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Yi JH, Li ZS, Hu LH. Pancreatic duct stents. J Dig Dis 2022; 23:675-686. [PMID: 36776138 DOI: 10.1111/1751-2980.13158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/14/2023]
Abstract
Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.
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Affiliation(s)
- Jin Hui Yi
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Zhao Shen Li
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
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2
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Sulieman I, Elaffandi A, Elmoghazy W, Khalaf H. USE of Biodegradable STENTS in Pancreaticoduodenectomy: Initial Experience. Surg Innov 2022:15533506221123355. [PMID: 36148813 DOI: 10.1177/15533506221123355] [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: 11/16/2022]
Abstract
Background. Plastic stents have been used to avoid postoperative pancreatic fistula (POPF) following Whipple's Pancreaticoduodenectomy (WPD), but they may cause some stent-related complications. Biodegradable stents have been recently introduced and might be a safe alternative. Here we present our initial experience with their use. Methods. Between March 1, 2020, and September 30, 2020, ten (10) consecutive patients underwent WPD. They all had conventional two-layer pancreaticojejunostomy with the placement of an internal biodegradable stent. They were assessed for technical feasibility, pancreatic leak, and stent-related complications. Results. The use of biodegradable stents was technically feasible in all patients, despite some difficulties in insertion due to stent stiffness and design. After a median follow-up period of 124 days, none of the patients suffered POPF. One patient had a biochemical pancreatic leak with no clinical significance. The median hospital stay was 7 days, and there were no stent-related complications. Conclusion. Biodegradable stents are technically feasible and safe in WPD with good short-term outcomes. They might provide a better alternative to plastic stents and their potential complications. Larger long-term studies are needed to validate efficacy and safety. Few modifications of the stent's design might be needed to facilitate use in open surgery.
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Affiliation(s)
- Ibnouf Sulieman
- Department of Surgery, Division of Organ Transplant, 36977Hamad General Hospital, Doha, Qatar
| | - Ahmed Elaffandi
- Department of Surgery, Division of Organ Transplant, 36977Hamad General Hospital, Doha, Qatar.,Department of Surgical Oncology, National Cancer Institute, 36977Cairo University, Egypt
| | - Walid Elmoghazy
- Department of Surgery, Division of Organ Transplant, 36977Hamad General Hospital, Doha, Qatar.,Department of Surgery, 36977Sohag University, Sohag, Egypt
| | - Hatem Khalaf
- Department of Surgery, Division of Organ Transplant, 36977Hamad General Hospital, Doha, Qatar.,Department of Surgery, College of Medicine, 36977Qatar University, Qatar
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3
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Guo C, Xie B, Guo D. Does pancreatic duct stent placement lead to decreased postoperative pancreatic fistula rates after pancreaticoduodenectomy? A meta-analysis. Int J Surg 2022; 103:106707. [PMID: 35697324 DOI: 10.1016/j.ijsu.2022.106707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To evaluate the effectiveness of pancreatic duct stent placement for preventing postoperative pancreatic fistula after pancreaticoduodenectomy. METHODS PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases were searched up to February 26, 2022. Studies comparing outcomes following pancreaticoduodenectomy with or without pancreatic duct stents were included. The primary outcome measured was postoperative pancreatic fistula rate, and secondary outcomes were in-hospital mortality rate, reoperation rate, delayed gastric emptying rate and wound infection rate. RESULTS Seven RCTs involving 847 patients met the inclusion criteria. No statistically significant difference between the stent group and non-stent group was detected in the incidence of postoperative pancreatic fistula (RR = 0.85, 95%CI: 0.57-1.26, P = 0.41), in-hospital mortality, reoperation, delayed gastric emptying rate and wound infection. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RR = 0.61, 95%CI: 0.43-0.86, P = 0.005). CONCLUSIONS Our preliminary results from this systematic review and meta-analysis revealed that pancreatic duct stents did not reduce the risk of POPF and other complications after pancreaticoduodenectomy compared with no stents. External stents were associated with a reduced POPF rate compared with no stents. Large-scale RCTs are required to assess the effectiveness and assist in clarifying the real role of pancreatic duct stents with respect to the POPF rates after pancreaticoduodenectomy.
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Affiliation(s)
- Chenchen Guo
- Department of General Surgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230001, China.
| | - Bin Xie
- Anhui Normal University, Wuhu, Anhui, 241000, China
| | - Diandian Guo
- School of Medicine, Southeast University, Nanjing, 210009, China
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Boralkar AK, Rafe A, Varudkar AS, Vikram Singh K. Pancreatico-Gastrostomy: A Modified Two-Layered Technique. Cureus 2022; 14:e26227. [PMID: 35891860 PMCID: PMC9308108 DOI: 10.7759/cureus.26227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction: Pancreato-duodenal resections are commonly done for periampullary carcinomas. The outcome of the procedure is decided by pancreato-enterostomy. Pancreato-jejunostomy (PJ) has been employed largely as pancreato-enterostomy. Recently, there has been a renewed interest in pancreato-gastrostomy (PG). The debate continues on the choice of reconstruction. Methods: A hundred cases of periampullary carcinoma were subjected to modified pancreatico-gastrostomy. The pancreatico-gastrectomy was evaluated by drain fluid amylase done on days 1, 3, and 5 post-operatively and clinical findings. The leaks were classified according to the International Study Group of Pancreatic Fistula (ISGPF) classification of biochemical leaks, postoperative pancreatic fistula (POPF) B and POPF C. The leaks were evaluated against pancreatic factors like duct diameter, consistency of the pancreas, the thickness of the pancreatic neck, and duct location. Observations: Eighty percent of patients had no leaks. The biochemical leak was seen in 10% of cases. POPF B and C were observed at 5% each. Mortality was 3%. The diameter of the pancreatic duct of more than 3 mm and the firm consistency of the pancreas were favourable factors in the outcome of the anastomosis. Conclusion: A modified pancreatico-gastrostomy technique appears to be technically feasible and safe. The leak rates and mortality appear to be low. We need a higher number of patients to confirm the efficacy of this modified pancreatico-enterostomy.
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Barannikov AY, Sakhno VD, Durleshter VM, Andreev AV, Tokarenko EV. The first experience of applying a new pancreatoenteroanastomosis with a «soft» pancreatic stump in pancreatoduodenal resection. GREKOV'S BULLETIN OF SURGERY 2022. [DOI: 10.24884/0042-4625-2022-181-2-63-70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The OBJECTIVE was to improve the results of pancreatoduodenal resection by reducing the incidence of pancreatoenteroanastomotic leak and postoperative pancreatitis with a «soft» pancreatic stump.METHODS AND MATERIALS. A new method for the formation of pancreatoenteroanastomosis has been developed and implemented: precision wirsungojejunoanastomosis with additional wide atraumatic peritonization of the pancreatic stump cutoff with the loop of the small intestine. From February 2016 to March 2018, this method was tested in 18 patients.RESULTS. Pancreatoenteroanastomotic leak of class A was noted in 2 (11.1 %) patients, was transient, asymptomatic, did not require additional medical measures and did not extend the duration of the postoperative period. There were no pancreatoenteroanastomotic leak of classes B and C, pancreonecrosis of the stump, lethal outcomes. Objectively worst statistical results were obtained in the comparison group.CONCLUSION. The formation of the small intestine anastomosis with a «soft» pancreatic stump according to the proposed method for pancreatoduodenal resection reduces the incidence of postoperative pancreatitis of the stump and pancreatoenteroanastomotic leak.
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Affiliation(s)
| | - V. D. Sakhno
- Regional Clinical Hospital № 2; Kuban State Medical University
| | | | - A. V. Andreev
- Regional Clinical Hospital № 2; Kuban State Medical University
| | - E. V. Tokarenko
- Multidisciplinary Medical Center Sogaz of Gelendzhik (LLC «RN-modern technologies»)
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Cai H, Lu F, Zhang M, Cai Y, Wang X, Li Y, Meng L, Gao P, Peng B. Pancreaticojejunostomy without pancreatic duct stent after laparoscopic pancreatoduodenectomy: preliminary outcomes from a prospective randomized controlled trial. Surg Endosc 2022; 36:3629-3636. [PMID: 34993588 DOI: 10.1007/s00464-021-08909-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/21/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Outcomes of pancreaticojejunostomy without pancreatic duct during open pancreaticoduodenectomy (OPD) are unknown and controversial, and corresponding reports in laparoscopic surgery are lacking. METHODS Patients were evaluated at West China Hospital, and standard laparoscopic pancreaticoduodenectomy (LPD) was planned. A prospective randomized trial was conducted, in which the patients were randomly assigned to the no-stent and internal-stent groups in a single-center trial. The primary outcomes were the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) and 90-day mortality. Preliminary results were reported. RESULTS From November 2019 to March 2021, we enrolled 90 patients (41 in the no-stent group and 49 in the internal-stent group) in the study. All baseline parameters of both groups, including age, sex ratio, pancreatic duct diameter, and intraoperative blood loss, were comparable between the two groups except for pathological diagnosis and the texture of remnants. Twenty-seven (65.9%) and 19 (38.8%) patients in the no-stent and internal-stent groups, respectively, had soft pancreatic remnants (P = 0.010). The total incidence of CR-POPF was 5.6% and included two patients (4.9%) in the no-stent group and three patients (6.1%) in the internal-stent group (P = 1.000). Only one patient in the internal-stent group died of heart failure within 90 days after the operation. No significant difference in other postoperative complications was observed between the groups except for biochemical fistula [no-stent group vs. internal-stent group = 31.7% vs. 12.2%, (P = 0.024)]. CONCLUSIONS In a high-volume LPD center, duct-to-mucosa pancreaticojejunostomy without pancreatic duct stent is safe and reliable. In addition, duct-to-mucosa pancreaticojejunostomy without pancreatic duct stent was more challenge. We recommend using the stent during anastomosis and pulling it out after the procedure.
