic enzyme replacement therapy is the mainstay of the management. PEI is common and remains undertreated after PD. Future studies are required for the identification of a well-tolerated, reliable and reproducible diagnostic test in this setting.

Is the remnant pancreas still working over a year after surgery in patients undergoing pancreaticoduodenectomy with reconstruction by pancreaticogastrostomy?

BACKGROUND

Pancreaticogastrostomy (PG) has been widely used as an alternative to pancreatojejunostomy (PJ) in patients undergoing pancreaticoduodenectomy (PD), but its long-term exocrine function remains unclear. The present study aimed to measure the secretion of pancreatic α-amylase (p-AMY) into the gastric cavity in patients who underwent PG reconstruction after PD over 1 year after surgery and to evaluate the relationship between gastric p-AMY level and clinically available indirect tests.

METHODS

Clinical records of 39 patients who underwent PG reconstruction after PD were reviewed. Pancreatic exocrine function was evaluated over 1 year after surgery using the following methods: 1) Measurement of p-AMY level in gastric fluids (gastric p-AMY level) during routine gastrointestinal endoscopy, 2) Qualitative faecal fat determination by Sudan III staining on faeces and 3) Pancreatic function diagnostic (PFD) test using oral administration of N-benzoyl-l-tyrosyl-p-aminobenzoic acid.

RESULTS

Gastric p-AMY level was detectable in 31 of 39 patients (79%), and 12 patients (30.8%) had steatorrhea over a year after surgery. Patients with steatorrhea had significantly lower gastric p-AMY level, larger diameter of remnant main pancreatic duct (MPD) and larger pancreatic duct to parenchymal thickness ratio than those without steatorrhea (84 IU/L vs 7979 IU/L, respectively; P < 0.001, 5.3 mm vs 3.2 mm, respectively; P = 0.001, and 0.38 vs 0.23, respectively; P = 0.007). Receiver operating characteristic analysis showed that the cut-off value of the diameter of the remnant MPD to predict steatorrhea was 3.5 mm (sensitivity, 92.3%; specificity, 70.4%). PFD test was not associated with any clinical data.

CONCLUSIONS

Pancreatic enzyme was detected in 79% of patients having PG reconstruction. Diameter of remnant MPD >3.5 mm and pancreatic parenchymal atrophy may be surrogate markers of postoperative exocrine insufficiency following PD.

Morphological changes of the pancreas after pancreaticoduodenectomy

The aim of this retrospective study was thus to evaluate postoperative morphological changes in the remnant pancreas after pancreaticoduodenectomy (PD) associated with postoperative pancreatic fistula (POPF). Fifty-one patients subjected to PD were enrolled in the study and allocated into 2 groups according to the presence (n = 16) or absence of POPF (n = 35). A morphological evaluation of the pancreas was conducted for up to a 20 months follow-up on CT scans and compared between groups. No significant differences were observed in morphology between the groups at the different preoperative and PO intervals, regardless of the clinical relevance of the POPF or POPF grade. However, in the overall patient analysis we observed a significant reduction of the entire pancreas over time. In fact, thickness decreased 0.4 mm/month, length 1.2 mm/month and volume 1.17 cm³/month over the PO. The impact of age, POPF, type of anastomosis, surgical technique and PO follow-up (time) was evaluated in a multivariate analysis using the general linear model, but only PO follow-up had a significant influence on the final model (p < 0.001). A significant reduction on pancreatic parenchyma (thickness, length and volume) occurs after PD with no significant differences between patients with or without POPF.

