Application of binding pancreatogastrostomy in laparoscopic central pancreatectomy

Modified binding pancreaticogastrostomy vs modified Blumgart pancreaticojejunostomy after laparoscopic pancreaticoduodenectomy for pancreatic or periampullary tumors

BACKGROUND

Laparoscopic pancreaticoenteric anastomosis is one of the technically challenging steps of minimally invasive pancreaticoduodenectomy (PD), especially during the learning curve. Despite multiple randomized controlled trials and meta-analyses, the type of pancreatico-enteric anastomosis as a risk factor for post-pancreatectomy complications is debatable. Also, the ideal technique of pancreatic reconstruction during the learning curve of laparoscopic PD has not been well studied.

AIM

To compare the short-term outcomes of modified binding pancreaticogastrostomy (PG) and Blumgart pancreaticojejunostomy (PJ) during learning curve of laparoscopic PD.

METHODS

The first 25 patients with resectable pancreatic or periampullary tumors who underwent laparoscopic PD with modified binding PG or modified Blumgart PJ between January 2015 and May 2020 were retrospectively analyzed to compare perioperative outcomes during the same learning curve. A single layer of the full-thickness purse-string suture was placed around the posterior gastrotomy in the modified binding PG. In the modified Blumgart technique, only a single transpancreatic horizontal mattress suture was placed on either side of the pancreatic duct (total two sutures) to secure the pancreatic parenchyma to the jejunum. Also, on the ventral surface, the knot is tied on the jejunal wall without going through the pancreatic parenchyma. Post pancreatectomy complications are graded as per the International Study Group for Pancreatic Surgery criteria.

RESULTS

During the study period, modified binding PG was performed in 27 patients and modified Blumgart PJ in 29 patients. The demographic and clinical parameters of the first 25 patients included in both groups were comparable. Lower end cholangiocarcinoma and ampullary adenocarcinoma were the primary indications for laparoscopic PD in both groups (32/50, 64%). The median operative time for pancreatic reconstruction was significantly lower in the binding PG group (42 vs 58 min, P = 0.01). The clinically relevant (Grade B/C) postoperative pancreatic fistula (POPF) was significantly more in the modified PJ group (28% vs 4%, P = 0.04). In contrast, intraluminal postpancreatectomy hemorrhage (PPH) was more in the binding PG group (32% vs 4%, P = 0.02). There was no significant difference in the incidence of delayed gastric emptying between the two groups.

CONCLUSION

During the learning curve of laparoscopic PD, modified binding PG reduces POPF but is associated with increased intraluminal PPH compared to PJ using the modified Blumgart technique.

The feasibility of modified pancreatogastrostomy in vivo and its effect on intestinal microecology

PURPOSE

To evaluate the feasibility of modified binding pancreatogastrostomy (MBPA) by comparing it with traditional pancreatogastrostomy (TPA) and to determine the surgical effects on the intestinal microecology.

METHODS

The surgical effects on the intestinal microecology of female Bama minipigs (n = 20) were determined by measuring the expressions of the intestinal microbial proteins in the gastric juice, gastric mucosa, and feces before and after MBPA and TPA. We then constructed an integrated interaction network based on the metabolomics and 16S amplicon data, the microbiota, the metabolites, and the associated pathways.

RESULTS

The average time required for anastomosis was significantly lower after MBPA than after TPA, but the breaking force did not significantly differ between them. We identified 25 and 51 differentially expressed metabolites and microbiota, respectively. An interaction network was constructed using 16 metabolites (including pyruvic and lactic acids), 27 microbiota (including Ruminococcaceae_UCG-00) and six pathways (including pyruvate metabolism).

CONCLUSION

Anastomosis might be achieved sooner and with less pancreatic leakage using MBPA compared with TPA. Pancreatogastrostomy inhibits Ruminococcaceae activity, leading to increased expressions of pyruvic and lactic acids in the gut.

How to Perform Total Laparoscopic Duodenum-Preserving Pancreatic Head Resection Safely and Efficiently with Innovative Techniques

BACKGROUND

Although rapid progress has been achieved in laparoscopic pancreaticoduodenectomy (PD) over the last decade, laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) remains a challenging surgery that has been rarely reported due to not only requiring complicated pancreaticojejunostomy (PJ) but also ensuring sufficient blood supplies to duodenum and common bile duct (CBD). We completed LDPPHR for 22 patients safely and efficiently with innovative techniques.