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Affiliation(s)
- He Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.,Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Fei Lu
- The Health Management Center of West China Hospital, Sichuan University, Chengdu, China
| | - Man Zhang
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.,Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yongbin Li
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Lingwei Meng
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Pan Gao
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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Kwon CI, Choi SH, Kim KS, Moon JP, Park S, Jeon J, Kim G, Jang JY, Sung MJ, Ko KH, Son JS. Preventive effect of biodegradable stents on biliary stricture and fibrosis after biliary anastomosis in a porcine model. Ann Surg Treat Res 2022; 102:90-99. [PMID: 35198512 PMCID: PMC8831087 DOI: 10.4174/astr.2022.102.2.90] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/29/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose The current drain tubes for preventing surgically biliary anastomotic stricture are not naturally and easily removed. If a drain tube using biodegradable material is easily available and the degradation time of the tube is well controlled, surgical anastomotic stricture and fibrosis could be prevented. The aim of this animal study was to evaluate the preventive effect of novel biodegradable stents (BS) on biliary stricture and fibrosis after duct-to-duct (DD) biliary anastomosis. Methods Ten mini-pigs were allocated to the control group (n = 5) and or the stent group (n = 5). The common bile duct was exposed through surgical laparotomy and then resected transversely. In the stent group, a 4-mm or 6-mm polydioxanone/magnesium sheath-core BS was inserted according to the width of the bile duct, followed by DD biliary anastomosis. In the control group, DD biliary anastomosis was performed without BS insertion. Results In the stent group, stents were observed without deformity for up to 4 weeks in all animals. Eight weeks later, histopathologic examination revealed that the common bile duct of the anastomosis site was relatively narrower in circumference in the control group compared to the stent group. The degree of fibrosis in the control group was more marked than in the stent group (3.84 mm vs. 0.68 mm, respectively; P < 0.05). Conclusion Our study showed that novel BS maintained their original shape and radial force for an adequate time and then disappeared without adverse events. The BS could prevent postoperative complications and strictures after DD biliary anastomosis.
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Affiliation(s)
- Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kyu Seok Kim
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Jong Pil Moon
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Sehwan Park
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Jinkyung Jeon
- Interventional Research Center, M.I.Tech, Co. Ltd., Pyeongtaek, Korea
| | - Gwangil Kim
- Department of Pathology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Young Jang
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Min Je Sung
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kwang Hyun Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jun Sik Son
- Korea Textile Development Institute, Daegu, Korea
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Park JH, Park J, Park Y, Kang JM, Ryu DS, Kyung J, Jang JK, Hwang C, Shim IK, Song HY, Yang SG, Kim SC. Acetazolamide-eluting biodegradable tubular stent prevents pancreaticojejunal anastomotic leakage. J Control Release 2021; 335:650-659. [PMID: 34118337 DOI: 10.1016/j.jconrel.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/23/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
Postoperative pancreatic fistula at the early stage can lead to auto-digestion, which may delay the recovery of the pancreaticojejunal (PJ) anastomosis. The efficacy and safety of an acetazolamide-eluting biodegradable tubular stent (AZ-BTS) for the prevention of self-digestion and intra-abdominal inflammatory diseases caused by pancreatic juice leakage after PJ anastomosis in a porcine model were investigated. The AZ-BTS was successfully fabricated using a multiple dip-coating process. Then, the drug amount and release profile were analyzed. The therapeutic effects of AZ were examined in vitro using two kinds of pancreatic cancer cell lines, AsPC-1 and PANC-1. The efficacy of AZ-BTS was assessed in a porcine PJ leakage model, with animals were each assigned to a leakage group, a BTS group and an AZ-BTS group. The overall mortality rates in these three groups were 44.4%, 16.6%, and 0%, respectively. Mean α-amylase concentrations were significantly higher in the leakage and BTS groups than in the AZ-BTS group on day 2-5 (p < 0.05 each all). The luminal diameters and areas of the pancreatic duct were significantly larger in the leakage group than in the BTS and AZ-BTS groups (p < 0.05 each all). These findings indicate that AZ-BTS can significantly suppress intra-abdominal inflammatory diseases caused by pancreatic juice leakage and also prevent late stricture formation at the PJ anastomotic site in a porcine model.
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Affiliation(s)
- Jung-Hoon Park
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Jieun Park
- Department of Biomedical Science, BK21 FOUR Program in Biomedical Science and Engineering, Inha University College of Medicine, 366 Seohae-Daero, Jung-Gu, Incheon 22332, Republic of Korea
| | - Yejong Park
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jeon Min Kang
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Dae Sung Ryu
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Jeongsu Kyung
- Department of Biomedical Science, BK21 FOUR Program in Biomedical Science and Engineering, Inha University College of Medicine, 366 Seohae-Daero, Jung-Gu, Incheon 22332, Republic of Korea
| | - Jong Keon Jang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Changmo Hwang
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - In Kyong Shim
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea; Asan Medical Institute of Convergence Science and Technology (AMIST), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Ho-Young Song
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea; Department of Radiology, UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Su-Geun Yang
- Department of Biomedical Science, BK21 FOUR Program in Biomedical Science and Engineering, Inha University College of Medicine, 366 Seohae-Daero, Jung-Gu, Incheon 22332, Republic of Korea.
| | - Song Cheol Kim
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea; Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea; Asan Medical Institute of Convergence Science and Technology (AMIST), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
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Mobarak S, Tarazi M, Davé MS, Varley RJ, Stott MC, Baltatzis M, Satyadas T. Roux-en-Y versus single loop reconstruction in pancreaticoduodenectomy: A systematic review and meta-analysis. Int J Surg 2021; 88:105923. [PMID: 33774175 DOI: 10.1016/j.ijsu.2021.105923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/04/2021] [Accepted: 03/11/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications. METHODS A systematic review and meta-analysis was conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models. RESULTS Fourteen studies were identified including four randomised controlled trials (RCTs) and 10 observational studies reporting a total of 2,031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction. DISCUSSION Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomised studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.
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Affiliation(s)
- Shahd Mobarak
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK.
| | - Munir Tarazi
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Madhav Sanatkumar Davé
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Rebecca J Varley
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Martyn C Stott
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Minas Baltatzis
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Thomas Satyadas
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
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Jiang Y, Chen Q, Shao Y, Gao Z, Jin M, Gao B, Zhou B, Yan S. The prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy in patients with FRS ≥ 4: a retrospective cohort study. BMC Surg 2021; 21:81. [PMID: 33579250 PMCID: PMC7881586 DOI: 10.1186/s12893-021-01074-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/25/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy remains controversial. This study aimed to evaluate the benefits of external and internal stents using the Fistula Risk Score system with regard to the incidence of clinically relevant postoperative pancreatic fistula. METHODS A total of 382 patients who underwent pancreaticoduodenectomy with duct to mucosa pancreaticojejunostomy were retrospectively enrolled from January 2015 to October 2019. The receiver operating characteristic curve was performed for subgroup analysis of the patients at different levels of risk for pancreatic fistula. RESULTS There were no significant differences in terms of pancreatic fistula or other postoperative complications. According to the receiver operating characteristic curve threshold of 3.5, 172 patients with a Fistula Risk Score ≥ 4 and 210 patients with a Fistula Risk Score < 4 were divided into separate groups. The number of valid cases was insufficient to support the subsequent research in patients with a Fistula Risk Score < 4. In patients with a Fistula Risk Score ≥ 4, the use of an external pancreatic duct stent was significantly more effective than the use of an internal stent, especially with regard to the risk for pancreatic fistula (Grade C) (P = 0.039), at ameliorating the incidence of clinically relevant postoperative pancreatic fistula (P = 0.019). Additionally, the incidence of lymphatic leakage was significantly higher in the external stent group compared with the internal stent group (P = 0.040). CONCLUSIONS Compared with internal stents, the use of an external stent could reduce the incidence of clinically relevant postoperative pancreatic fistula in patients with a Fistula Risk Score ≥ 4. More large-scale prospective clinical trials are warranted to further clarify our results.
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Affiliation(s)
- Yuancong Jiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Qin Chen
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi Shao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenzhen Gao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Ming Jin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Bingqiang Gao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Bo Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China.
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China.
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11
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Singh K, Kaman L, Tandup C, Raypattanaik N, Dahiya D, Behera A. Internal stenting across the pancreaticojejunostomy anastomosis and main pancreatic duct after pancreaticoduodenectomy. POLISH JOURNAL OF SURGERY 2021; 93:1-5. [PMID: 33949332 DOI: 10.5604/01.3001.0014.7225] [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: 11/13/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is associated with high morbidity and mortality. Studies have reported internal stenting of the pancreaticojejunostomy anastomosis to reduce postoperative pancreatic fistula, but it is still controversial. MATERIALS AND METHODS Fifty patients undergoing elective pancreaticoduodenectomy, were included. Patients were divided into 2 groups in randomized fashion; Group A (n-25) without internal stenting across the pancreaticojejunostomy anastomosis and Group B (n-25) with internal stenting of the pancreaticojejunostomy anastomosis. Primary endpoint was the occurrence of postoperative pancreatic fistula. RESULT Both the groups were comparable in demographics, co morbidities, pathologies, pancreatic texture and pancreatic duct diameter. Out of 50 patients studied, total 23(46.0%) patients developed postoperative pancreatic fistula. Ten (40%) in group A and 13 (52%) in group B (p 0.156). Sixteen patients (32%) developed Grade A and 7 (14%) patients had Grade B postoperative pancreatic fistula. In group A, 6 patients developed grade A and 4 patients developed grade B postoperative pancreatic fistula. In group B, 10 patients developed grade A and 3 patients developed grade B postoperative pancreatic fistula. There was no Grade C fistula. All patients had satisfactory recovery on conservative management. Eight patients (16%) developed delayed gastric emptying [5 in group A and 3 in group B; p-0.366]. Six patients developed superficial surgical site infection (2 in group A and 4 in group B; p-0.445). The length of hospital stay was comparable in two groups. There was no mortality. CONCLUSION Internal stenting of pancreaticojejunostomy anastomosis does not decrease the rate of postoperative pancreatic fistula after pancreaticoduodenectomy.