Assessment of Exocrine Function of Pancreas Following Pancreaticoduodenectomy

Pancreatic exocrine insufficiency (PEI) is a common long-term complication after pancreaticoduodenectomy (PD) and is observed in 23-80% of patients. As the postoperative mortality after PD has substantially decreased, it warrants more attention on the diagnosis and treatment of functional long-term consequences after PD. These include PEI and endocrine insufficiency that can result in significant nutritional impairment and often adversely impacts quality of life (QOL) of the patient. A PubMed search was performed for articles using key words "pancreatic exocrine insufficiency"; "pancreaticoduodenectomy"; "quality of life after pancreaticoduodenectomy"; "stool elastase"; "direct, indirect tests for pancreatic exocrine insufficiency"; "pancreatic enzyme replacement therapy." Relevant studies were shortlisted and analyzed. This review summarizes relevant studies addressing PEI following PD. We also discuss functional changes after PD, risk factors and predictive factors for postoperative PEI, clinical symptoms, direct and indirect tests for estimation of PEI, pancreatic enzyme replacement therapy (PERT), and QOL after pancreatic resection for malignancy. It was found that significant PEI occurs in most patients following PD. Fecal elastase 1 is an easy indirect test and should be performed routinely in both symptomatic and asymptomatic patients after PD. PERT should be considered in every patient after PD with the aim to improve the QOL and perhaps even their long time survival.

Management of delayed stenosis of pancreatico-enteric anastomosis following pancreatoduodenectomy

Stenosis of the pancreatico-enteric anastomosis following pancreatoduodenectomy (PD), a late post-operative complication that is seen mainly after PD for diseases with good prognosis, has been reported in less than 3% of cases in the literature. Most often asymptomatic, pancreatic-enteric anastomotic stenosis can lead to pancreatitis, pain or pancreatic insufficiency. Symptomatic stenosis is difficult to treat and its management is not standardized. Magnetic resonance cholangiopancreatography is the best investigation to confirm the diagnosis of stenosis. The Endoscopic UltraSonography (EUS) « rendezvous » technique, associating an endoscopic approach and EUS-guided puncture of the main pancreatic duct, has been available since 2010. Of note, however, the failure rate of the EUS series is as high as 25%, leading to repeat procedures. Surgical reconstruction of the anastomosis has been reported with good results in terms of morbidity. Surgical re-do of the pancreatico-enteric anastomosis for stenosis following PD carries a low risk of pancreatic fistula (around 5%) and an overall morbidity rate of around 20%.

Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection

Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery

OBJECTIVE

To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery.

BACKGROUND

EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients.

METHODS

Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement.

RESULTS

These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement.

CONCLUSIONS

EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.

Secretin-Stimulated Magnetic Resonance Imaging Assessment of the Benign Pancreatic Disorders: Systematic Review and Proposal for a Standardized Protocol

This systemic review summarizes the current literature and general consensus on secretin-stimulated magnetic resonance imaging (s-MRI) of the benign pancreatic disorders and discusses important aspects on how s-MRI is optimally performed. The aim is to provide an overview, for clinicians and radiologist, of the s-MRI protocols and the range of clinical applications. Furthermore, the review will summarize the criteria for evaluation of pancreatic morphology and function based on s-MRI.The literature search indentified 69 original articles and 15 reviews. Chronic pancreatitis was the disease that was most frequently assessed by s-MRI (33%), followed by acute pancreatitis (9%). Dynamic thick-slab 2-dimensional magnetic resonance cholangiopancreatography was the most used imaging sequence (86%). The diameter of the main pancreatic duct (75%) and pancreatic exocrine function based on visual grading of duodenal filling (67%) were the most evaluated pancreatic features. Sufficient similarities between studies were identified to propose the most agreeable standardized s-MRI protocol for morphological and functional assessment of the pancreas. In the future, more research and increased collaboration between centers is necessary to achieve more consensus and optimization of s-MRI protocols.

Meta-analysis of pancreaticogastrostomy versus pancreaticojejunostomy on occurrences of postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND/OBJECTIVE

Pancreatic fistula (PF) is the most common and challenging complication after pancreaticoduodenectomy (PD). This meta-analysis aimed to evaluate the impact of pancreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) on occurrences of postoperative PF.

METHODS

A systematic literature search in the Medline, EMBASE, OVID, and Cochrane databases was performed to identify all eligible randomized controlled trials (RCTs). Pooled estimates were presented with 95% confidence intervals (CI).

