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Tu J, Huang C, Xu W, Gong S, Cao Z, Wan P, Ying J, Rao X. Application of split pancreatic duct stent in laparoscopic pancreaticoduodenectomy. Medicine (Baltimore) 2023; 102:e34049. [PMID: 37543786 PMCID: PMC10403010 DOI: 10.1097/md.0000000000034049] [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] [Indexed: 08/07/2023] Open
Abstract
Laparoscopic pancreaticoduodenectomy (LPD) is a classic surgical method for diseases, such as tumors at the lower end of the common bile duct, pancreatic head, and benign and malignant tumors of the duodenum. Postoperative pancreatic fistula (POPF) is one of the most serious complications of LPD. To reduce the incidence of grade B or C POPF and other complications after LPD, we applied a split pancreatic duct stent combined with the characteristics of internal and external stent drainage. Between September 2020 and September 2022,12 patients underwent placement of the Split pancreatic duct stent during LPD. Data on basic characteristics of patients, surgical related indicators and postoperative POPF incidence were collected and analyzed. The results showed that the average operation time was 294.2 ± 36 minutes, average time for pancreaticojejunostomy was 35.9 ± 4.1 minutes, and average estimated blood loss was 204.2 ± 58.2 mL. Biochemical leakage occurred in 2 patients (16.7%), whereas no grade B or C POPF, 1 case (8.3%) had postoperative bleeding, and no death occurred within 30 days after the operation. Preliminary experience shows that the split pancreatic duct stent can effectively reduce the incidence of complications after LPD, especially grade B or C POPF.
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Affiliation(s)
- Jianhua Tu
- Nanchang University Medical College, Nanchang, China
- Department of Hepatobiliary Surgery, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | | | - Wenyan Xu
- Nanchang University Medical College, Nanchang, China
| | - Shuaichang Gong
- Department of Hepatobiliary Surgery, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Zhenjun Cao
- Department of Hepatobiliary Surgery, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Ping Wan
- Department of Hepatobiliary Surgery, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Junxiang Ying
- Department of Hepatobiliary Surgery, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
| | - Xuefeng Rao
- Department of Hepatobiliary Surgery, Jiangxi Provincial People's Hospital (The First Affiliated Hospital of Nanchang Medical College), Nanchang, China
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Zhang L, Zhu X, Zhu Y, Huang J, Tao L, Chen Y. Chen's penetrating-suture technique for pancreaticojejunostomy following pancreaticoduodenectomy. BMC Surg 2023; 23:146. [PMID: 37248522 DOI: 10.1186/s12893-023-02054-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 05/23/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most serious complication and the main reason for morbidity and mortality after pancreaticoduodenectomy (PD). Currently, there exists no flawless pancreaticojejunal anastomosis approach. We presents a new approach called Chen's penetrating-suture technique for pancreaticojejunostomy (PPJ), which involves end-to-side pancreaticojejunostomy by suture penetrating the full-thickness of the pancreas and jejunum, and evaluates its safety and efficacy. METHODS To assess this new approach, between May 2006 and July 2018, 193 consecutive patients who accepted the new Chen's Penetrating-Suture technique after a PD were enrolled in this study. Postoperative morbidity and mortality were evaluated. RESULTS All cases recovered well after PD. The median operative time was 256 (range 208-352) min, with a median time of 12 (range 8-25) min for performing pancreaticojejunostomy. Postoperative morbidity was 19.7% (38/193) and mortality was zero. The POPF rate was 4.7% (9/193) for Grade A, 1.0% (2/193) for Grade B, and no Grade C cases and one urinary tract infection. CONCLUSION PPJ is a simple, safe, and reliable technique with ideal postoperative clinical results.
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Affiliation(s)
- Lihong Zhang
- Department of Hepatobiliary Surgery, Affiliated Hospital of Yangzhou University, 368 Hanjiang Road, Yangzhou, 225012, Jiangsu Province, China
| | - Xuefeng Zhu
- Department of Hepatobiliary Surgery, Taixing People's Hospital of Yangzhou University, 1 Changzheng Road, Taixing, 225400, Jiangsu Province, China
| | - Yongsheng Zhu
- Department of Hepatobiliary Surgery, Taixing People's Hospital of Yangzhou University, 1 Changzheng Road, Taixing, 225400, Jiangsu Province, China
| | - Jianjun Huang
- Department of Hepatobiliary Surgery, Taixing People's Hospital of Yangzhou University, 1 Changzheng Road, Taixing, 225400, Jiangsu Province, China
| | - Lide Tao
- Department of Hepatobiliary Surgery, Affiliated Hospital of Yangzhou University, 368 Hanjiang Road, Yangzhou, 225012, Jiangsu Province, China
| | - Yijun Chen
- Department of Hepatobiliary Surgery, Taixing People's Hospital of Yangzhou University, 1 Changzheng Road, Taixing, 225400, Jiangsu Province, China.