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Affiliation(s)
| | | | | | | | - Divya Dahiya
- Department of Surgery, PGIMER, Chandigarh, India
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Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis. Sci Rep 2020; 10:17896. [PMID: 33087777 PMCID: PMC7578105 DOI: 10.1038/s41598-020-74812-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/07/2020] [Indexed: 02/05/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.
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Comparison of surgical outcomes between isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis. BMC Gastroenterol 2020; 20:279. [PMID: 32819274 PMCID: PMC7439684 DOI: 10.1186/s12876-020-01415-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We aimed to compare the safety and effectiveness of the following procedures after pancreaticoduodenectomy: isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy. METHODS We performed a systematic search of the following databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until 1 January 2020. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated using STATA 12.0 statistical software. RESULTS Thirteen studies involving 1942 patients were included in this study. Pooled analysis showed that reoperation rates following isolated pancreaticojejunostomy were lower reoperation than with conventional pancreaticojejunostomy (OR = 0.36, 95% CI: 0.15-0.86, p = 0.02, respectively), and that isolated pancreaticojejunostomy required longer operation time vs conventional pancreaticojejunostomy (WMD = 43.61, 95% CI: 21.64-65.58, P = 0.00). Regarding postoperative pancreatic fistula, clinically-relevant postoperative pancreatic fistula, delayed gastric emptying, clinically-relevant delayed gastric emptying, bile leakage, hemorrhage, reoperation, length of postoperative hospital stay, major complications, overall complications, and mortality, we found no significant differences for either isolated pancreaticojejunostomy versus conventional pancreaticojejunostomy or isolated gastrojejunostomy versus conventional pancreaticojejunostomy. CONCLUSIONS This study showed that isolated pancreaticojejunostomy was associated with a lower reoperation rate, but required longer operation time vs conventional pancreaticojejunostomy. Considering the limitations, high-quality randomized controlled trials are required.
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Bao L, Chen ZT, Huang JC, Li MX, Zhang LL, Wan DL, Lin SZ. Small bowel perforation caused by pancreaticojejunal anastomotic stent migration after pancreaticoduodenectomy: A case report. Medicine (Baltimore) 2020; 99:e21120. [PMID: 32791686 PMCID: PMC7386991 DOI: 10.1097/md.0000000000021120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Pancreaticoduodenectomy (PD) has been widely applied as a standard surgical procedure to treat periampullary diseases. The placement of a pancreaticojejunal anastomotic stent is considered an effective and safe method for preventing pancreatic fistula after PD. Recently, the role of pancreaticojejunal anastomotic stents has been challenged, as gradually increasing complications have been observed. Stent-related small bowel perforation has only occurred in 2 cases as long-term complications but has not been reported to occur within 1 week after surgery. PATIENT CONCERNS Here, we report the case of a 71-year-old female patient complaining of painless jaundice who underwent PD with a pancreaticojejunal anastomotic stent for a duodenal papillary adenocarcinoma (T4N1M0). Four days after surgery, she had a sudden rise in temperature, high white blood cell count, significantly elevated C-reactive protein and 400 ml green-brown drainage fluid. Enhanced computed tomography showed hydrops abdominis. DIAGNOSIS Small bowel perforation caused by stent migration was considered first. INTERVENTIONS An emergency exploratory laparotomy was performed. We located the pancreaticojejunal anastomotic stent, which extended 2 cm from the small bowel, and sutured the jejunum hole after cutting away the protruding part of the stent. OUTCOMES The patient recovered smoothly and was discharged on the 7th day after the second surgery. After more than 12 months of follow-up, the patient is doing well and is free of any symptoms related to the procedure. CONCLUSION We caution that stent-related complications can occur when perioperative patients suffer from unexplained or sudden changes in vital signs after PD. In addition, the function of the pancreaticojejunal anastomotic stent needs to be reevaluated by future studies.
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Affiliation(s)
- Li Bao
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine
| | - Zhi-Tao Chen
- Zhejiang University School of Medicine, Hangzhou, China
| | | | - Meng-Xia Li
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine
| | - Le-Le Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine
| | - Da-Long Wan
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine
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Wu J, Zhang G, Yao X, Xiang Y, Lin R, Yang Y, Zhang X. Achilles'heel of laparoscopic pancreatectomy: reconstruction of the remnant pancreas. Expert Rev Gastroenterol Hepatol 2020; 14:527-537. [PMID: 32567383 DOI: 10.1080/17474124.2020.1775582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Laparoscopic pancreatic reconstruction is a challenging procedure and is considered the Achilles' heel of laparoscopic pancreatectomy. Multiple techniques of laparoscopic pancreatic reconstruction have been reported, but the optimal technique remains unclear. AREAS COVERED This paper provides a brief introduction to the developmental status and major related complications of laparoscopic pancreatic reconstruction. We reviewed all published literature on the technology of laparoscopic pancreatic reconstruction within the last 5 years and herein discuss the advantages and disadvantages of different reconstruction methods. We also discuss several details of different reconstruction techniques in terms of their significance to the operation and complications. EXPERT OPINION No individual method of laparoscopic pancreatic reconstruction is considered optimal for all conditions. The reconstruction strategy should be based on the surgeon's proficiency with laparoscopic technology and the patient's individual risk factors. Personalized methods of pancreatic reconstruction may more effectively reduce morbidity and mortality.
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Affiliation(s)
- Jiacheng Wu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| | - Guofeng Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Xiaoxiao Yao
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Yien Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
| | - Ruixin Lin
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Yongsheng Yang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia
| | - Xuewen Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Jilin University , 130041, Changchun, China, East Asia.,Jilin Engineering Laboratory for Translational Medicine of Hepatobiliary and Pancreatic Diseases , 130041, Changchun, China, East Asia
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Jiang Y, Chen Q, Wang Z, Shao Y, Hu C, Ding Y, Shen Z, Jin M, Yan S. The Prognostic Value of External vs Internal Pancreatic Duct Stents in CR-POPF after Pancreaticoduodenectomy: A Systematic Review and Meta-analysis. J INVEST SURG 2020; 34:738-746. [PMID: 32093527 DOI: 10.1080/08941939.2019.1691687] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no specific evidence regarding the benefits of external and internal pancreatic duct stents after pancreaticoduodenectomy since pancreatic fistula (grade A) have been redefined with no clinical treatment effect. We aimed to reevaluate the prognostic value of external and internal stents in clinically relevant postoperative pancreatic fistula over pancreaticoduodenectomy. METHODS PubMed, Web of Science, EMBASE and the Cochrane Database were specifically searched for pertinent and original articles published before May 2019. The project has been registered in PROSPERO (Registration number: CRD42019137579). RESULTS Four randomized controlled trials and six nonrandomized controlled trials with a total of 2101 patients were enrolled in this meta-analysis. The use of an external stent resulted in better performance than the use of an internal stent in terms of pancreatic fistula (grade C) (OR 0.58, P = 0.03) but did not reduce the rate of pancreatic fistula (grade B) (OR 0.99, P = 0.94) in all studies. The meta-analysis of randomized controlled trials found that the use of an external stent approached a level of significance for an increased rate of clinically relevant postoperative pancreatic fistula compared to the use of an internal stent (OR 1.40, P = 0.10) but had no significant effect on pancreatic fistula (grade B) (OR 1.34, P = 0.26) or pancreatic fistula (grade C) (OR 1.68, P = 0.62). CONCLUSION Compared with internal stents, the use of external stent might be associated with a lower rate of pancreatic fistula (grade C). More randomized clinical trials are warranted to further explore safety and efficacy of pancreatic duct external stents.
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Affiliation(s)
- Yuancong Jiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qin Chen
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhize Wang
- Department of Urology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yi Shao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chen Hu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuan Ding
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenhua Shen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming Jin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Aksel B, Güven HE. Pancreatic fistula rates after internal and external stenting of the pancreatojejunostomy anastomosis following pancreatoduodenectomy. Acta Chir Belg 2020; 120:16-22. [PMID: 30424714 DOI: 10.1080/00015458.2018.1538283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: This retrospective comparative case series study aims to analyze the pancreatic fistula rates of internal and external stenting of the pancreatojejunostomy (PJ) anastomosis in patients who underwent pancreatoduodenectomy (PD) for periampullary tumors.Methods: Ninety-eight patients with periampullary tumors who were operated between 2010 and 2017 were enrolled in this study. A classic open PD with Roux-en-Y PJ reconstruction was performed in all cases.Results: The PJ anastomosis of 53 patients (54%) were stented internally whereas in 45 patients (46%) external stenting was preferred. Pancreatic fistula was observed in 29 patients (29.6%). Internal stenting and soft pancreatic tissue were found to be related to higher pancreatic fistula rates with odds ratios of 3.27 (p = .024) and 3.4 (p = .017), respectively. When only grade B and grade C fistulas were taken into account, the type of stenting has lost its significance but the texture of the remnant pancreas was still associated with 'clinically important' pancreatic fistula.Conclusions: We concluded that the external stenting of the PJ anastomosis may be considered as an effective approach for reducing postoperative pancreatic leaks in PD-planned patients for periampullary tumors. Although our study was retrospectively designed, we used standard charts to gather patient data and compared two stenting methods among homogeneous patient groups.
