External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial

The role of "fatty pancreas" and of BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy

INTRODUCTION

Pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is still a serious complication. We hypothesized that the amount of fatty tissue in the pancreatic parenchyma could be associated with the occurrence of PF after PD with pancreatogastrostomy.

MATERIAL AND METHODS

From January 2004 to December 2006, 111 consecutive patients underwent PD with pancreatogastrostomy. The microscopic amount of fatty tissue in the pancreas was evaluated.

RESULTS

The morbidity and mortality rates were 35.1% and 1.8%, respectively. PF occurred in 10.8% (n = 12). PF was of grade A in nine, grade B in two, and grade C in one patient. Univariate analysis showed that a body mass index (BMI) > 25 (P = 0.035), a soft pancreatic parenchyma (P = <0.003), a pancreatic duct size <3 mm (P = 0.015), and a fatty infiltration of the pancreas of more than 10% (P = 0.0003) were associated with the occurrence of PF. The advanced age (P = 0.049) and the BMI (P < 0.0001) were significantly associated with the presence of >10% of pancreatic fat.

CONCLUSIONS

A pancreatic fatty infiltration of the pancreas over 10% constitutes a risk factor for PF after PD. Age and BMI are useful preoperative predictors of the percentage of pancreatic fat.

Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents

BACKGROUND

Pancreatic duct stents are used for a variety of endoscopic pancreatic manipulations, and small surgical stents are used prophylactically to bridge pancreatic-enteric anastomoses. With increasing use of pancreatic stents, many complications have been recognized.

OBJECTIVE

To determine the complications and outcomes of pancreatic stent migration.

DESIGN

Case series from a retrospective review of all cases of upstream or proximally migrated pancreatic duct stents, placed either endoscopically or surgically, identified between 2000 and 2007.

SETTING

Tertiary referral center.

PATIENTS

This study involved 33 patients; 23 postendoscopic and 10 postsurgical stents.

MAIN OUTCOME MEASUREMENTS

Retrieval rates, minor/major complications.

RESULTS

Endoscopic stents had a successful retrieval rate of 78%. Most patients were asymptomatic. The most common procedure was balloon extraction (8 of 18; 44%). Nine patients required multiple procedures (3 patients, 2 attempts; 5 patients, 3 attempts; 1 patient, 4 attempts). Five stents could not be retrieved. Of these, 4 were associated with downstream stenosis. Four patients underwent surgery, and 1 patient was treated with observation. Complications included pancreatic duct disruption (1 of 23), stent fragmentation (1 of 23), and postprocedure pancreatitis (1 of 23). Surgically placed stents had a successful retrieval rate of 80%. Most surgical stents had migrated into the biliary tree (8 of 10). All of these patients were symptomatic with pain or fever. Two stents could not be retrieved; 1 of those patients underwent surgery.

LIMITATION

Retrospective study.

CONCLUSION

The majority of upstream-migrated stents can be endoscopically removed. Despite manipulation of the pancreatic duct, pancreatitis was infrequent. Surgically placed pancreatic stents migrate downstream and into the open biliary anastomosis and are associated with pain, cholangitis, or liver abscesses.

Totally laparoscopic pancreaticoduodenectomy for locally advanced gastric cancer

BACKGROUND

In patients having locally advanced cancer of the stomach with suspected tumor infiltration to the pancreatic head or the duodenum, a concurrent pancreaticoduodenectomy with gastrectomy is occasionally prerequisite to achieve a microscopically tumor-free surgical margin.

MATERIALS AND METHODS

We present the first series of successful totally laparoscopic pancreaticoduodenectomy (TLPD) for advanced gastric cancer with suspected infiltration to the pancreatic head.

RESULTS

TLPD was successfully performed without adverse events during surgery and resulted in favorable short-term outcomes of three patients with locally advanced gastric cancer with suspected invasion to the pancreas.

CONCLUSIONS

Although TLPD for locally advanced gastric cancer is a technically difficult challenging operation that requires careful dissection along the major vessels, intracorporeal tie sutures, and the placement of an external drainage tube into a narrow pancreatic duct, this procedure is technically feasible and safe in the hands of experienced surgeons. Long-term follow-up is mandatory to validate oncological outcome.