RESULTS

Six RCTs involving 1005 patients met the inclusion criteria. The incidence of PF [odds ratio (OR) 0.58, 95% CI, 0.42-0.81; p = 0.001], intra-abdominal abscess or collections (OR 0.43, 95% CI, 0.28-0.65; p < 0.001), and biliary fistula (OR 0.28, 95% CI, 0.11-0.74; p = 0.01) were found to be significantly lower in the PG group than in the PJ group. There was no significant difference in overall morbidity, other complications, hospital mortality, or length of hospital stay between the two groups.

CONCLUSION

The meta-analysis showed that PG following PD represents a safe procedure associated with fewer PFs compared with PJ.

Radiofrequency pancreatic ablation and section of the main pancreatic duct does not lead to necrotizing pancreatitis

OBJECTIVE

The aim of this study was to determine whether radiofrequency ablation (RFA) of the pancreas and subsequent transection of the main pancreatic duct may avoid the risk of both necrotizing pancreatitis and postoperative pancreatic fistula (POPF) formation.

METHODS

Thirty-two rats were subjected to RFA and section of the pancreas over their portal vein. Animals were killed at 3, 7, 15, and 21 days (groups 0-3, respectively). Two additional control groups (sham operation and user manipulation only, respectively) of 15 days of postoperative period were considered. Postoperative complications, histological changes (including morphometric and immunohistochemical analysis), and incidence of POPF were evaluated.

RESULTS

A significant increase in serum amylase levels (P < 0.05) on the third postoperative day, which return to baseline levels in the following weeks, was noted in groups 0 to 3. Those groups showed a rapid atrophy of the distal pancreas by apoptosis with no signs of necrotizing pancreatitis or POPF. The distal pancreas in groups 1 to 3 compared with group 0 and control groups showed a significant increase of small islets (<1000 µm).

CONCLUSIONS

The rapid acinar atrophy of the distal pancreas after RFA and section of the pancreatic ducts in this model does not lead to necrotizing pancreatitis.

Does the type of pancreaticojejunostomy after Whipple alter the leak rate?

Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.

Decreasing the pancreatic leak rate after pancreaticoduodenectomy

Although pancreaticoduodenectomy has become a safe and effective procedure for benign and malignant pancreatic diseases in recent years, leakage of pancreaticoenteric anastomosis still remains a major cause of morbidity and even mortality. Various methods have been used to prevent pancreatic fistula with either pharmacologic or technical approaches. Based on meta-analysis of results from European and American trials, prophylactic use of octreotide to inhibit pancreatic secretion cannot be recommended for routine use in pancreaticoduodenectomy. Further randomized trials are required to clarify the role of selective use of octreotide in patients at high risk for pancreatic leakage. Technical improvement by surgeons is probably the most important approach to reduce pancreatic anastomotic leakage rate. Various technical modifications for pancreaticoenteric anastomosis have been suggested; some have been tested in randomized controlled trials, but data from randomized trials are generally scarce. Use of PG instead of PJ anastomosis, internal stenting of PJ anastomosis, pancreatic duct occlusion, and fibrin glue have not been shown to be effective in reducing pancreatic leakage rate after pancreaticoduodenectomy. One randomized trial recently showed significant reduction of pancreatic leakage rate using an external diverting stent after PJ anastomosis, and another randomized trial showed significant reduction in PJ anastomosis leakage using the binding PJ anastomosis technique. Nonetheless, further high-quality randomized controlled trials are needed to evaluate the benefit of these technical modifications in decreasing the pancreatic leakage rate after pancreaticoduodenectomy.

No mortality after 150 consecutive pancreatoduodenctomies with duct-to-mucosa pancreaticogastrostomy

BACKGROUND AND OBJECTIVES

The mortality rate after pancreatoduodenectomy (PD) remains 0-5% at major surgical centers with the major cause of operative death being a leak at the pancreaticojejunal anastomosis. The aim of this retrospective study was to evaluate the safety of duct-to-mucosa pancreaticogastrostomy (PG) at a single institute.

METHODS

One hundred fifty consecutive patients with pancreato-biliary diseases undergoing duct-to-mucosa PG following PD between 1995 and 2005 were evaluated. One hundred forty patients underwent a pylorus-preserving PD and 10 patients underwent a conventional PD (Whipple operation). External drainage of pancreatic juice was performed in 77 cases.