PATIENTS AND METHODS

Clinical outcomes, including rate of conversion to laparotomy, time of residual pancreatic duct reconstruction, incidence of postoperative complications, and time of hospital stay, were collected for 22 consecutive patients who underwent LDPPHR with innovative techniques as follows: application of indocyanine green (ICG) to visualize and preserve CBD and the vessels supplying the duodenum and CBD, Hong's PJ, and pancreatic duct end-to-end anastomosis (ETEA) for the residual pancreas.

RESULTS

All surgeries were performed successfully under laparoscopy except for one case. The duration of ETEA was significantly shorter than PJ (18.2 ± 5.1 min versus 27.5 ± 8.3 min, p < 0.05). There was no significant difference in incidence of postoperative complications between the Hong's PJ and ETEA group. The overall incidence of postoperative pancreatic fistula (POPF) in the Hong's PJ and ETEA group was 23.5% and 20%, respectively, without grade C fistula. All complications were resolved after conservative treatment.

CONCLUSIONS

By utilizing intraoperative ICG navigation, LDPPHR is a minimally invasive, safe, and efficient approach for chronic pancreatitis with pancreatic head stones by using pancreatic duct ETEA and benign or low-grade malignant tumors of the pancreatic head by using Hong's PJ.

Systematic Review and Meta-analysis of Minimally Invasive Pancreatectomies for Solid Pseudopapillary Neoplasms of the Pancreas

OBJECTIVES

We report the first systematic review and meta-analysis on minimally invasive pancreatectomy (MIP) for solid pseudopapillary neoplasms (SPPN) of the pancreas.

METHODS

A systematic review of all studies reporting patient characteristics and outcomes of MIP for SPPN was conducted.

RESULTS

We reviewed 27 studies comprising 149 patients with SPPN managed via MIP. Five were comparative retrospective cohort studies, comprising 46 and 60 patients in the minimally-invasive and open groups, respectively. Tumor size was smaller in the minimally-invasive group (mean difference, -2.20; 95% confidence interval (CI), -3.09 to -1.32; P < 0.001). The MI group had lower intraoperative blood loss (mean difference, -180.19; 95% CI, -344.28 to -16.09; P = 0.03) and transfusion requirement (relative risk, 0.24; 95% CI, 0.06-0.94; P = 0.04), and a shorter time to diet (mean difference, -2.99; 95% CI, -3.96 to -2.03; P < 0.001) and length of stay (mean difference, -3.61; 95% CI, -6.98 to -0.24; P = 0.04). There was no significant difference in operating time, margin positivity, postoperative morbidity, and postoperative pancreatic fistula rates.

CONCLUSIONS

Minimally invasive pancreatectomy for SPPN is associated with decreased intraoperative blood loss and transfusion requirements and a shorter postoperative time to diet and hospital stay.

Laparoscopic long sleeve pancreaticogastrostomy (LPG): a novel pancreatic anastomosis following central pancreatectomy

BACKGROUND

Central pancreatectomy (CP) is preferred to distal pancreatectomy (DP) for the excision of benign tumours at the neck or body of the pancreas, in order to preserve pancreatic function and the spleen. However, the pancreaticoenterostomy is technically difficult to perform laparoscopically and the postoperative pancreatic fistula (POPF) rate is high.

METHODS

A novel laparoscopic reconstruction of the pancreatic stump during CP is described, the laparoscopic long sleeve pancreaticogastrostomy (LPG).

RESULTS

Two males and two females with a median age of 49 years had a laparoscopic CP with LPG. After a median follow-up of 27.5 months, there was no mortality. One patient had a grade A POPF, managed conservatively.

CONCLUSIONS

The LPG is a safe and technically less demanding method to reconstruct pancreatic drainage laparoscopically.