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Affiliation(s)
- Bülent Aksel
- Ankara Oncology Training and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Hikmet Erhan Güven
- Gülhane Training and Research Hospital, Health Sciences University, Ankara, Turkey
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Krishna A, Bansal VK, Kumar S, Garg P, Kapoor BML, Misra MC. Pancreaticogastrostomy After Whipple’s Surgery Avoids Pancreatic Fistula—a Large Case Series Analysis. Indian J Surg 2019. [DOI: 10.1007/s12262-019-01991-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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19
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Quesada R, Simón C, Radosevic A, Poves I, Grande L, Burdío F. Morphological changes of the pancreas after pancreaticoduodenectomy. Sci Rep 2019; 9:14517. [PMID: 31601993 PMCID: PMC6787177 DOI: 10.1038/s41598-019-51173-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 09/17/2019] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Rita Quesada
- Experimental and Health Sciences Department, Universitat Pompeu Fabra, Barcelona, Spain.
| | - Clara Simón
- School of Medicine, Universitat Pompeu Fabra and UAB, Barcelona, Spain
| | | | - Ignasi Poves
- General Surgery Department, Hospital del Mar, Barcelona, Spain
| | - Luis Grande
- General Surgery Department, Hospital del Mar, Barcelona, Spain
| | - Fernando Burdío
- General Surgery Department, Hospital del Mar, Barcelona, Spain
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Gupta V, Kumar S, Gupta V, Joshi P, Rahul R, Yadav RK, Dangi A, Chandra A. Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes. Hepatobiliary Pancreat Dis Int 2019; 18:181-187. [PMID: 30772208 DOI: 10.1016/j.hbpd.2019.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/25/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Blumgart's pancreaticojejunostomy (PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes. METHODS We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula (CR-POPF) and analysis of its risk factors. RESULTS The CR-POPF rate was 12.3%. Fistula risk score (FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay. CONCLUSION Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Vivek Gupta
- Department of Human Organ Transplant, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Pradeep Joshi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Rahul Rahul
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Rakesh Kumar Yadav
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Amit Dangi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
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Comparison of long-term clinical outcomes of external and internal pancreatic stents in pancreaticoduodenectomy: randomized controlled study. HPB (Oxford) 2019; 21:51-59. [PMID: 30093143 DOI: 10.1016/j.hpb.2018.06.1795] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/27/2018] [Accepted: 06/05/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine the most appropriate pancreatic drainage method, by investigating differences in 12-month clinical outcomes in patients implanted with external and internal pancreatic stents as an extension to a previous study on short-term outcome. METHODS This prospective randomized controlled trial enrolled 213 patients who underwent pancreaticoduodenectomy with duct to mucosa pancreaticojejunostomy between August 2010 and January 2014 (NCT01023594). Of the 185 patients followed-up for 12 months, 97 underwent external and 88 underwent internal stenting. Their long-term clinical outcomes were compared. RESULTS Overall late complication rates were similar in the external and internal stent groups (P = 0.621). The percentage of patients with >50% atrophy of the remnant pancreatic volume after 12 months was similar in both groups (P = 0.580). Factors associated with pancreatic exocrine or endocrine function, including stool elastase level (P = 0.571) and rate of new-onset diabetes (P = 0.179), were also comparable. There were no significant between-group differences in quality of life, as evaluated by the EORTC QLQ-C30 and QLQ PAN26 questionnaires. CONCLUSION External and internal stents showed comparable long-term, as well as short-term clinical outcomes, including late complication rates, preservation of pancreatic duct diameters, pancreatic volume changes with functional derangements, and quality of life after surgery.
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El Shobary M, El Nakeeb A, Sultan A, Ali MAEW, El Dosoky M, Shehta A, Ezzat H, Elsabbagh AM. Surgical Loupe at 4.0× Magnification in Pancreaticoduodenectomy-Does It Affect the Surgical Outcomes? A Propensity Score-Matched Study. Surg Innov 2018; 26:201-208. [PMID: 30419788 DOI: 10.1177/1553350618812322] [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: 11/16/2022]
Abstract
BACKGROUND There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD. PATIENTS AND METHOD This is a propensity score-matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay. RESULTS The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to oral intake, total amount of drainage, and time of nasogastric tube removal. Univariate and multivariate analyses demonstrated 3 independent factors of development of postoperative pancreatic fistula: pancreatic duct <3 mm, body mass index >25, and soft pancreas. CONCLUSION Surgical loupes 4.0× added no advantage in surgical outcomes of PD with regard to improvement of postoperative complications rate or mortality rate.
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Yin J, Lu Z, Wu P, Wu J, Gao W, Wei J, Guo F, Chen J, Jiang K, Miao Y. Afferent Loop Decompression Technique is Associated with a Reduction in Pancreatic Fistula Following Pancreaticoduodenectomy. World J Surg 2018; 42:3726-3735. [PMID: 29968100 DOI: 10.1007/s00268-018-4679-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Postoperative pancreatic fistula (POPF) is a major complication and main cause of mortality after pancreaticoduodenectomy (PD). Afferent loop decompression technique (ALDT) has theoretical feasibility to reduce the rate of POPF. The aim of this study is to determine whether ALDT is a protective factor for POPF. METHODS A total of 492 consecutive patients who underwent PD between January 2012 and December 2014 were identified from a prospective database. All data were extracted and events were judged based on medical records. Propensity score matching was conducted to balance several variables. Univariate and multivariate analyses were performed, respectively, to investigate the independent risk factors for pancreatic fistula. ALDT required a nasogastric tube with multiple side holes to be placed deep into the afferent jejunal limb. The rationale for this technique was to prevent pancreatic fistula by decreasing intraluminal pressure in the afferent jejunal loop by placement of the nasogastric tube and the application of continuous low-pressure suction after surgery. RESULTS The total rate of POPF for the entire cohort was 30.7%, and ISGPS grade-A/B/C POPF rates were 18.1, 10.6 and 2.0%, respectively. In-hospital mortality was 1.6%. Among the 331 patients who received ALDT, 89 developed pancreatic leakage (26.9 vs. 38.5% for non-ALDT; P = 0.009) and eight developed biliary leakage (2.4 vs. 6.2% for non-ALDT; P = 0.035). Apart from ALDT, decreased preoperative ALT, soft pancreas, long operative time and tumour presence in the lower common bile duct (as opposed to the pancreas) were identified as other independent risk factors for POPF following multivariate logistic regression analysis. CONCLUSIONS ALDT may reduce the incidence of POPF after PD.
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Affiliation(s)
- Jie Yin
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Zipeng Lu
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Pengfei Wu
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Junli Wu
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Wentao Gao
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jishu Wei
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Feng Guo
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jianmin Chen
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Kuirong Jiang
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Yi Miao
- Department of General Surgery, Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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Chhaidar A, Mabrouk MB, Ali AB. Isolated Roux loop pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: A case-control study. Int J Surg Case Rep 2018; 53:223-227. [PMID: 30428436 PMCID: PMC6232583 DOI: 10.1016/j.ijscr.2018.10.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/05/2018] [Accepted: 10/13/2018] [Indexed: 12/22/2022] Open
Abstract
Pancreaticojejunostomy is commonly used in the reconstruction after pancreaticoduodenectomy, but the incidence of POPF remains high. There are a number of theoretical advantages to the isolated Roux loop pancreaticojejunostomy reconstruction, mainly related to the physical separation of bile acids and the pancreaticojejunostomy. The use of an isolated Roux loop pancreaticojejunostomy seems to be associated with decrease in the rate of postoperative PF in patients undergoing PD.
Objectives The aim of this study was to compare the postoperative outcomes of isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD). Methods Data of patients who underwent IPJ were compared with those of a pair-matched equal number of patients undergoing CPJ. The matching was performed according to age, gender, nature of the lesion indicating PD and the texture of the pancreas. The primary outcome was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality. Results Seventy patients treated by PD (35 patients in each group) were included in the study. The two groups were comparable with regards to the pre-operative and intra-operative parameters. Postoperative pancreatic fistula developed in 10 out of 35 patients in the CPJ group and 3 out of 35 patients in the IPJ group (p = 0.031). Nine CPJ patients and one IPJ patient had POPF of type B or C (p = 0.006). Re-laparotomy was significantly more frequent in the CPJ group (11.1% versus 34.6%; p = 0.04). Time to resumption of oral feeding was shorter in the IPJ group (p = 0.001). Conclusions The use of IPJ is associated with decrease in the rate of postoperative PF in patients undergoing PD. In addition, patients with IPJ reconstruction have lesser need for re-laparotomy and early resumption of oral feeding.
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Affiliation(s)
- Amine Chhaidar
- Department of Surgery, Sahloul Hospital, Sousse, Tunisia.
| | | | - Ali Ben Ali
- Department of Surgery, Sahloul Hospital, Sousse, Tunisia.
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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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Prospective Evaluation of Pasireotide in Patients Undergoing Pancreaticoduodenectomy: The Washington University Experience. J Am Coll Surg 2018; 226:147-154.e1. [DOI: 10.1016/j.jamcollsurg.2017.10.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 10/15/2017] [Accepted: 10/18/2017] [Indexed: 01/13/2023]
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Goossen K, Tenckhoff S, Probst P, Grummich K, Mihaljevic AL, Büchler MW, Diener MK. Optimal literature search for systematic reviews in surgery. Langenbecks Arch Surg 2017; 403:119-129. [PMID: 29209758 DOI: 10.1007/s00423-017-1646-x] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/27/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of the present study was to determine empirically which electronic databases contribute best to a literature search in surgical systematic reviews. METHODS For ten published systematic reviews, the systematic literature searches were repeated in the databases MEDLINE, Web of Science, CENTRAL, and EMBASE. On the basis of these reviews, a gold standard set of eligible articles was created. Recall (%), precision (%), unique contribution (%), and numbers needed to read (NNR) were calculated for each database, as well as for searches of citing references and of the reference lists of related systematic reviews (hand search). RESULTS CENTRAL yielded the highest recall (88.4%) and precision (8.3%) for randomized controlled trials (RCT), MEDLINE for non-randomized studies (NRS; recall 92.6%, precision 5.2%). The most effective combination of two databases plus hand searching for RCT was MEDLINE/CENTRAL (98.6% recall, NNR 97). Adding EMBASE marginally increased the recall to 99.3%, but with an NNR of 152. For NRS, the most effective combination was MEDLINE/Web of Science (99.5% recall, NNR 60). CONCLUSIONS For surgical systematic reviews, the optimal literature search for RCT employs MEDLINE and CENTRAL. For surgical systematic reviews of NRS, Web of Science instead of CENTRAL should be searched. EMBASE does not contribute substantially to reviews with a surgical intervention.