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Bellotti R, Cardini B, Strolz CJ, Stättner S, Oberhuber R, Braunwarth E, Resch T, Scheidl S, Margreiter C, Schneeberger S, Öfner D, Maglione M. Single Center, Propensity Score Matching Analysis of Different Reconstruction Techniques following Pancreatoduodenectomy. J Clin Med 2023; 12:3318. [PMID: 37176758 PMCID: PMC10179219 DOI: 10.3390/jcm12093318] [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: 03/13/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy is still hampered by significant morbidity. So far, there is no universally accepted technique aimed at minimizing postoperative complications. Herein, we compare three different reconstruction techniques. METHODS This is a retrospective study of a prospectively maintained database including 283 patients operated between January 2010 and December 2020. Three reconstruction techniques were compared: (1) the Neuhaus-style telescope pancreatojejunostomy, (2) the pancreatogastrostomy, and (3) the modified Blumgart-style, duct-to-mucosa pancreatojejunostomy. The primary endpoint consisted in determining the rates of clinically relevant postoperative pancreatic fistulas (CR-POPF); the secondary endpoints included 90 days morbidity and mortality rates. A propensity score matching analysis was used. RESULTS Rates of CR-POPF did not differ significantly between the groups (Neuhaus-style pancreatojejunostomy 16%, pancreatogastrostomy 17%, modified Blumgart-style pancreatojejunostomy 15%), neither in the unmatched nor in the matched analysis (p = 0.993 and p = 0.901, respectively). Similarly, no significant differences could be observed with regard to major morbidity (unmatched p = 0.596, matched p = 0.188) and mortality rates (unmatched p = 0.371, matched p = 0.209) within the first 90 days following surgery. Propensity-score matching analyses revealed, however, a higher occurrence of post-pancreatectomy hemorrhage after pancreatogastrostomy (p = 0.015). CONCLUSION Similar CR-POPF rates suggest no crucial role of the applied reconstruction technique. Increased incidence of intraluminal post-pancreatectomy hemorrhages following pancreatogastrostomy demands awareness for meticulous hemostasis.
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Affiliation(s)
- Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Carola J. Strolz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergut Hospital, 4840 Vöcklabruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Eva Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
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Lee KF, Wong KKC, Lo EYJ, Kung JWC, Lok HT, Chong CCN, Wong J, Lai PBS, Ng KKC. What is the pancreatic duct size limit for a safe duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy? A retrospective study. Ann Hepatobiliary Pancreat Surg 2021; 26:84-90. [PMID: 34903678 PMCID: PMC8901978 DOI: 10.14701/ahbps.21-054] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/12/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a dreadful complication. Duct-to-mucosa pancreaticojejunostomy (DTMPJ) is a commonly performed anastomosis after PD. This study aims to evaluate whether there is a size limit of pancreatic duct below which POPF rate increases significantly after DTMPJ. Methods A retrospective study was performed from a database with prospectively collected data on consecutive patients undergoing DTMPJ. Results Between the years 2003 and 2019, a total of 288 patients with DTMPJ were recruited. POPF occurred in 56.3% of the patients, of which 43.8% were biochemical leak, 8.7% were grade B, and 1.4% were grade C. Overall operative morbidity was 51.4%, of which 19.1% were major complications. Five patients (1.7%) died within 90 days of operation. Patients with grade B/C POPF had significantly soft pancreas (p < 0.001), smaller duct size (p = 0.031), and a diagnosis of carcinoma of the pancreas (p = 0.027). When a clinically significant POPF rate was analysed based on the pancreatic duct diameter, pancreatic duct size ≤ 1 mm had the highest POPF rate (35.7%). There was a significant difference in POPF rate between adjacent ductal diameter ≤ 1 mm and > 1 mm to 2 mm (35.7% vs 13.3%; p = 0.040). Multivariable analysis showed that for the soft pancreas, pancreatic duct diameter ≤ 1 mm was the only significant predictive factor for POPF (p = 0.027). Conclusions DTMPJ can be safely performed for pancreatic duct > 1 mm without significantly increased POPF risk.