Binding pancreaticogastrostomy in laparoscopic central pancreatectomy: a novel technique in laparoscopic pancreatic surgery

BACKGROUND

Even though more and more cases of laparoscopic central pancreatectomy (LCP) are reported (Machado et al. in Surg Laparosc Endosc Percutan Tech 23(6):486-490, 2013; Hong et al. in World J Surg Oncol 10:223, 2012; Gonzalez et al. in JOP 14(3):273-276, 2013, Zhang et al. in J Laparoendosc Adv Surg Tech A 23(11):912-918, 2013; Sucandy et al. in N Am J Med Sci 2(9):438-441, 2010; Sa Cunha et al. in Surgery 142(3):405-409, 2007), the management for pancreatic stumps remains the most technically challenging part which is the same as in pancreatoduodenectomy (PD), making it the bottleneck for laparoscopic pancreatic surgery. In open surgery, various pancreatic reconstruction techniques designed for either pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) have been attempted to reduce the postoperative pancreatic fistula (POPF), including the binding anastomosis, invented by our team, i.e., binding PG (BPG) and binding PJ, which have been proved to be effective to reduce the POPF (Hong et al. 2012; Peng et al. in Ann Surg 245(5):692-698, 2007; Peng et al. in Updates Surg 63(2):69-74, 2011). However, despite of this, few reports are seen addressing such technique for laparoscopic surgery even though laparoscopic pancreatic surgery is more performed. After a previous successful laparoscopic BPG in a case of laparoscopic CP (LCP; Hong et al. 2012) and more than 50 cases of open PD and CP (Peng et al. 2011), we further performed laparoscopic BPG in 10 consecutive cases of LCP with satisfactory outcomes.

OBJECTIVE

To explore the feasibility and efficacy of LCP with BPG.

METHODS

Between October 2011 and July 2014, LCP with laparoscopic BPG was performed in ten consecutive patients with lesions of benign or low malignancy at the pancreatic neck. Operative and pathological data, complications, hospital stay and details on the surgical techniques were introduced.

RESULTS

The operations were successfully performed in all the ten cases, with no conversions. The tumor size ranged from 2.0-3.0 to 2.5-3.0 cm, average (2.50 ± 0.35) to (2.66 ± 0.35) cm, and the diameter of pancreatic duct was (1.6-2.1) mm, average (1.71 ± 0.17) mm. Operation time was 170-250 (198.50 ± 25.82) min, and blood loss was 20-300 (125 ± 107.31) mL. Three cases had grade A pancreatic fistula (PF), and one case had delayed gastric emptying, which were all managed with conservative treatment. Upper GI bleeding occurred in one case which was cured with second operation, time for the recovery of bowl movement was 3-5 (4.2 ± 0.8) days, the time for semifluid dieting was 6-10 (8.2 ± 1.5) days, and the hospital stay was 8-20 (12.8 ± 4.63) days. The postoperative fast blood sugar was (6.3 ± 1.6) mmol/L with the normal diet, which was not significantly different from the preoperative data (5.3 ± 0.5) mmol/L (P > 0.05). The postoperative pathology was as follows: five cases of cystic serous adenoma, one case of intraductal papillary mucinous neoplasm, two cases of neuroendocrine tumor, and two cases of solid pseudopapillary tumor of pancreas. All the patients were followed up for 7-40 months, no recurrence happened, and no new incidence of diabetes or insufficiency of pancreatic exocrine function occurred.

CONCLUSIONS

LCP with BPG is feasible and safe; the advantages lie in its minimal invasiveness, the efficacy for avoiding PF, and the preservation of the pancreatic endocrine and exocrine function insufficiency, making it an ideal procedure for the benign or low-malignant lesions at the pancreatic neck.

Comparison of two laparoscopic splenectomy plus pericardial devascularization techniques for management of portal hypertension and hypersplenism

OBJECTIVE

Our research was conducted to analyze the outcomes of two laparoscopic splenectomy plus pericardial devascularization (LSPD) techniques in the management of portal hypertension (PTH) and hypersplenism.

METHODS

Between May 2012 and May 2013, 41 patients with PTH and hypersplenism undergoing LSPD were retrospectively analyzed. Of them, 29 patients received LSPD by LigaSure Vessel Sealing System (LVSS) and Endo-GIA universal endoscopic vascular linear staplers (Endo-GIA) (EG Group) and 12 patients received LSPD by LVSS and Hem-o-Lock (HL Group). Operating time, intraoperative blood loss, postoperative course, and hospitalization costs were compared between the two LSPD combination techniques.