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Affiliation(s)
- Käthe Goossen
- Study Center of the German Surgical Society (SDGC), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Solveig Tenckhoff
- Study Center of the German Surgical Society (SDGC), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Pascal Probst
- Study Center of the German Surgical Society (SDGC), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.,Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Kathrin Grummich
- Study Center of the German Surgical Society (SDGC), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Study Center of the German Surgical Society (SDGC), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.,Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Study Center of the German Surgical Society (SDGC), Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany. .,Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Technical Details and Results of a Modified End-to-Side Technique of Pancreatojejunostomy: a Personal Series of 100 Patients. J Gastrointest Surg 2017; 21:2090-2099. [PMID: 28936588 DOI: 10.1007/s11605-017-3587-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/12/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The treatment of pancreatic stump is a critical step of pancreatoduodenectomy (PD) because leaks from this anastomosis incur major morbidity and mortality. We describe the technical details of a modified end-to-side pancreatojejunostomy (mPJ), and report on the outcome of the first 100 patients. METHODS From October 2008 to June 2017, 424 pancreatic resections were performed, of which 203 were PD. The mPJ was introduced in November 2010 and used in 100 consecutive patients, by a single surgeon. Data were retrieved from a prospectively collected Institutional database, and used for the present retrospective evaluation. Post-operative pancreatic fistulas (POPF) were stratified with the Fistula Risk Score (FRS), based on the 2005-International Study Group of Pancreatic Fistula classification (ISGPFc) and on the subsequent 2016-revised version (ISGPSc). RESULTS ISGPFc POPF occurred in 17/100 (17%): grade A in 10/100 (10%), grade B in 6/100 (6%) and grade C in 1/100 (1%). On the ISGPSc, POPF rate averaged 7%: grade B in 6/100 (6%) and grade C in 1/100 (1%). POPF rate associated with high FRS was 18.8%/6.3% (ISGPFc/ISGPSc). With low and intermediate FRS, POPFs were 5.3%/0% (ISGPFc/ISGPSc) and 21.3%/9.8% (ISGPFc/ISGPSc) respectively. Re-operation rate was 3%. In-hospital mortality rate was 2% and specific mortality rate for POPF was 1%. CONCLUSIONS The mPJ technique is associated with a POPF rate which was less than expected, especially for "difficult" pancreas with high FRS (soft gland texture and small duct). A larger prospective series is needed in addition to comparative studies with other techniques for robust assessment.
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Singh AN, Pal S, Mangla V, Kilambi R, George J, Dash NR, Chattopadhyay TK, Sahni P. Pancreaticojejunostomy: Does the technique matter? A randomized trial. J Surg Oncol 2017; 117:389-396. [PMID: 29044532 DOI: 10.1002/jso.24873] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a randomized trial. METHODS This open-label randomized trial was done at a tertiary care center from January 2009 to October 2015. Patients with resectable periampullary tumours with a pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the two techniques using computer generated random numbers. The primary outcome was postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency of other postoperative complications. RESULTS A total of 193 patients were randomized and analyzed (intention-to-treat analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable for baseline demographic and clinical profiles. The incidence of POPF in the entire study group was 23.8%. There was no statistically significant difference between the two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C (clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups were comparable with respect to the secondary outcomes. DISCUSSION The duct-to-mucosa technique of PJ after PD is not superior to the dunking technique with respect to POPF rate. (CTRI/2010/091/000531).
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Affiliation(s)
- Anand N Singh
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Mangla
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Ragini Kilambi
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Joseph George
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar R Dash
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar K Chattopadhyay
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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Jwa EK, Hwang S. Extended pancreatic transection for secure pancreatic reconstruction during pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2017; 21:138-145. [PMID: 28990000 PMCID: PMC5620474 DOI: 10.14701/ahbps.2017.21.3.138] [Citation(s) in RCA: 2] [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: 07/17/2017] [Revised: 08/11/2017] [Accepted: 08/17/2017] [Indexed: 12/30/2022] Open
Abstract
Backgrounds/Aims Pancreaticoduodenectomy (PD) is associated with various surgical complications including healing failure of the pancreaticojejunostomy (PJ). This study intended to ensure blood supply to the pancreatic stump through extended pancreatic transection (EPT). Methods This study assessed whether EPT reduces PJ-associated complications and whether EPT is harmful on the remnant pancreatic function. The EPT group included 19 patients undergoing PD, pylorus-preserving PD (PPPD) or hepatopancreaticoduodenectomy. The propensity score matched control group included 45 patients who had undergone PPPD. Pancreatic transection was performed at the level of the celiac axis in the EPT group, by which the pancreatic body was additionally removed by 3 cm in length comparing with the conventional pancreatic transection. Results A small invagination fissure suspected as the embryonic fusion site was identified at the ventro-caudal edge of the pancreatic body in all patients undergoing EPT. A sizable fissure permitting easy separation of the pancreatic parenchyma was identified in 15 of 19 patients (78.9%). The incidence of significant postoperative pancreatic fistula was significantly lower in the EPT group than in the control group (p=0.047). There was no significant increase in the postoperative de novo diabetes mellitus in EPT group (p=0.60). Conclusions The EPT technique contributes to the prevention of major pancreatic fistula without impairing remnant pancreatic function. EPT is feasible for routine clinical application or at least in patients with any known risk of PJ leak.
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Affiliation(s)
- Eun-Kyoung Jwa
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Predictive factors of severe complications for ampullary, bile duct and duodenal cancers following pancreaticoduodenectomy: Multivariate analysis of a 10-year multicentre retrospective series. Surgeon 2017; 15:251-258. [DOI: 10.1016/j.surge.2015.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 10/09/2015] [Accepted: 11/20/2015] [Indexed: 12/19/2022]
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Jin S, Shi XJ, Wang SY, Zhang P, Lv GY, Du XH, Wang GY. Drainage fluid and serum amylase levels accurately predict development of postoperative pancreatic fistula. World J Gastroenterol 2017; 23:6357-6364. [PMID: 28974903 PMCID: PMC5603503 DOI: 10.3748/wjg.v23.i34.6357] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/04/2017] [Accepted: 05/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate potential biomarkers for predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD).
METHODS We prospectively recruited 83 patients to this study. All patients underwent PD (Child’s procedure) at the Division of Hepatobiliary and Pancreas Surgery at the First Bethune Hospital of Jilin University between June 2011 and April 2015. Data pertaining to demographic variables, clinical characteristics, texture of pancreas, surgical approach, histopathological results, white blood cell count, amylase and choline levels in the serum, pancreatic/gastric drainage fluid, and choline and amylase levels in abdominal drainage fluid were included in the analysis. Potential correlations between these parameters and postoperative complications such as, POPF, acute pancreatitis, hemorrhage, delayed gastric emptying, and biliary fistula, were assessed.
RESULTS Twenty-eight out of the 83 (33.7%) patients developed POPF. The severity of POPF was classified as Grade A in 8 (28%) patients, grade B in 16 (58%), and grade C in 4 (14%), according to the pancreatic fistula criteria. On univariate and multivariate logistic regression analyses, higher amylase level in the abdominal drainage fluid on postoperative day (POD)1 and higher serum amylase levels on POD4 showed a significant correlation with POPF (P < 0.05). On receiver operating characteristic curve analysis, amylase cut-off level of 2365.5 U/L in the abdominal drainage fluid was associated with a 78.6% sensitivity and 80% specificity [area under the curve (AUC): 0.844; P = 0.009]. A cut-off serum amylase level of 44.2 U/L was associated with a 78.6% sensitivity and 70.9% specificity (AUC: 0.784; P = 0.05).
CONCLUSION Amylase level in the abdominal drainage fluid on POD1 and serum amylase level on POD4 represent novel biomarkers associated with POPF development.
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Affiliation(s)
- Shuo Jin
- School of Clinical Medicine, Tsinghua University, Beijing 100084, China
- Department of Hepatobiliary and Pancreatic Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing 100084, China
| | - Xiao-Ju Shi
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Si-Yuan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-yang Hospital Affiliated to Capital Medical University, Beijing 100020, China
| | - Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Yue Lv
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Xiao-Hong Du
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guang-Yi Wang
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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One hundred and forty five total laparoscopic pancreatoduodenectomies: A single centre experience. Pancreatology 2017; 17:936-942. [PMID: 28867529 DOI: 10.1016/j.pan.2017.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 07/25/2017] [Accepted: 08/18/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Laparoscopic pancreatoduodenectomy (LPD) remains one of the most challenging minimal invasive operations today. PATIENTS AND METHODS Between January 2007 and December 2016, 197 patients were scheduled for LPD but 162 patients (from January 2007 to July 2016) were analysed in this cohort series. RESULTS Total LPD concerned for 162 patients (five patients did not undergo PD and 12 underwent conversion): standard LPD in 104 patients (66%), and laparoscopic pylorus-preserving PD in 41 patients (26%). Median operative time was 415 (240-765) min. Median blood loss was 200 (50-2100) ml. Twelve patients required blood transfusion. Clinically relevant pancreatic fistula (ISGPF grades B and C) occurred in 21 (13%) patients: 16 (10.0%) grade B, and 5 (3%) grade C. Grades B and C delayed gastric emptying occurred in five patients each. Grades B and C post-pancreatectomy bleeding occurred in 9 (5.7%) and 3 (1.9%) patients, respectively. LPD was performed for 18 (11.4%) benign and 139 (88.5%) malignant lesions. Superior mesenteric and/or portal vein involvement required major venous resection in eight patients. The 90-day mortality 5.0%. The median overall survival for pancreatic ductal adenocarcinoma was 22.5 months. CONCLUSION Morbidity and mortality for LPD are comparable to open procedures rates in the literature. Laparoscopic major venous resection is feasible and safe.
