Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy

BACKGROUND

It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We compared PJ and PG after pancreaticoduodenectomy (PD).

METHODS

A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the secondary outcomes were overall morbidity and mortality. We used the Student t, Mann-Whitney U and χ(2) tests for intention to treat analysis. The effect of randomization, American Society of Anesthesiologists score, soft pancreatic texture and use of pancreatic stent on overall complications and fistula rates was calculated using logistic regression.

RESULTS

Our trial included 98 patients. The rate of pancreatic fistula formation was 18% in the PJ and 25% in the PG groups (p = 0.40). Postoperative complications occurred in 48% of patients in the PJ and 58% in the PG groups (p = 0.31). There were no significant predictors of overall complications in the multivariate analysis. Only soft pancreatic gland predicted the occurrence of pancreatic fistula (odds ratio 5.89, p = 0.003).

CONCLUSION

There was no difference in the rates of pancreatic leak/fistula, overall complications or mortality between patients undergoing PG and and those undergoing PJ after PD.

Techniques for prevention of pancreatic leak after pancreatectomy

Pancreatic resections are some of the most technically challenging operations performed by surgeons, and post-operative pancreatic fistula (POPF) are not uncommon, developing in approximately 13% of pancreaticoduodenectomies and 30% of distal pancreatectomies. Multiple trials of various operative techniques in the creation of the pancreatic ductal anastomosis have been conducted throughout the years, and herein we review the literature and outcomes data regarding these techniques, although no one technique of pancreatic ductal anastomosis has been shown to be superior in decreasing rate of POPF. Similarly, we review the literature regarding techniques of pancreatic closure after distal pancreatectomy. Again, no one technique has been shown to be superior in preventing POPF; however the use of buttressing material on the pancreatic staple line in the future may be a successful means of decreasing POPF. We review adjunctive techniques to decrease POPF such as pancreatic ductal stenting, the use of various topical biologic glues, and the use of somatostatin analogue medications. We conclude that future trials will need to be conducted to find optimal techniques to decrease POPF, and meticulous attention to intra-operative details and post-operative care by surgeons is necessary to prevent POPF and optimally care for patients undergoing pancreatic resection.

Modified technique of pancreaticogastrostomy for soft pancreas with two continuous hemstitch sutures: a single-center prospective study

Postoperative pancreatic fistula (POPF) remains a persistent problem after pancreaticoduodenectomy (PD), especially in the presence of a soft, nonfibrotic pancreas. To reduce the risk of POPF, pancreaticogastrostomy (PG) is an optional reconstruction technique for surgeons after PD. This study presents a new technique of PG for a soft, nonfibrotic pancreas with double-binding continuous hemstitch sutures and evaluates its safety and reliability. From January 2011 to June 2012, 92 cases of patients with periampullary malignancy with a soft pancreas underwent this technique. A modified technique of PG was performed with two continuous hemstitch sutures placed in the mucosal and seromuscular layers of the posterior gastric wall, respectively. Then the morbidity and mortality was calculated. This technique was applied in 92 patients after PD all with soft pancreas. The median time for the anastomosis was 12 min (range, 8-24). Operative mortality was zero, and morbidity was 16.3 % (n = 15), including hemorrhage (n = 2), biliary fistula (n = 2), pulmonary infection (n = 1), delayed gastric emptying (DGE; n = 5, 5.4 %), abdominal abscess (n = 3, one caused by PF), and POPF (n = 2, 2.2 %). Two patients developed a pancreatic fistula (one type A and one type B) classified according to the International Study Group on Pancreatic Fistula. The described technique is a simple and safe reconstruction procedure after PD, especially for patients with a soft and fragile pancreas.

Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010

Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.

Gastroduodenal artery-preserving pancreaticoduodenectomy after subtotal esophagectomy and gastric pull-up

PURPOSE

Division of the gastroduodenal artery is commonly performed during pancreaticoduodenectomy for both malignant and benign disease. We describe here a technical modification of pylorus preserving pancreaticoduodenectomy with gastroduodenal artery preservation performed in a patient who previously underwent subtotal esophagectomy with gastric pull-up discussing advantages and drawbacks of the technique.

METHODS

A 73-year-old man with a previous history of right nephrectomy and lower esophagectomy for cancer was referred to our center for the treatment of a 5-cm tumor of the pancreatic head. Following the preliminary steps of a standard pancreaticoduodenectomy, the gastroduodenal artery was isolated at its origin from the common hepatic artery. The entire length of the gastroduodenal artery was dissected after having sectioned the posterior-superior pancreaticoduodenal artery. The right gastroepiploic vessels were preserved along with the gastroduodenal artery. Digestive reconstruction was completed just as for pylorus-preserving pancreaticoduodenectomy.

RESULTS

The preservation of the gastroduodenal artery along with the gastroepiloic vessels was safely performed with an operative time of 300 min and minimal blood loss. Pathology showed a solitary 5-cm renal cell carcinoma metastasis.

CONCLUSIONS

Gastroduodenal artery preserving pancreaticoduodenectomy can serve as an additional option in the armamentarium of a pancreatic surgeon. This technique constitutes an interesting technical option that ensures optimal vascular supply to the gastric remnant after previous esophagectomy. Its clinical application remains limited to selected indications and deserves further experience and comparison with standard techniques.

Do transanastomotic pancreatic ductal stents after pancreatic resections improve outcomes?

OBJECTIVES

Despite strategies aimed at reducing a postoperative pancreatic fistula (POPF) after pancreatectomies, the overall incidence remains unchanged. One such procedure, until now incompletely explored, is transanastomotic pancreatic (TAP) ductal stenting.

METHODS

We conducted a systematic search using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1983-2008 to determine if TAP ductal stents provide any benefit and, if so, in which clinical scenarios they can be recommended.

RESULTS

Stents can be internal or external, intraoperative only, or temporary (several days). One randomized trial on internal stents across pancreaticojejunostomy (PJ) suggested a higher POPF rate in the stented group. One nonrandomized study using an internal stent for pancreaticogastrostomy (PG) revealed a 0% POPF rate. Results from studies where external stents were used across PJ/PG reported a lower incidence of POPF. No statistically significant difference was reported in a POPF incidence when internal stents were compared with externalized stents. Available data suggest improved outcomes of pancreatoenteric anastomosis when TAP ductal stent is inserted in small ducts (< or =3 mm).

CONCLUSIONS

There is insufficient evidence to support or refute improved outcomes after TAP ductal stent insertion in patients with PJ/PG with small ducts (< or =3 mm) or soft pancreata. More evidence of benefit is needed before use of external stents can be recommended.

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.