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Affiliation(s)
- Kit-Fai Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kandy Kam Cheung Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Eugene Yee Juen Lo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Janet Wui Cheung Kung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hon-Ting Lok
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Charing Ching Ning Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - John Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Paul Bo San Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kelvin Kwok Chai Ng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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Li Y, Hua R. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: a network meta-analysis. Minerva Surg 2021; 77:65-71. [PMID: 34160171 DOI: 10.23736/s2724-5691.21.08802-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile. EVIDENCE ACQUISITION A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistula(ISGPF) definition of POPF. The main outcomes were POPF and clinically relevant POPF. RESULTS Three techniques of pancreatic anastomosis following PD were directly compared in 16 RCTs comprising 2365 patients. EVIDENCE SYNTHESIS Overall, 929 patients underwent duct-to-mucosa pancreaticojejunostomy(PJ DTM), 760 patients invagination pancreaticojejunostomy(PJ Inv), and 676 patients underwent pancreatogastrostomy(PG). The results of comparisons of POPF, clinically relevant POPF, biliary leakage, delayed gastric emptying(DGE), in hospital mortality, internal hemorrhage, reoperation in our network meta-analysis suggested there were no significant differences among the 3 procedures. CONCLUSIONS There are no significant differences among PJ DTM, PJ Inv and PG in the prevention of POPF, clinically relevant POPF, biliary leakage, DGE, internal hemorrhage and reoperation. However, further randomized controlled trials should be undertaken to ascertain these findings.
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Affiliation(s)
- Yujie Li
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China.,Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Rong Hua
- Department of Pancreaticobiliary Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China -
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Popov AY, Lishchishin VY, Petrovskiy AN, Lishchenko AN, Grigorov SP, Baryshev AG, Porkhanov VA. [Immediate outcomes of pancreatoduodenectomy after different digestive reconstruction procedures]. Khirurgiia (Mosk) 2021:14-19. [PMID: 33570349 DOI: 10.17116/hirurgia202102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the immediate results of pancreatoduodenectomy depending on digestive reconstruction procedure. MATERIAL AND METHODS We analyzed 242 patients who underwent pancreatoduodenectomy for the period from January 2013 to December 2019. There were 32 combined procedures: 28 (11.6%) with portal vein resection and 8 (3.3%) simultaneous operations (right-sided hemicolectomy - 4, right-sided adrenalectomy - 2, gastrectomy with splenectomy - 2). Pancreatic stump was inserted into the jejunum in 156 (64.5%) patients, into the stomach - in 86 (35.5%) cases. RESULTS Postoperative period was uneventful in 180 (74.4%) patients. Eighty postoperative complications were observed in 62 (25.6%) patients; 221 (91.3%) patients were discharged, 21 (8.7%) patients died. Pancreatic necrosis was the most common postoperative event and provoked 65 (82.5%) various complications (38 (72.1%) in patients with pancreaticojejunostomy and 20 (71.5%) in those with pancreaticogastrostomy). Incidence of complications was similar in both groups. However, pancreaticojejunostomy was followed by severe pancreatic fistula type C in 12 (23.1%) patients, type B in 24 (46.1%) cases. In case of pancreaticogastrostomy, pancreatic fistula type C occurred in 4 (14.3%) cases, type B - in 8 (28.6%) patients. CONCLUSION Pancreatic necrosis was the most common postoperative event after pancreatoduodenectomy. Fewer severe pancreatic fistulae (type C) were recorded after pancreaticogastrostomy although these patients had lower density of the pancreas and unclear pancreatic duct. Choice of pancreatic-digestive anastomosis should be determined by features of pancreatic parenchyma, pancreatic duct diameter. Nevertheless, final decision is a prerogative of surgeon. Pancreaticogastrostomy is especially advisable in minimally invasive PDEs that will simplify inclusion of the pancreas into digestive system and reduce the incidence of complications and mortality.
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Affiliation(s)
- A Yu Popov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - V Ya Lishchishin
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - A N Petrovskiy
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - A N Lishchenko
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - S P Grigorov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - A G Baryshev
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - V A Porkhanov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
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8
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Daamen LA, Smits FJ, Besselink MG, Busch OR, Borel Rinkes IH, van Santvoort HC, Molenaar IQ. A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy. HPB (Oxford) 2018; 20:777-785. [PMID: 29773356 DOI: 10.1016/j.hpb.2018.03.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/05/2018] [Accepted: 03/14/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Many pancreatic anastomoses have been proposed to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, but a complete overview is lacking. This systematic review and meta-analysis aims to provide an online overview of all pancreatic anastomosis techniques and to evaluate the incidence of clinically relevant POPF in randomized controlled trials (RCTs). METHODS A literature search was performed to December 2017. Included were studies giving a detailed description of the pancreatic anastomosis after open pancreatoduodenectomy and RCTs comparing techniques for the incidence of POPF (International Study Group of Pancreatic Surgery [ISGPS] Grade B/C). Meta-analyses were performed using a random-effects model. RESULTS A total of 61 different anastomoses were found and summarized in 19 subgroups (www.pancreatic-anastomosis.com). In 6 RCTs, the POPF rate was 12% after pancreaticogastrostomy (n = 69/555) versus 20% after pancreaticojejunostomy (n = 106/531) (RR0.59; 95%CI 0.35-1.01, P = 0.05). Six RCTs comparing subtypes of pancreaticojejunostomy showed a pooled POPF rate of 10% (n = 109/1057). Duct-to-mucosa and invagination pancreaticojejunostomy showed similar results, respectively 14% (n = 39/278) versus 10% (n = 27/278) (RR1.40, 95%CI 0.47-4.15, P = 0.54). CONCLUSION The proposed online overview can be used as an interactive platform, for uniformity in reporting anastomotic techniques and for educational purposes. The meta-analysis showed no significant difference in POPF rate between pancreatic anastomosis techniques.