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Bin X, Lian B, Jianping G, Bin T. Comparison of patient outcomes with and without stenting tube in pancreaticoduodenectomy. J Int Med Res 2017; 46:403-410. [PMID: 28718685 PMCID: PMC6011316 DOI: 10.1177/0300060517717400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective To evaluate the clinical effect of different pancreaticojejunostomy techniques in the treatment of pancreaticoduodenectomy and investigate the applicability of pancreaticojejunostomy without pancreatic duct stenting. Methods From January 2012 to December 2015, 87 patients who underwent pancreaticoduodenectomy were randomly assigned to either Group A (duct-to-mucosa anastomosis with pancreatic duct stenting, n = 43) or Group B (pancreas-jejunum end-to-side anastomosis without stenting (n = 44). The operative duration of pancreaticojejunostomy, postoperative hospital stay, and incidence of postoperative complications were compared between the two methods. Results The operative duration of pancreaticojejunostomy without use of the pancreatic duct stent was significantly shorter in Group B than in Group A (t = 7.137). The postoperative hospital stay was significantly shorter in Group B than in Group A (t = 2.408). The differences in the incidence of postoperative complications such as pancreatic fistula, abdominal bleeding, abdominal infection and delayed gastric emptying were not significantly different between the two groups (χ2 = 0.181, 0.322, 0.603, and 0.001, respectively). Conclusion Pancreaticoduodenectomy without pancreatic duct stenting is safe and reliable and can reduce the operative time and hospital stay. No significant differences were observed in the incidence of postoperative complications.
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Affiliation(s)
- Xiong Bin
- 2 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chong Qing, China
| | - Bai Lian
- 1 The Second Department of General Surgery, Yongchuan Hospital of Chongqing Medical University, Chong Qing, China
| | - Gong Jianping
- 2 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chong Qing, China
| | - Tu Bin
- 2 Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chong Qing, China
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Pedrazzoli S. Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore) 2017; 96:e6858. [PMID: 28489778 PMCID: PMC5428612 DOI: 10.1097/md.0000000000006858] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is one of the most technically demanding operations challenging surgeons, and a postoperative pancreatic fistula (POPF) can complicate an otherwise uneventful postoperative (PO) course. This review examined the methods and procedures used to prevent postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). METHODS A comprehensive systematic search of the literature was performed using PubMed (Medline), Embase, Web of science, and the Cochrane databases for studies published between January 1, 1990 and December 31, 2015. English language articles involving at least 100 patients undergoing PDs carried out in centers performing at least 10 PDs/y were screened for data regarding the Grade of any POPFs according to the definition of the International Study Group on Pancreatic Fistula (ISGPF) and the overall rate of PO mortality related to POPF. RESULTS We reviewed 7119 references through the major databases, and an additional 841 studies were identified by cross-checking the bibliographies of the full-text articles retrieved. After excluding 7379 out of 7960 studies, because they did not meet the eligibility criteria, the full texts of 581 articles were examined; 96 studies were excluded at this point, because they concerned partially or totally duplicate data that had already been reported. The remaining 485 articles were screened carefully for POPF-related mortality and POPF Grades as defined by the ISGPF. Of the 485 articles, 208 reported the POPF-related PO mortality rate and 162 the Grades (A, B, and C) of POPFs in 60,739 and 54,232 patients, respectively. The POPF-related mortality rates after pancreatojejunostomy and pancreatogastrostomy were similar but were less (0.5% vs. 1%; P = .014) when an externally draining, trans-anastomotic stent was placed intraoperatively. The incidence of the different Grades of POPF Grade was quite variable, but Grade C POPFs were associated with a PO mortality rate of 25.7% (range 0-100%). CONCLUSIONS The POPF-related mortality rate has remained at approximately 1% over the past 25 years. Only externally draining, trans-anastomotic stents decreased the POPF-related mortality rate. However, adequately designed venting drains were never tested in randomized controlled trials (RCTs).
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Tajima Y, Kawabata Y, Hirahara N. Preoperative imaging evaluation of pancreatic pathologies for the objective prediction of pancreatic fistula after pancreaticoduodenectomy. Surg Today 2017; 48:140-150. [DOI: 10.1007/s00595-017-1529-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 03/31/2017] [Indexed: 12/13/2022]
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Deng LH, Xiong JJ, Xia Q. Isolated Roux-en-Y pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis. J Evid Based Med 2017; 10:37-45. [PMID: 27314553 DOI: 10.1111/jebm.12202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/07/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the advantage between isolated Roux loop pancreaticojejunostomy (IPJ) and conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy (PD). METHODS Comparative studies on this topic published between January 1976 and April 2015 in PubMed, EMbase, EBSCO, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched, and selected based on specific inclusion and exclusion criteria. Perioperative outcomes such as postoperative pancreatic fistula, delayed gastric emptying, operation time, intraoperative blood loss, intraoperative blood transfusion, postoperative bleeding, intra-abdominal abscess, bile leakage, wound infection, morbidity and mortality were compared. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95% confidence interval (CI) were calculated using either fixed- or random-effects model. RESULTS Six studies were included with two randomized controlled and four nonrandomized trials. A total of 712 patients (359 patients from the IPJ group and 353 patients from the CPJ group) were analyzed. The pooled results revealed that IPJ had longer operation time (WMD = 36.55, 95% CI 6.98 to 66.11, P = 0.02). However, there were no significant differences between both groups in postoperative pancreatic fistula, intraoperative blood loss, blood transfusion, delayed gastric emptying, postoperative bleeding, intra-abdominal abscess, bile leakage, wound infection, morbidity, mortality and postoperative hospital stay. CONCLUSIONS PD with IPJ was comparable to CPJ in intraoperative outcomes and postoperative complications. However, further randomized controlled trials should be undertaken to ascertain these findings.
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Affiliation(s)
- Li Hui Deng
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Jie Xiong
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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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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Zhang H, Tan C, Wang X, Kang D, Chen Y, Xiong J, Tian B, Li K, Hu W, Chen X, Ke N, Li A, Liu X. Preventive effects of ulinastatin on complications related to pancreaticoduodenectomy: A Consort-prospective, randomized, double-blind, placebo-controlled trial. Medicine (Baltimore) 2016; 95:e3731. [PMID: 27310952 PMCID: PMC4998438 DOI: 10.1097/md.0000000000003731] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is one of the most common major complications after pancreaticoduodenectomy (PD). Ulinastatin is an intrinsic trypsin inhibitor and mainly used to treat acute pancreatitis, chronic recurrent pancreatitis, and acute circulatory failure. The study aims to investigate the efficacy of ulinastatin on pancreatic fistula and other complications after PD. This prospective, randomized, double-blind, placebo-controlled trial was conducted in West China Hospital of Sichuan University from December 2012 to December 2014. A total of 106 consecutive patients undergoing PD were randomly assigned to receive ulinastatin or placebo during and after the surgery for 5 days. Baseline clinical characteristics and outcomes of patients were recorded and analyzed. Ninety-two patients including 42 in the ulinastatin group and 50 in the placebo group were available for outcome assessment. The POPF rates were comparable between ulinastatin group (43%) and placebo group (26%), whereas the severe pancreatic fistula rate (grade B + C) was significantly less in ulinastatin group than that in placebo group (7% vs 24%, P = 0.045). For patients with small pancreatic duct diameter (≤3 mm), ulinastatin could significantly reduce the risk of POPF (P = 0.022). Ulinastatin had protective effects for patients undergoing PD on the prevention of severe postoperative pancreatic fistula.
