Effect of Jejunal and Biliary Decompression on Postoperative Complications and Pancreatic Leakage Arising from Pancreatojejunostomy after Pancreatoduodenectomy

Lung adenocarcinoma metastasis to pancreas after the absence of primary tumour for almost two years

This case report can argue in favour of optimal surgical management for isolated metastases to the pancreas, especially in patients with low surgical risk.

Efficacy of Enteral Nutrition by Double Elementary Diet Tube after Pylorus-Preserving Pancreatoduodenectomy

Nutritional support after pylorus-preserving pancreaticoduodenectomy (PpPD) is still controversial. This study aimed to evaluate the efficacy of enteral nutrition (EN) via the double elementary diet (W-ED) tube after PpPD. One hundred two patients who received EN by the W-ED tube were compared with 52 patients who received total parental nutrition (TPN) previously. Clinicopatho-logical and postoperative features were analyzed among the two groups. Patients with EN by the W-ED tube after PpPD had a lower incidence of postoperative pancreatic fistula than those with TPN. The total protein and albumin levels on discharge in the EN group were significantly higher than those in the TPN group. In the case without complication, decreasing rate of the third lumbar vertebra skeletal muscle area was significantly lower in the EN group. In the cases of soft pancreas, drainage volume by the W-ED tube until four postoperative day was significantly larger in the case without postoperative pancreatic fistula. The W-ED tube offers the advantages of reducing gastrointestinal pressure and enabling reduction of complications after PpPD surgery.

Meta-analysis of an artery-first approach versus standard pancreatoduodenectomy on perioperative outcomes and survival

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate perioperative outcomes and survival in patients undergoing an artery-first approach to pancreatoduodenectomy in comparison with those having standard pancreatoduodenectomy.

METHODS

A systematic search of PubMed, MEDLINE, Embase and the Cochrane Database of Systematic Reviews was performed in accordance with PRISMA guidelines. Comparative studies including patients who underwent artery-first pancreatoduodenectomy and standard pancreatoduodenectomy were analysed.

RESULTS

Seventeen studies were included in the final analysis. There were 16 retrospective cohort or case-control studies and one RCT. A total of 1472 patients were included in the meta-analysis, of whom 771 underwent artery-first pancreatoduodenectomy and 701 had standard pancreatoduodenectomy. Intraoperative blood loss (mean difference -389 ml; P < 0·001) and the proportion of patients requiring intraoperative transfusion (10·6 per cent (54 of 508) versus 40·1 per cent (186 of 464); P < 0·001) were significantly lower in the artery-first group. Although rates of perioperative mortality were comparable between the two groups, perioperative morbidity (35·5 per cent (263 of 741) versus 44·3 per cent (277 of 625); P = 0·002), and the incidence of grade B/C pancreatic fistula (7·4 per cent (26 of 353) versus 12·8 per cent (42 of 327); P = 0·031) were significantly lower in the artery-first group. The R0 resection rate (75·8 per cent (269 of 355) versus 67·0 per cent (280 of 418); P < 0·001) and overall survival (hazard ratio 0·72, 95 per cent c.i. 0·60 to 0·87; P < 0·001) were significantly higher in the artery-first group.

CONCLUSION

The artery-first approach to pancreatoduodenectomy may be associated with improved perioperative outcomes and survival.

Three hundred and sixty-eight consecutive pancreaticoduodenectomies with zero mortality

BACKGROUND

Only a limited number of reports have documented zero mortality in consecutive pancreaticoduodenectomy series. The aim of this study is to review and verify our management aiming to eliminate mortality after pancreaticoduodenectomy.

METHODS

Three hundred and sixty-eight consecutive patients undergoing pancreaticoduodenectomy between 2002 and 2015 were retrospectively reviewed. During this period, in order to enhance the safety of pancreaticoduodenectomy, we have used a consistent strategy consisting of early ligation of the inferior pancreatoduodenal artery, mucosal sutureless pancreaticojejunostomy combined with external pancreatic duct stenting, conditional two-stage pancreaticojejunostomy, jejunal decompression using tube jejunostomy, application of an omental flap to cover the stump of the gastroduodenal artery, and careful postoperative drain management.