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Affiliation(s)
- Lois A Daamen
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Jasmijn Smits
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G Besselink
- Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R Busch
- Dept. of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Inne H Borel Rinkes
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Dept. of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Dept. of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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[Pancreaticojejunostomy: duct-to-mucosa anastomosis or invagination anastomosis?]. Chirurg 2018; 89:311. [PMID: 29572642 DOI: 10.1007/s00104-018-0627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cheng Y, Briarava M, Lai M, Wang X, Tu B, Cheng N, Gong J, Yuan Y, Pilati P, Mocellin S. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2017; 9:CD012257. [PMID: 28898386 PMCID: PMC6483797 DOI: 10.1002/14651858.cd012257.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatoduodenectomy is a surgical procedure used to treat diseases of the pancreatic head and, less often, the duodenum. The most common disease treated is cancer, but pancreatoduodenectomy is also used for people with traumatic lesions and chronic pancreatitis. Following pancreatoduodenectomy, the pancreatic stump must be connected with the small bowel where pancreatic juice can play its role in food digestion. Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are surgical procedures commonly used to reconstruct the pancreatic stump after pancreatoduodenectomy. Both of these procedures have a non-negligible rate of postoperative complications. Since it is unclear which procedure is better, there are currently no international guidelines on how to reconstruct the pancreatic stump after pancreatoduodenectomy, and the choice is based on the surgeon's personal preference. OBJECTIVES To assess the effects of pancreaticogastrostomy compared to pancreaticojejunostomy on postoperative pancreatic fistula in participants undergoing pancreaticoduodenectomy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9), Ovid MEDLINE (1946 to 30 September 2016), Ovid Embase (1974 to 30 September 2016) and CINAHL (1982 to 30 September 2016). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) and screened references of eligible articles and systematic reviews on this subject. There were no language or publication date restrictions. SELECTION CRITERIA We included all randomized controlled trials (RCTs) assessing the clinical outcomes of PJ compared to PG in people undergoing pancreatoduodenectomy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. We performed descriptive analyses of the included RCTs for the primary (rate of postoperative pancreatic fistula and mortality) and secondary outcomes (length of hospital stay, rate of surgical re-intervention, overall rate of surgical complications, rate of postoperative bleeding, rate of intra-abdominal abscess, quality of life, cost analysis). We used a random-effects model for all analyses. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes (using PG as the reference) with 95% confidence intervals (CI) as a measure of variability. MAIN RESULTS We included 10 RCTs that enrolled a total of 1629 participants. The characteristics of all studies matched the requirements to compare the two types of surgical reconstruction following pancreatoduodenectomy. All studies reported incidence of postoperative pancreatic fistula (the main complication) and postoperative mortality.Overall, the risk of bias in included studies was high; only one included study was assessed at low risk of bias.There was little or no difference between PJ and PG in overall risk of postoperative pancreatic fistula (PJ 24.3%; PG 21.4%; RR 1.19, 95% CI 0.88 to 1.62; 7 studies; low-quality evidence). Inclusion of studies that clearly distinguished clinically significant pancreatic fistula resulted in us being uncertain whether PJ improved the risk of pancreatic fistula when compared with PG (19.3% versus 12.8%; RR 1.51, 95% CI 0.92 to 2.47; very low-quality evidence). PJ probably has little or no difference from PG in risk of postoperative mortality (3.9% versus 4.8%; RR 0.84, 95% CI 0.53 to 1.34; moderate-quality evidence).We found low-quality evidence that PJ may differ little from PG in length of hospital stay (MD 1.04 days, 95% CI -1.18 to 3.27; 4 studies, N = 502) or risk of surgical re-intervention (11.6% versus 10.3%; RR 1.18, 95% CI 0.86 to 1.61; 7 studies, N = 1263). We found moderate-quality evidence suggesting little difference between PJ and PG in terms of risk of any surgical complication (46.5% versus 44.5%; RR 1.03, 95% CI 0.90 to 1.18; 9 studies, N = 1513). PJ may slightly improve the risk of postoperative bleeding (9.3% versus 13.8%; RR 0.69, 95% CI: 0.51 to 0.93; low-quality evidence; 8 studies, N = 1386), but may slightly worsen the risk of developing intra-abdominal abscess (14.7% versus 8.0%; RR 1.77, 95% CI 1.11 to 2.81; 7 studies, N = 1121; low quality evidence). Only one study reported quality of life (N = 320); PG may improve some quality of life parameters over PJ (low-quality evidence). No studies reported cost analysis data. AUTHORS' CONCLUSIONS There is no reliable evidence to support the use of pancreatojejunostomy over pancreatogastrostomy. Future large international studies may shed new light on this field of investigation.