RESULTS

The mean operating time was 378 min and the mean blood loss was 1,640 ml. Blood transfusion was not required in 97 patients (65%). The morbidity rate was 50% (75/150), but the mortality rate was 0%. Pancreatic fistulae occurred in 11 patients (7%). Gender, age, operative procedure, portal vein resection, external drainage of the pancreatic juice, operative time, blood loss and blood transfusion did not affect the rate of pancreatic fistula. The rate of pancreatic fistulae tended to be lower in pancreatic carcinoma (3%) than non-pancreatic carcinoma (11%).

CONCLUSIONS

Duct-to-mucosa PG is a safe procedure for reconstruction following PD.

Management of a stenotic pancreatico-digestive tract anastomosis following pancreatoduodenectomy

Early postoperative complications of pancreatico-digestive anastomosis following pancreatoduodenectomy are pancreatic fistula and pancreatitis affecting the pancreatic tail. Stenosis of the anastomosis is a later complication. Symptomatic and painful presentations are difficult to treat, and the optimal treatment is not currently defined. The aim of this work was to retrospectively report two cases of pancreaticogastrostomy stenosis. In both patients, the complication was diagnosed, with pancreatitis that developed following pancreatoduodenectomy. These patients were treated surgically, by fashioning a new anastomosis. Pancreaticogastrostomy has been viewed as a simpler and more secure reconstruction technique, with a lower occurrence rate of pancreatic fistula, than that of pancreaticojejunostomy. One complication of this surgery, however, is stenosis of the anastomosis. Following pancreatoduodenectomy, stenosis of the pancreaticogastrostomy may not occur until many years later. In a significant percentage of patients it is without clinical signs. It may be discovered after systematic explorations of patients following pancreaticogastrostomy or pancreaticojejunostomy. There is no study regarding the optimal treatment of postoperative stenosis of a pancreatico-gastric anastomosis. We believe that the optimal treatment is surgical. The intervention involves resection of the stenosis, and the formation of a new anastomosis.

Functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy

OBJECTIVES

Pancreatic exocrine insufficiency has been reported to be more common in pancreaticogastrostomy (PG) than in pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). This study aimed to evaluate the long-term outcome after PD between these 2 groups.

METHODS

We evaluated the long-term functional status of 42 surviving patients diagnosed with periampullary lesions who underwent PJ or PG after PD and followed up for more than 1 year. Among these, 23 patients underwent PJ and 19 patients underwent PG. To compare the 2 groups, we analyzed the (1) pancreatic exocrine insufficiency by questioning the presence or absence of steatorrhea, (2) pancreatic endocrine function by measuring glycohemoglobin A1c, fasting blood glucose, and history of new-onset diabetes, (3) nutritional status by measuring serum total protein, albumin, cholesterol, and triglyceride, (4) gastric emptying time, (5) panendoscopic findings, (6) changes of pancreatic duct diameter by computed tomography, and (7) relaparotomy rate.

RESULTS

The mean follow-up time for PG and PJ were 37 +/- 23 and 103 +/- 52 months, respectively (P < 0.05). A total of 52.4% patients developed pancreatic exocrine insufficiency, and 11.9% had new-onset diabetes. There was no significant difference between PJ and PG groups. A significantly improved postoperative nutritional state regarding serum total protein and albumin were noticed in both groups. There was no significant difference in terms of gastric emptying time, positive panendoscopic findings, and changes in pancreatic duct diameter. The pancreatic remnant-related relaparotomy rate was higher in the PJ group as compared with the PG group (17.4% vs 0%; P = 0.056).

CONCLUSIONS

There is no significant difference in pancreatic exocrine or endocrine insufficiency, gastric emptying time, and positive panendoscopic findings between PJ and PG. Pancreaticojejunostomy was associated with a higher pancreatic remnant-related relaparotomy rate; however, because of a shorter follow-up in the PG group, a continuous long-term follow-up is still needed.