Controversies and appraisals about gastrointestinal reconstruction in pancreatoduodenectomy

Gastrointestinal reconstruction has been considered to be closely related to postoperative morbidity, mortality and quality of life of the patients who undergo pancreatoduodenectomy (PD). For more than half a century, the scholars all around the world have offered numerous operative modifications and new procedures to improve the alimentary reconstruction for PD, but the effect and appraisal of these methods have always been controversial. In recent years many large prospective randomized controlled trials have been reported and the questions above have been re-studied based on the meta-analysis, which enables us to have a correct understanding about these questions for the first time. This article summarized newest research findings, and carried out the synthesis contrast analysis of the main methods of digestive canal reconstruction for PD such as pancreaticojejunostomy (PJ) versus pancreaticogastrostomy (PG), the child type or Roux-en-Y technique, pylorus-preserving pancreatoduodenectomy (PPPD) and the classic Whipple procedure (WPD), duct-to- mucosa anastomosis versus end-to-end invaginated PD, etc. The objective effects of these commonly clinically used procedures are discussed in this paper.

Pancreaticoduodenectomy with external drainage of the pancreatic remnant

OBJECTIVE

Leakage of the pancreaticojejunal anastomosis is a serious complication after pancreaticoduodenectomy. External drainage of the pancreatic remnant is one of several methods for reducing pancreaticojejunal anastomotic leakage or fistula. We investigated complications after pancreaticoduodenectomy with and without external drainage of the pancreatic remnant.

METHODS

Patients who underwent pancreaticoduodenectomy at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from November 1991 to October 2007 were enrolled. Before 2001, no external pancreatic drainage was employed during pancreaticojejunal anastomosis (non-stented group). Since 2001, external drainage of the pancreatic remnant has been routinely performed with a paediatric feeding tube (stented group).

RESULTS

There were 28 patients in the non-stented group and 45 in the stented group. Stented patients had undergone significantly more previous abdominal operations, pylorus preserving pancreaticoduodenectomy, and end to end anastomosis of the pancreatic remnant and jejunal limb. Leakage of the pancreaticojejunal anastomosis or pancreatic fistula, overall complications, and re-laparotomy rate were significantly higher in the non-stented group (leakage or fistula 21.4% vs. 6.7%, overall complications 50% vs. 33.3%, and re-laparotomy 18% vs. 2.2%). The only death was in the non-stented group.

CONCLUSION

External drainage of the pancreatic remnant after pancreaticoduodenectomy is an effective method for prevention of pancreaticojejunal anastomosis leakage and other related complications.

Pancreatic duct holder for facilitating duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy

Duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy may be technically difficult, particularly in cases in which the remnant pancreas is soft with a small main pancreatic duct. We devised a pancreatic duct holder for duct-to-mucosa pancreatojejunostomy. The holder has a cone-shaped tip. A one-third circle of the tip is cut away, which makes a slit. As the tip is inserted gently into the pancreatic duct, the duct can be adequately expanded. The holder provides a good surgical field for anastomosis. A slit of the tip allows needle insertion. The holder facilitates stitches of the jejunum also. Twelve patients underwent pancreatoduodenectomy, followed by duct-to-mucosa pancreatojejunostomy using the holder. The holder allowed 8 or more stitches in duct-to-mucosa anastomosis, even in patients with a small pancreatic duct. No patients developed prolonged pancreatic leakage or pancreatic fistula postoperatively. In conclusion, the pancreatic duct holder is a simple and useful tool for facilitating duct-to-mucosa pancreatojejunostomy.

Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy: a prospective randomized study

OBJECTIVE

To compare the results of postoperative morbidity rate of a new pancreatogastrostomy technique, pylorus-preserving pancreaticoduodenectomy (PPPD) with gastric partition (PPPD-GP) with the conventional technique of pancreaticojejunostomy (PJ).