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Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Marta Briarava
- University of PadovaDepartment of Surgery, Oncology and GastroenterologyPadovaItaly
| | - Mingliang Lai
- Jiangjin Central HospitalDepartment of Clinical LaboratoryNo. 65, Jiang Zhou RoadChongqingChina402260
| | - Xiaomei Wang
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Bing Tu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Yuhong Yuan
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1280 Main Street WestRoom HSC 3N51HamiltonONCanadaL8S 4K1
| | - Pierluigi Pilati
- University of PadovaMeta‐Analysis Unit, Department of Surgery, Oncology and Gastroenterologyvia Giustiniani 2PadovaItaly35128
| | - Simone Mocellin
- University of PadovaDepartment of Surgery, Oncology and GastroenterologyPadovaItaly
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Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol 2016; 51:1147-54. [PMID: 27216233 PMCID: PMC4975078 DOI: 10.3109/00365521.2016.1169317] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers. METHODS A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF. RESULTS A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained. CONCLUSIONS Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital,
Stavanger,
Norway,Department of Clinical Medicine, University of Bergen,
Bergen,
Norway,CONTACT Kjetil Søreide
Department of Gastrointestinal Surgery, Stavanger University Hospital, POB 8100,
N-4068Stavanger,
Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital,
Oslo,
Norway
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Mocellin S, Briarava M, Yuan Y, Pilati P. Anastomosis to stomach versus anastomosis to jejunum for reconstructing the pancreatic stump after pancreatoduodenectomy. Hippokratia 2016. [DOI: 10.1002/14651858.cd012308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Simone Mocellin
- University of Padova; Department of Surgery, Oncology and Gastroenterology; Via Giustiniani 2 Padova Veneto Italy 35128
- IOV-IRCCS; Istituto Oncologico Veneto; Padova Italy 35100
| | - Marta Briarava
- University of Padova; Department of Surgery, Oncology and Gastroenterology; Via Giustiniani 2 Padova Veneto Italy 35128
| | - Yuhong Yuan
- McMaster University; Department of Medicine, Division of Gastroenterology; 1280 Main Street West Room HSC 3N51 Hamilton ON Canada L8S 4K1
| | - Pierluigi Pilati
- University of Padova; Meta-Analysis Unit, Department of Surgery, Oncology and Gastroenterology; via Giustiniani 2 Padova Italy 35128
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13
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Testini M, Piccinni G, Lissidini G, Gurrado A, Tedeschi M, Franco IF, Di Meo G, Pasculli A, De Luca GM, Ribezzi M, Falconi M. Surgical management of the pancreatic stump following pancreato-duodenectomy. J Visc Surg 2016; 153:193-202. [PMID: 27130693 DOI: 10.1016/j.jviscsurg.2016.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.
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Affiliation(s)
- M Testini
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy.
| | - G Piccinni
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G Lissidini
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - A Gurrado
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Tedeschi
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - I F Franco
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G Di Meo
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - A Pasculli
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G M De Luca
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Ribezzi
- Anesthesiology Unit, Department of Emergency Surgery and Organs Transplantation, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Falconi
- Pancreatic Surgery Unit, San Raffaele Hospital IRCCS, University Vita e Salute, Milan, Italy
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14
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Pancreatic fistula following pancreatoduodenectomy. Evaluation of different surgical approaches in the management of pancreatic stump. Literature review. Int J Surg 2015; 21 Suppl 1:S4-9. [DOI: 10.1016/j.ijsu.2015.04.088] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 03/23/2015] [Accepted: 04/10/2015] [Indexed: 02/08/2023]
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