Obstructed pancreaticojejunostomy partly explains exocrine insufficiency after pancreatic head resection

OBJECTIVE

The majority of patients with long-term survival after pancreatic head resection suffer from pancreatic exocrine insufficiency. The objective of this study was to investigate whether this is due to glandular malfunction or obstructed pancreaticojejunal anastomosis.

MATERIAL AND METHODS

Twenty-six patients (10 M, 16 F, mean age 61 years, range 34-81 years) were re-examined a median of 52 months (range 3-76 months) after pancreatic head resection and end-to-end invaginated pancreaticojejunostomy. Pancreatic exocrine function was measured by fecal elastase-1 assay. The size of the pancreatic remnant, glandular secretion and the flow through the anastomosis were analyzed with secretin-stimulated dynamic magnetic resonance pancreatography (D-MRP).

RESULTS

All patients had pancreatic exocrine insufficiency, 24 (92%) of them having severe insufficiency. Eighteen patients (69%) reported moderate to severe diarrhea. Lowest fecal elastase-1 concentrations were associated with the initial diagnosis of chronic pancreatitis or ductal adenocarcinoma, suggesting preoperative primary or secondary chronic pancreatitis as important determinants. The size of the remnant gland did not correlate with the fecal elastase-1 concentrations. D-MRP failed in three patients. Severe glandular malfunctions were found in 7 (30%) of the 23 successful D-MRP examinations. The anastomosis was totally obstructed in 5 patients (22%) or partially obstructed in 6 (26%) but remained perfectly open in 5 patients (22%). The five patients with perfect anastomoses had the highest measured median fecal elastase-1 activity.

CONCLUSIONS

Although late diarrhea and pancreatic exocrine insufficiency may be partly induced already by the disease treated with resection, at least half may be explained by obstructed anastomosis. To obtain better late functional results, improvements may be required in the surgical techniques.

Personal experience of pancreas reconstruction following pancreaticoduodenectomy

BACKGROUND

This study was designed to evaluate the surgical outcomes of an alternative method of pancreaticojejunostomy and pancreaticogastrostomy according to the size of the remnant pancreatic duct following pancreaticoduodenectomy.

METHODS

Eighty-four patients who underwent pancreaticoduodenectomy by the same surgeon were retrospectively reviewed from February 1997 to December 2004. Pancreaticojejunostomy for large remnant pancreatic ducts (>5 mm in diameter) and pancreaticogastrostomy for smaller remnant pancreatic ducts (<5 mm in diameter) were alternately carried out by the surgeon. Patients' perioperative data were evaluated.

RESULTS

The size of the remnant pancreatic duct was significantly different between the pancreaticojejunostomy and pancreaticogastrostomy groups (7.2 +/- 4.3 mm vs 2.9 +/- 1.6 mm, P < 0.001). Pancreaticojejunostomy was carried out in 27 patients (33.3%) and pancreaticogastrostomy was carried out in 51 patients (66.7%). The mean operation time was 327 +/- 67.4 min and the mean duration of the hospital stay was 25.5 +/- 9.1 days. Pancreatic leakage was found in 10 patients (12.3%) without leading to mortality and was successfully treated by temporary restriction of oral intake and conservative management. None of the patients required an additional surgical procedure for pancreatic leak. Other postoperative complications were unremarkable when compared with previous results. One case of massive bleeding found in the pancreaticogastrostomy group required surgical intervention.

CONCLUSION

Pancreaticogastrostomy and pancreaticojejunostomy according to the size of the remnant pancreatic duct can be an alternative strategy to maintain the postoperative rate of pancreatic leak within an acceptable range without hospital mortality related to this complication.

Pancréatites récidivantes après duodénopancréatectomie céphalique : réintervention pour sténose de l'anastomose pancréatico-jéjunale

Stenosis of the pancreaticojejunostomy is a late and rarely symptomatic complication of pancreaticoduodenectomy, observed in approximately 30% of cases. Treatment of symptomatic strictures is difficult. We report a case of reoperation for stenosis of the pancreaticojejunostomy responsible for recurrent pancreatitis. The treatment strategy is discussed.