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Affiliation(s)
| | | | | | - Deying Kang
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | | | | | | | | | | | | | | | - Ang Li
- Department of Pancreatic Surgery
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Dong Z, Xu J, Wang Z, Petrov MS. Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2016; 2016:CD008914. [PMID: 27153248 PMCID: PMC7156907 DOI: 10.1002/14651858.cd008914.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting, with or without replacement, is preferable. This is an update of a systematic review. OBJECTIVES To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and four major Chinese biomedical databases up to November 2015. We also searched several major trials registers. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents, replacement versus no replacement following pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. We showed the results as risk ratio (RR) or mean difference (MD), with 95% confidence interval (CI). We assessed the quality of evidence using GRADE (http://www.gradeworkinggroup.org/). MAIN RESULTS We included eight studies (1018 participants). The average age of the participants ranged from 56 to 68 years. Most of the studies were conducted in single centers in Japan (four studies), China (two studies), France (one study), and the USA (one study). The risk of bias was low or unclear for most domains across the studies. Stents versus no stentsThe effect of stents on reducing pancreatic fistula in people undergoing pancreaticoduodenectomy was uncertain due to the low quality of the evidence (RR 0.67, 95% CI 0.39 to 1.14; 605 participants; 4 studies). The risk of in-hospital mortality was 3% in people who did receive stents compared with 2% (95% CI 1% to 6%) in people who had stents (RR 0.73, 0.28 to 1.94; 605 participants; 4 studies; moderate-quality evidence). The effect of stents on reoperation was uncertain due to wide confidence intervals (RR 0.67, 0.36 to 1.22; 512 participants; 3 studies; moderate-quality evidence). We found moderate-quality evidence that using stents reduces total hospital stay by just under four days (mean difference (MD) -3.68, 95% CI -6.52 to -0.84; 605 participants; 4 studies). The risk of delayed gastric emptying, wound infection, and intra-abdominal abscess was uncertain (gastric emptying: RR 0.75, 95% CI 0.24 to 2.35; moderate-quality evidence) (wound infection: RR 0.73, 95% CI 0.40 to 1.32; moderate-quality evidence) (abscess: RR 1.38, 0.49 to 3.85; low-quality evidence). Subgroup analysis by type of stent provided limited evidence that external stents lead to lower risk of fistula compared with internal stents. External versus internal stentsThe effect of external stents on the risk of pancreatic fistula, reoperation, delayed gastric emptying, and intra-abdominal abscess compared with internal stents was uncertain due to low-quality evidence (fistula: RR 1.44, 0.94 to 2.21; 362 participants; 3 studies) (reoperation: RR 2.02, 95% CI 0.38 to 10.79; 319 participants; 3 studies) (gastric emptying: RR 1.65, 0.66 to 4.09; 362 participants; 3 studies) (abscess: RR 1.91, 95% CI 0.80 to 4.58; 362 participants; 3 studies). The rate of in-hospital mortality was lower in studies comparing internal and external stents than in those comparing stents with no stents. One death occurred in the external-stent group (RR 0.33, 0.01 to 7.99; low-quality evidence). There were no cases of pancreatitis in participants who had internal stents compared with three in those who had external stents (RR 0.15, 0.01 to 2.73; low-quality evidence). The difference between internal and external stents on total hospital stay was uncertain due to the wide confidence intervals around the average effect of 1.7 days fewer with internal stents (9.18 days fewer to 5.84 days longer; 262 participants; 2 studies; low-quality evidence). The analysis of wound infection could not exclude a protective effect with either approach (RR 1.41, 0.44 to 4.48; 319 participants; 2 studies; moderate-quality evidence). Operative replacement of pancreatic juice versus not replacing pancreatic juice There was insufficient evidence available from a small trial to ascertain the effect of replacing pancreatic juice. AUTHORS' CONCLUSIONS This systematic review has identified limited evidence on the effects of stents. We have not been able to identify convincing direct evidence of superiority of external over internal stents. We found a limited number of RCTs with small sample sizes. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.
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Affiliation(s)
- Zhiyong Dong
- The First Affiliated Hospital of Jinan UniversityDepartment of SurgeryNo.613, HuangPu Avenu WestGuangzhouGuangdongChina510630
- Affiliated Hospital of Pu Tian UniversityDepartment of SurgeryNo. 999, Dongzhen RoadPutianFujian ProvinceChina351100
- The First Affiliated Hospital of Guangxi Medical UniversityHepato‐Pancreato‐Biliary SurgeryNanningChina
| | - Jing Xu
- The First Affiliated Hospital of Guangxi Medical UniversityHepato‐Pancreato‐Biliary SurgeryNanningChina
| | - Zhen Wang
- The First Affiliated Hospital of Guangxi Medical UniversityDepartment of Gastrointestinal SurgeryNo.6, Shuang Yong RoadNanningGuangxiChina530021
| | - Maxim S Petrov
- The University of AucklandDepartment of SurgeryPrivate Bag 92019AucklandNew Zealand1142
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Xiong J, Szatmary P, Huang W, de la Iglesia-Garcia D, Nunes QM, Xia Q, Hu W, Sutton R, Liu X, Raraty MG. Enhanced Recovery After Surgery Program in Patients Undergoing Pancreaticoduodenectomy: A PRISMA-Compliant Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3497. [PMID: 27149448 PMCID: PMC4863765 DOI: 10.1097/md.0000000000003497] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) pathways are multimodal, evidence-based approaches to optimize patient outcome after surgery. However, the use of ERAS protocols to improve morbidity and recovery time without compromising safety following pancreaticoduodenectomy (PD) remains to be elucidated.We conducted a systemic review and meta-analysis to assess the safety and efficacy of ERAS protocols compared with conventional perioperative care (CPC) in patients following PD.PubMed, Medline, Embase, and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched between January 2000 and June 2015.The patients who underwent PD with ERAS protocols or CPC were eligible. The studies that compared postoperative length of hospital stay (PLOS), postoperative complications, or in-hospital costs in the 2 groups were included.A meta-analysis, meta-regression, sensitivity analysis, and subgroup analysis were performed to estimate the postoperative outcomes between the 2 groups and identified the potential confounders. We used the methodological index for nonrandomized studies checklist to assess methodological qualities. Weighted mean differences (WMD) or odds ratios (OR) were calculated with their corresponding 95% confidence intervals (CI). The publication bias tests were also performed through the funnel plots.In total, 14 nonrandomized comparative studies with 1409 ERAS cases and 1310 controls were analyzed. Implementation of an ERAS protocol significantly reduced PLOS (WMD: -4.17 days; 95%CI: -5.72 to -2.61), delayed gastric emptying (OR: 0.56; 95%CI: 0.44-0.71), overall morbidity (OR: 0.63; 95% CI: 0.54-0.74), and in-hospital costs compared to CPC (all P < 0.001). There were no statistically significant differences in other postoperative outcomes. Age, gender, and ERAS component implementation did not significantly contribute to heterogeneity for PLOS as shown by meta-regression analysis.Our study suggested that ERAS was as safe as CPC and improved recovery of patients undergoing PD, thus reducing in-hospital costs. General adoption of ERAS protocols during PD should be recommended.
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Affiliation(s)
- Junjie Xiong
- From the Department of Pancreatic Surgery (JJX, WMH, XBL); Department of Integrated Traditional and Western Medicine (WH, QX), Sichuan Provincial Pancreatitis Center, West China Hospital, Sichuan University, Chengdu, China; NIHR Liverpool Pancreas Biomedical Research Unit (PS, QMN, RS, MGR), Royal Liverpool University Hospital, Liverpool, UK; and Department of Gastroenterology and Hepatology (DI-G), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
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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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Jang JY, Chang YR, Kim SW, Choi SH, Park SJ, Lee SE, Lim CS, Kang MJ, Lee H, Heo JS. Randomized multicentre trial comparing external and internal pancreatic stenting during pancreaticoduodenectomy. Br J Surg 2016; 103:668-675. [PMID: 27040594 DOI: 10.1002/bjs.10160] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 01/22/2016] [Accepted: 02/12/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is no consensus on the best method of preventing postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). This multicentre, parallel group, randomized equivalence trial investigated the effect of two ways of pancreatic stenting after PD on the rate of POPF. METHODS Patients undergoing elective PD or pylorus-preserving PD with duct-to-mucosa pancreaticojejunostomy were enrolled from four tertiary referral hospitals. Randomization was stratified according to surgeon with a 1 : 1 allocation ratio to avoid any related technical factors. The primary endpoint was clinically relevant POPF rate. Secondary endpoints were nutritional index, remnant pancreatic volume, long-term complications and quality of life 2 years after PD. RESULTS A total of 328 patients were randomized to the external (164 patients) or internal (164) stent group between August 2010 and January 2014. The rates of clinically relevant POPF were 24·4 per cent in the external and 18·9 per cent in the internal stent group (risk difference 5·5 per cent). As the 90 per cent confidence interval (-2·0 to 13·0 per cent) did not fall within the predefined equivalence limits (-10 to 10 per cent), the clinically relevant POPF rates in the two groups were not equivalent. Similar results were observed for patients with soft pancreatic texture and high fistula risk score. Other postoperative outcomes were comparable between the two groups. Five stent-related complications occurred in the external stent group. Multivariable analysis revealed that soft pancreatic texture, non-pancreatic disease and high body mass index (23·3 kg/m2 or above) predicted clinically relevant POPF. CONCLUSION External stenting after PD was associated with a higher rate of clinically relevant POPF than internal stenting. Registration number: NCT01023594 (https://www.clinicaltrials.gov).
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Affiliation(s)
- J-Y Jang
- Departments of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Y R Chang
- Departments of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - S-W Kim
- Departments of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - S H Choi
- Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - S J Park
- Centre for Liver Cancer, National Cancer Centre, Gyeonggido, Republic of Korea
| | - S E Lee
- Chung-Ang University Hospital, Seoul, Republic of Korea
| | - C-S Lim
- Departments of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - M J Kang
- Departments of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - H Lee
- Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - J S Heo
- Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Kitahata Y, Kawai M, Yamaue H. Clinical trials to reduce pancreatic fistula after pancreatic surgery-review of randomized controlled trials. Transl Gastroenterol Hepatol 2016; 1:4. [PMID: 28138572 DOI: 10.21037/tgh.2016.03.19] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/01/2016] [Indexed: 12/17/2022] Open
Abstract
Pancreatic fistula is one of severe postoperative complications that occur after pancreatic surgery, such as pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). Because pancreatic fistula is associated with a higher incidence of life-threatening complications. In order to evaluate procedure or postoperative management to reduce pancreatic fistula after pancreatic surgery, we summarized some randomized controlled trials (RCTs) regarding pancreaticoenterostomy during PD, pancreatic duct stent during PD, procedure to resect pancreatic parenchyma during DP, and somatostatin and somatostatin analogues after pancreatic surgery. At first, we reviewed nine RCTs to compare pancreaticogastrostomy (PG) with pancreaticojejunostomy (PJ) during PD. Next, we reviewed five RCTs, to evaluate the impact of pancreatic duct stent during PD. Regarding DP, we reviewed six RCTs to evaluate appropriate procedure to reduce pancreatic fistula after DP. Finally, we reviewed eight RCTs to evaluate the impact of somatostatin and somatostatin analogues after pancreatic surgery to reduce pancreatic fistula. The best way to prevent pancreatic fistula after pancreatic surgery remains still controversial. However, several RCTs clarify a useful procedure to reduce in reducing the incidence of pancreatic fistula after pancreatic surgery. Further RCTs to study innovative approaches remain a high priority for pancreatic surgeons to prevent pancreatic fistula after pancreatic surgery.