SUMMARY AND BACKGROUND DATA

Pancreatojejunostomy and pancreatogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreatoduodenectomy (PD). All randomized controlled trials failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally results. However, postoperative morbidity remains high. The best technique in pancreatic anastomosis is still debated.

METHOD

Described here is a new technique, PPPD-GP; in this technique the gastroepiploic arcade is preserved. Gastric partition was performed using 2 endo-Gia staplers along the greater curvature of the stomach, 3 cm from the border. This gastric segment, 10 to 12 cm in length is placed in close proximity to the cut edge of the pancreatic stump. An end-to-side, duct-to-mucosa anastomosis (with pancreatic duct stent) is constructed. One hundred eight patients undergoing PPPD for benign and malignant diseases of the pancreatic head and the periampullary region were randomized to receive PG (PPPD-GP) or end-to-side PJ (PPPD-PJ).

RESULTS

The two treatment groups showed no differences in preoperative parameters and intraoperative factors. The overall postoperative complications were 23% after PPPD-GP and 44% after PPPD-PJ (P < 0.01). The incidence of pancreatic fistula was 4% after PPPD-GP and 18% after PPPD-PJ (P < 0.01). The mean + SD hospital stay was 12 +/- 2 days after PPPD-GP and 16 +/- 3 days after PPPD-PJ.

CONCLUSIONS

This study shows that PPPD-GP can be performed safely and is associated with less complication than PPPD-PJ. The advantage of this technique over other PG techniques is that the anastomosis is outside the area of the stomach where the contents empty into the jejunum, but pancreatic juice drains directly into the stomach.

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.

Preoperative liver function tests and hemoglobin will predict complications following pancreaticoduodenectomy

INTRODUCTION

Previous studies identified an association between dilated pancreatic and biliary ducts and lower rates of pancreatic leak after pancreaticoduodenectomy, but it remains unclear whether elevated liver function tests are also associated with lower rates of complications. The purpose of this study was to determine if preoperative liver function tests are associated with postoperative complications.

MATERIALS AND METHODS

We identified 452 patients who received a pancreaticoduodenectomy from 1990-2007. Clinicopathological data was collected for each patient, and regression analyses were performed to identify predictors of postoperative complications.

RESULTS

Of the patients studied, 289 (64%) experienced no postoperative complications. In univariate analysis, patients with a low or normal preoperative aspartate aminotransferase (p = 0.03) or alkaline phosphatase (p = 0.03), had higher rates of complications. Multivariate analysis confirmed an elevated alkaline phosphatase was associated with a lower incidence of complications (OR = 0.56, p = 0.02), while preoperative anemia was found to be a predictor of complications following pancreaticoduodenectomy (OR = 2.01, p = 0.02).

CONCLUSION

Anemic patients and those with normal liver function tests were more likely to experience complications after pancreaticoduodenectomy. This may represent extent of disease and tumors not causing biliary or pancreatic dilatation, respectively. Precautions, such as intraoperative ductal stents, should be considered when operating on this group of patients to minimize complications.

Pancreatic fistula after pancreatectomy: Evolving definitions, preventive strategies and modern management

Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a demanding procedure and whereas mortality after a pancreaticoduodenectomy is currently < 3%-5% in experienced high-volume centers, post-operative morbidity is considerable, about 30%-50%. At present, the single most significant cause of morbidity and mortality after pancreatectomy is the development of pancreatic leakage and fistula (PF). The occurrence of a PF increases the length of hospital stay and the cost of treatment, requires additional investigations and procedures, and can result in life-threatening complications. There is no universally accepted definition of PF that would allow standardized reporting and proper comparison of outcomes between different centers. However, early recognition of a PF and prompt institution of appropriate treatment is critical to the prevention of potentially devastating consequences. The present article, reviews the evolution of post resection pancreatic fistula as a concept, and discusses evolving definitions, the current preventive strategies and the management of this problem.

Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors

BACKGROUND

Pancreatic fistula (PF) is one of the most common postoperative complications of pancreatoduodenectomy (PD). A recent International Study Group on Pancreatic Fistula (ISGPF) definition grades the severity of PF according to the clinical impact on the patient's hospital course. Although PF is generally treated conservatively (grade A), some cases may require interventional procedures (grade B) or may be life-threatening and necessitate emergency reoperation (grade C). The aim of the present study was to evaluate the incidence of postoperative grade C PF after PD and to assess the prognosis and risk factors for this life-threatening condition.