RESULTS

There were no significant differences in preoperative patient characteristics of the two groups. Significantly less operating time, intraoperative blood loss, and postoperative complications were observed in EG Group. The incidence of portal vein thrombosis was lower in the EG Group (3.4 vs. 8.3%), as well as the incidence of pancreatic fistula (0 vs. 8.3%). Upper gastrointestinal hemorrhage was not observed in either group. Uncontrolled bleeding warranted conversion to open surgery in one case in EG Group (conversion rate 3.4%) and in two cases in HL Group (conversion rate 16.7%). Two patients (16.7%) in HL Group underwent successful emergency exploratory laparotomy due to uncontrolled intraabdominal bleeding postoperatively. No re-operation was needed in EG Group. Two patients experienced liver failure after surgery in each group. Of those, three patients were managed successfully and one patient refused further therapy. While the overall complication rate was significantly lower in EG Group (17.2 vs. 58.3%, P < 0.05), overall hospitalization costs remained significantly higher for EG Group.

CONCLUSION

The results suggest that the modified Endo-GIA and LVSS technique is a safe and effective combination approach to LSPD with shorter operative time, less intraoperative blood loss, lower conversion rate to laparotomy, shorter hospital stay, better recovery, and lower postoperative complication rate compared with the Hem-o-Lock and LVSS approach. Higher hospitalization expenses associated with the Endo-GIA and LVSS approach.

Laparoscopic central pancreatectomy with pancreaticojejunostomy: preliminary experience with 8 cases

BACKGROUND

Central pancreatectomy has been accepted as an alternative procedure for treating benign or low-grade malignant tumors in the pancreatic neck or proximal body of the pancreas, which preserves pancreatic parenchyma and function. In this study, we present our experience of laparoscopic central pancreatectomy with pancreaticojejunostomy.

PATIENTS AND METHODS

From April 2011 to February 2013, 8 patients underwent laparoscopic central pancreatectomy with a Roux-en-Y modified "dunking" or duct-to-mucosa pancreaticojejunostomy for benign or low-grade malignant tumors in the pancreatic neck or proximal body of the pancreas at the Department of General Surgery, Sir Run Run Shaw Hospital, Hangzhou, China. Surgical procedure, postoperative course, and follow-up data were collected.

RESULTS

Laparoscopic central pancreatectomy was performed successfully in all the patients. The pancreaticojejunostomy was executed with a modified "dunking" pancreaticojejunostomy (n=7) or duct-to-mucosa pancreaticojejunostomy (n=1). The mean operative time was 286±27 minutes (range, 250-330 minutes), with a mean blood loss of 57±21 mL (range, 30-100 mL). Mortality was 0%, and perioperative morbidity was 37.5% (pancreatic fistula [grade A], bleeding of a splenic vein branch, and retroperitoneal infection). The median postoperative hospital stay was 10 days (range, 6-38 days). At a median follow-up of 7.5 months (range, 2-24 months), all patients were alive without any exocrine or endocrine insufficiency or recurrence.

CONCLUSIONS

Laparoscopic central pancreatectomy is feasible and safe. The modified "dunking" pancreaticojejunostomy can be performed safely in this approach.

Pancreaticodigestive anastomosis and the postoperative management strategies to prevent postoperative pancreatic fistula formation after pancreaticoduodenectomy

Over the past 100 years, advances in surgical techniques and perioperative management have reduced the morbidity and mortality after pancreaticoduodenectomy (PD). Many techniques have been proposed for the reconstruction of the pancreaticodigestive anastomosis to prevent the development of a postoperative pancreatic fistula (POPF), but which is the best approach is still highly debated. We carried out a systematic review to determine and compare the effectiveness of various methods of anastomosis after PD. A meta-analysis and most randomized controlled trials (RCTs) showed that the mortality, POPF rate and incidence of other postoperative complications were not statistically different between the pancreaticogastrostomy and pancreaticojejunostomy (PJ) groups. One RCT showed that a binding PJ significantly decreased the risk of POPF and other postoperative complications compared with conventional PJ. External duct stenting reduced the risk of clinically relevant POPF in a meta-analysis and RCTs. The prophylactic use of octreotide after PD does not result in a reduced incidence of POPF. In conclusion, our findings suggest that the successful management of pancreatic anastomoses may depend more on the meticulous surgical technique, surgical volume, and other management parameters than on the type of technique used. However, some new approaches, such as binding PJ, and the use of external stents should be considered in further RCTs.