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Affiliation(s)
- Yuji Kitahata
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
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45
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Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
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46
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Wang G, Li L, Ma Y, Qu FZ, Zhu H, Lv JC, Jia YH, Wu LF, Sun B. External Versus Internal Pancreatic Duct Drainage for the Early Efficacy After Pancreaticoduodenectomy: A Retrospectively Comparative Study. J INVEST SURG 2016; 29:226-33. [DOI: 10.3109/08941939.2015.1105327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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47
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Park SH, Kim JH, Noh SY, Byun JH, Lee SS, Kim HJ, Park SH, Lee SK, Hwang DW, Kim SC, Han DJ, Lee MG. Migration of Internal Pancreaticojejunostomy Stents into the Bile Ducts in Patients Undergoing Pancreatoduodenectomy. J Gastrointest Surg 2015; 19:1995-2002. [PMID: 26245635 DOI: 10.1007/s11605-015-2906-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/28/2015] [Indexed: 01/31/2023]
Abstract
PURPOSE To investigate the incidence, complications, and risk factors of the migration of internal pancreaticojejunostomy (PJ) stents into the bile ducts in patients undergoing pancreatoduodenectomy. METHODS Postoperative computed tomography (CT) and clinical data of 802 patients with CT-detectable internal PJ stents were reviewed to assess the occurrence of stent migration into the bile ducts and stent-induced complications with their clinical significance. Risk factors for stent migration and stent-induced complications were determined. RESULTS Stent migration into the bile ducts occurred in 135 patients (16.8 %); 40 of these (29.6 %) showed stent-induced complications including bile duct stricture, stone, and liver abscess. Clinically significant complications were identified in only eight patients. Neither the stent length nor diameter was associated with stent migration. A small stent diameter, peripheral location of the stent, absence of stent remigration from the bile ducts to the intestine, and longer stent retention time in the bile ducts were risk factors of stent-induced complications. CONCLUSIONS The incidence of internal PJ stent migration into the bile ducts was 16.8 %. Migrated stents frequently caused complications, although they were mostly subclinical. Stent-induced complications were associated with stent diameter and location, stent remigration to the intestine, and stent retention time in the bile ducts.
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Affiliation(s)
- So Hyun Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Jin Hee Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea.
| | - Seung Yeon Noh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Hyoung Jung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Sung Koo Lee
- Department of Internal Medicine, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Dae Wook Hwang
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Song Cheol Kim
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
| | - Moon-Gyu Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, College of Medicine, University of Ulsan, 88 Olympic-ro, 43-gil, Songpa-Gu, Seoul, 138-736, South Korea
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Romano G, Agrusa A, Galia M, Di Buono G, Chianetta D, Sorce V, Gulotta L, Brancatelli G, Gulotta G. Whipple's pancreaticoduodenectomy: Surgical technique and perioperative clinical outcomes in a single center. Int J Surg 2015; 21 Suppl 1:S68-71. [PMID: 26122590 DOI: 10.1016/j.ijsu.2015.06.062] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 03/25/2015] [Accepted: 04/10/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Pancreatic cancer is the fourth cause of death from cancer in Western countries. The radical surgical resection is the only curative option for this pathology. The prevalence of this disease increases with age in population. The causes of pancreatic cancer are unknown, but we consider risk factors like smoke and tobacco usage, alcohol consumption coffee, history of diabetes or chronic pancreatitis. In this study we report our experience in the treatment of resectable pancreatic cancer and periampullary neoplasms with particular attention to evaluate the evolution of surgical technique and the clinical postoperative outcomes. METHODS In our Department between January 2010 and December 2014 we performed a total of 97 pancreaticoduodenectomy. We considered only resectable pancreatic cancer and periampullary neoplasms defined by absence of distant metastases, absence of local tumor extension to the celiac axis and hepatic artery as the lack of involvement of the superior mesenteric vasculature. None of these patients received neoadjuvant chemotherapy. RESULTS The mean age of these patients was 64.5 years. Jaundice was the commonest presenting symptom associated to anorexia and weight loss. The mean operative time was 295 min (± 55 min). The mean blood loss was 450 ml and median blood transfusion was 1 units. 12.1% of patients had an intra-abdominal complication. The commonest complication was Delayed Gastric Emptying responsable of increased length of hospital stay and readmission rate. Postoperative pancreatic fistula of grade C occurred in 4 patients. 2 patients developed a postpancreatectomy hemorrhage. Perioperative mortality was 4.1%. CONCLUSION Pancreaticoduodenectomy is a complex surgical technique and the associated high morbidity and mortality resulted in initial reluctance to adopt this surgery for the management of pancreatic and periampullary tumors. Surgical outcomes of pancreatic surgery are better at high-volume experienced center reporting mortality rates below 5%. We perform an end-to-side duct-to-mucosa pancreaticojejunostomy with routinely use of internal pancreatic stent. However no one technique has been shown to definitely be the solution to the problem of postoperative pancreatic fistula. At our center we have a reasonable volume and our data are comparable to literature data.
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Affiliation(s)
- Giorgio Romano
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy.
| | - Antonino Agrusa
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy.
| | - Massimo Galia
- Section of Radiology, Di.Bi.Me.F., University of Palermo, Italy.
| | - Giuseppe Di Buono
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy.
| | - Daniela Chianetta
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy.
| | - Vincenzo Sorce
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy.
| | - Leonardo Gulotta
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy
| | | | - Gaspare Gulotta
- Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy.
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Matsuda M, Haruta S, Shinohara H, Sasaki K, Watanabe G. Pancreaticogastrostomy in pure laparoscopic pancreaticoduodenectomy--A novel pancreatic-gastric anastomosis technique. BMC Surg 2015; 15:80. [PMID: 26133767 PMCID: PMC4487839 DOI: 10.1186/s12893-015-0061-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 06/01/2015] [Indexed: 12/25/2022] Open
Abstract
Background Although many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not commonly performed because of the technical difficulty of pancreatic resection and the associated reconstruction procedures. Several pancreatic-enteric anastomosis techniques for LPD have been reported, but most are adaptations of open procedures. To accomplish pure LPD, we consider it necessary to establish new pancreatic-enteric anastomosis techniques that are specifically developed for LPD and are safe and feasible to perform. Results One patient developed a postoperative pancreatic fistula (International Study Group of Pancreatic Fistula criteria, grade B) and subsequent postoperative delayed gastric emptying (International Study Group of Pancreatic Surgery criteria, grade C). No other major complications occurred. We developed a novel pancreatic-gastric anastomosis technique that enabled us to safely perform pure LPD. The main pancreatic duct was stented with a 4-Fr polyvinyl catheter during pancreatic resection. A small hole was created in the posterior wall of the stomach and was bluntly dilated. A 5-cm incision was made in the anterior stomach, and the pancreatic drainage tube was passed into the stomach through the hole in the posterior wall. The remnant pancreas was pulled into the stomach, and was easily positioned and secured in place with only four to six sutures between the pancreatic capsule and the gastric mucosa. We used this technique to perform pure LPD in five patients between December 2012 and July 2013. Conclusions Our new technique is technically easy and provides secure fixation between the gastric wall and the pancreas. This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized. Although this technique requires further investigation as it may increase the risk of delayed gastric emptying, it may be a useful method of performing pancreaticogastrostomy in pure LPD. Trial registration ISRCTN16761283. Registered 16 January 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12893-015-0061-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Masamichi Matsuda
- Department of Surgery, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan.
| | - Shusuke Haruta
- Department of Surgery, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | - Hisashi Shinohara
- Department of Surgery, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | - Kazunari Sasaki
- Department of Surgery, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
| | - Goro Watanabe
- Department of Surgery, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan
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50
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Cyr DP, Truong JL, Lam-McCulloch J, Cleary SP, Karanicolas PJ. Canadian practice patterns for pancreaticoduodenectomy. Can J Surg 2015; 58:121-7. [PMID: 25799248 DOI: 10.1503/cjs.011714] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Discordant practice patterns may be a consequence of evidence-practice gaps or deficiencies in knowledge translation. We examined the current strategies used by hepato-pancreatico-biliary (HPB) surgeons in Canada for the perioperative management of pancreaticoduodenectomy (PD). METHODS We generated a web-based survey that focused on the perioperative measures surrounding PD. The survey was distributed to all members of the Canadian Hepato-Pancreatico-Biliary Association. RESULTS The survey was distributed to 74 surgeons and received a response rate of 50%. Many similarities in surgical techniques were reported; for example, most surgeons (86.5%) reconstruct the pancreas with pancreaticojejunostomy rather than pancreaticogastrostomy. In contrast, variable techniques regarding the use of peritoneal drainage tubes, anastomotic stents, octreotide and other intraoperative modalities were reported. Most surgeons (75.7%) reported that their patients frequently required preoperative biliary drainage, yet there was minimal agreement with the designated criteria. There was variability in postoperative care, including the use of epidural analgesia and timing of postoperative oral nutrition. CONCLUSION We identified heterogeneity among Canadian HPB surgeons, suggesting a number of evidence-practice gaps within specific domains of pancreatic resections. Focused research in these areas may facilitate technical agreement and improve patient outcomes following PD.
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Affiliation(s)
- David P Cyr
- The Department of Surgery, University of Toronto and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Jessica L Truong
- The Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Jenny Lam-McCulloch
- The Department of Surgery, University of Toronto and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
| | - Sean P Cleary
- The Department of Surgery, University of Toronto, and the Department of Surgery, University Health Network, Toronto, Ont
| | - Paul J Karanicolas
- The Department of Surgery, University of Toronto, and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont
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