STUDY DESIGN

Between January 2000 and December 2006, 680 consecutive patients underwent PD in 5 digestive surgery departments in the northwest region of France (Lille, Amiens, Rouen, and Caen). PF was defined as drain output of any measurable volume of fluid on or after postoperative day 3 with amylase content greater than 3 times the serum amylase activity (ISGPF guidelines). To identify possible risk factors for grade C PF, we reviewed the records of 111 (16.3%) patients with postoperative PF and compared grade C cases with grade A+B cases.

RESULTS

The median age was 59 years (range 22-87). The male-to-female ratio was 1.6:1. Fifty-six (50.4%) PDs were performed via pancreaticogastrostomy and 55 via pancreaticojejunostomy. Overall mortality was 2% (n = 14). Grade C PF was observed in 36 (32%) patients, of whom 17 (47%) had sepsis due to an abdominal collection, 16 (44%) had postoperative bleeding, 10 (27.7%) had bleeding associated with abdominal collection, and 3 (9%) had multi-organ failure due to other causes. Of these 36 patients, 35 (97%) underwent reoperation. The mortality rate in grade C PF patients was 38.8%. The major causes of death were sepsis (n = 6) and recurrent bleeding after reoperation (n = 5). Grade C PF increased the duration of postoperative hospitalization (46 vs 29 days, P < .001). Univariate analysis showed that peroperative soft pancreatic parenchyma, peroperative blood transfusion, and postoperative bleeding were significant risk factors for grade C PF, with P values of .011, .003, and .001, respectively. No risk factors for grade C PF were identified in a multivariate analysis. The sensibility, specificity, positive predictive value, and negative predictive value of the presence of the 3 risk factors for grade C PF were 13.89%, 100%, 100%, and 70.75%, respectively.

CONCLUSION

Sixteen percent of patients had PF after PD. Among them, 30% had grade C PF, with a mortality rate of about 40%. Achievement of a 100% predictive positive value for grade C PF after PD in individuals with 3 discriminant risk factors (peroperative soft pancreatic parenchyma, peroperative transfusion, and postoperative bleeding) is a first step towards the identification of high-risk patients who should be managed differently from other patients with PF during or after PD.

Pancreatic surgery

PURPOSE OF REVIEW

Pancreatic surgery is a very challenging field and the management of pancreatic diseases continues to evolve. This report reviews the most recent information relating to pancreatic surgery.

RECENT FINDINGS

Startlingly, it appears that a third of patients with resectable pancreatic cancer do not receive an operation in the United States, but for those who do receive surgery new emphasis on adequate lymph node staging has been reported. Assessment of guidelines for the treatment of intraductal papillary mucinous neoplasm and cystic lesions of the pancreas appear to validate the current practice. Extended pancreatic resections with vascular resection appear safe and with reasonable survival outcomes. The use of laparoscopic techniques for the pancreas continues to advance. Finally, patients with chronic pancreatitis appear better served by operative techniques rather than endoscopic approaches.

SUMMARY

Pancreatic surgery is a fascinating field as we learn more about the biology of the conditions that afflict this gland and the best practices to address these diseases.

Pancreatic anastomosis after pancreaticoduodenectomy: how we do it

While mortality following pancreaticoduodenectomy has progressively decreased over the last decade, its morbidity, especially the development of pancreatic fistula, has remained constant over the years. However, high volume centers and individual surgeons report a major decrease in the rate of post-operative pancreatic fistulas. Technical refinements are crucial to reduce, and if possible prevent, the development of pancreatic fistula. No uniformity of opinion exists as to the method of pancreatic anastomosis after resection and few reports provide a detailed description of the actual technique employed. This article illustrates step-by-step the technique of pancreaticojejunostomy as practiced by the authors. Apart from presenting our previously published experience, results from other centres around the world are also provided in this review article.