RESULTS

Major postoperative complications (Clavien-Dindo grade ≥ IIIa) occurred in 20 patients (5%). Grade A/B/C pancreatic fistula was observed in 49/29/4 patients (13%/8%/1%), respectively. Reoperation and readmission was necessary in five and four patients (1% and 1%), respectively. There was no in-hospital or 90-day mortality.

CONCLUSIONS

To achieve zero mortality in pancreaticoduodenectomy, it is crucial to incorporate various strategies to minimize the degree of surgical invasiveness and the damage caused by pancreatic fistula with a meticulous approach to perioperative management.

Factors influencing clinically significant delayed gastric emptying after subtotal stomach-preserving pancreatoduodenectomy

BACKGROUND

Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pylorus ring is resected and most of the stomach is preserved, has been performed recently in Japan. This study was undertaken to clarify the incidence of delayed gastric emptying (DGE) after SSPPD at a high-volume hospital and to determine the independent factors that influence the development of DGE after SSPPD.

METHODS

Between 2002 and 2011, 201 consecutive patients underwent standardized SSPPD. After SSPPD, DGE (defined according to the International Study Group of Pancreatic Surgery) was analyzed, and associated variables were assessed by univariate and multivariate analyses, retrospectively.

RESULTS

Clinically significant DGE (grades B and C) occurred in 35 (17 %) of the 201 patients; 26 patients had other accompanying abdominal complications (secondary DGE), and pancreatic leakage was the sole risk factor for DGE (odds ratio 6.63, 95 % CI 2.86-15.74; p < 0.001). Only nine (4 % of all patients) of the 35 patients with clinically significant DGE were classified as having DGE that had arisen without any obvious etiology (primary DGE).

CONCLUSIONS

DGE after SSPPD is strongly linked to the occurrence of other postoperative intra-abdominal complications such as pancreatic fistula. The incidence rate of primary DGE after SSPPD was 4 %. Although the ISGPS classification of DGE is clearly applicable, the grades do not explain why DGE occurs. Primary and secondary DGE should therefore be defined separately.

Validation of Mucosal Sutureless Pancreatojejunostomy after Pancreatoduodenectomy

Although duct-to-mucosa pancreatojejunostomy has been considered safer than other techniques, this procedure is particularly difficult when the pancreatic duct is small. It has therefore become increasingly necessary to develop a simple mucosal sutureless pancreatojejunostomy technique to replace the conventional hand-sewing one. Two hundred fourteen patients who underwent mucosal sutureless pancreatojejunostomy were classified into two groups: those with a normal pancreatic duct diameter (less than 3 mm, n = 97) and those with a dilated pancreatic duct (3 mm or greater, n = 117). The rate of clinically significant pancreatic fistula (Grade B or C by the International Study Group on Pancreatic Fistula definition) among the patients as a whole was 8 per cent. The overall incidence of pancreatic fistula was significantly higher in the patients with a pancreatic duct diameter of less than 3 mm than in those with a pancreatic duct diameter of 3 mm or greater. However, the incidence of clinically significant pancreatic fistula did not differ between the groups (less than 3 mm, 11%; 3 mm or greater, 5%; P = 0.09). Grade C pancreatic fistula developed in one patient with a pancreatic duct diameter of less than 3 mm and in two with a pancreatic duct diameter 3 mm or greater. Although two patients required reoperation, all of the fistulas were cured and the postoperative mortality rate related to pancreatoduodenectomy was zero. Mucosal sutureless pancreatojejunostomy combined with pancreatic duct stenting is associated with a low rate of clinically significant pancreatic fistula even in patients with a small pancreatic duct diameter less than 3 mm.

Development of hepatic steatosis after pancreatoduodenectomy

OBJECTIVE

To determine the effects of pancreatoduodenectomy on hepatic fat content, hepatic CT attenuation was evaluated after pancreatoduodenectomy.

CONCLUSION

Pancreatoduodenectomy had a significant influence on hepatic fat content and was associated with frequent occurrence of hepatic steatosis, which was easily recognized with CT.