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Wong A, Sim N, Kam J, Rajarethinam R, Tan B, Tan A. The primary prevention of pancreatic fistula using a vascularised rectus abdominis muscle flap - A porcine model. JPRAS Open 2024; 40:150-157. [PMID: 38533305 PMCID: PMC10963183 DOI: 10.1016/j.jpra.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/11/2024] [Indexed: 03/28/2024] Open
Abstract
Background A pancreatic fistula is one of the most devastating complications following a Whipple's procedure. Fistula rates remain high despite various modifications to surgical techniques. We propose the use of a vascularised muscle flap in the primary prevention of pancreatic fistulas. Method A distal pancreatectomy was performed on 5 pigs in our porcine model. A pancreaticojejunal (PJ) anastomotic leak was simulated. The pigs were divided into treatment (4 pigs) and control groups (1 pig). A left pedicled rectus abdominis flap was wrapped around the PJ anastomosis for the treatment group and omitted for the control group. Serum and drain amylase levels were recorded. The PJ-rectus abdominis flap complex was evaluated histologically. Results There was no biochemical evidence of anastomotic leak in the treatment group. The drain-serum amylase ratio was less than 1.5 in the treatment group (p=0.006). Microscopically, the muscle adjacent to the anastomotic leak showed mild necrotic changes with an affected muscle depth of less than 10%. Conclusion The vascularised rectus abdominis muscle is a durable flap to withstand proteolytic pancreatic enzymes. It is able to provide a water-tight seal around the PJ anastomosis and mitigate intraperitoneal haemorrhage and infection caused by erosion from the pancreatic fistula.
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Affiliation(s)
- A.W.J. Wong
- Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
| | - N.H.S. Sim
- Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
| | - J.H. Kam
- Hepato Pancreato Biliary Service, Department of General Surgery, Sengkang General Hospital, Singapore
| | - R. Rajarethinam
- Institute of Molecular and Cell Biology (IMCB), Agency for Science, Technology and Research (A*STAR), Singapore
| | - B.K. Tan
- Department of Plastic, Reconstructive & Aesthetic Surgery, Singapore General Hospital, Singapore
| | - A.Y.H. Tan
- Hepato Pancreato Biliary Service, Department of General Surgery, Sengkang General Hospital, Singapore
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Liang Z, Lan M, Xu X, Liu F, Tao B, Wang X, Zeng J. Case Report: Robotic pylorus-preserving pancreatoduodenectomy for periampullary rhabdomyosarcoma in a 3-year-old patient. Front Surg 2024; 11:1284257. [PMID: 38440415 PMCID: PMC10910038 DOI: 10.3389/fsurg.2024.1284257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 02/02/2024] [Indexed: 03/06/2024] Open
Abstract
Periampullary neoplasm is rare in pediatric patients and has constituted a strict indication for pancreatoduodenectomy (PD), which is a procedure sporadically reported in the literature among children. Robotic PD has been routinely performed for periampullary neoplasm in periampullary neoplasm, but only a few cases in pediatric patients have been reported. Here, we report the case of a 3-year-old patient with periampullary rhabdomyosarcoma treated with robotic pylorus-preserving PD and share our experience with this procedure in pediatric patients. A 3-year-old patient presented with obstructive jaundice and a mass in the pancreatic head revealed by imaging. A laparoscopic biopsy was performed. Jaundice progressed with abdominal pain and elevated alpha-amylase leading to urgent robotic exploration in which a periampullary neoplasm was revealed and pathologically diagnosed as rhabdomyosarcoma by frozen section examination. After pylorus-preserving PD, we performed a conventional jejunal loop following a child reconstruction, including an end-to-end pancreaticojejunostomy, followed by end-to-side hepaticojejunostomy and duodenojejunostomy. Delayed gastric emptying (DGE) presented with increasing drain from the nasogastric tube (NGT) a week after the surgery and improved spontaneously within 10 days. In a 13-month follow-up until the present, our case patient recovered well without potentially fatal complications, such as pancreatic fistula. Robotic PD in pediatric patients was safe and effective without intra- or postoperative complications.
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Affiliation(s)
| | | | | | | | | | | | - Jixiao Zeng
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
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Wu JY, Zheng Y, Li YN, Yan ML. Double-Stitch Full-Layer Pancreaticojejunostomy: a Novel Pancreatic Remnant Reconstruction Method for Laparoscopic Pancreaticoduodenectomy. J Gastrointest Surg 2023; 27:2205-2208. [PMID: 37580488 DOI: 10.1007/s11605-023-05799-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/21/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Jia-Yi Wu
- Shengli Clinical Medical College, Fujian Medical University, Dongjie Road 134, Fuzhou, 350001, Fujian Province, China
- Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Dongjie Road 134, Fuzhou, 350001, Fujian Province, China
| | - Yu Zheng
- Shengli Clinical Medical College, Fujian Medical University, Dongjie Road 134, Fuzhou, 350001, Fujian Province, China
- Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Dongjie Road 134, Fuzhou, 350001, Fujian Province, China
| | - Yi-Nan Li
- Shengli Clinical Medical College, Fujian Medical University, Dongjie Road 134, Fuzhou, 350001, Fujian Province, China
| | - Mao-Lin Yan
- Shengli Clinical Medical College, Fujian Medical University, Dongjie Road 134, Fuzhou, 350001, Fujian Province, China.
- Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Dongjie Road 134, Fuzhou, 350001, Fujian Province, China.
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Mastalier B, Cauni V, Tihon C, Septimiu Petrutescu M, Ghita B, Popescu V, Andras D, Radu IM, Vlasceanu VG, Floroiu MF, Draghici C, Botezatu C, Cretoiu D, Varlas VN, Lazar AM. Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score. J Clin Med 2023; 12:6193. [PMID: 37834836 PMCID: PMC10573877 DOI: 10.3390/jcm12196193] [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: 08/12/2023] [Revised: 09/07/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.
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Affiliation(s)
- Bogdan Mastalier
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Victor Cauni
- Urology Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania;
| | - Constantin Tihon
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Marius Septimiu Petrutescu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Bogdan Ghita
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Valentin Popescu
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Dan Andras
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Ion Mircea Radu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Vasile Gabriel Vlasceanu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Marius Florian Floroiu
- Anaesthesia Intensive Care Unit, Colentina Clinical Hospital, 020125 Bucharest, Romania; (M.F.F.); (C.D.)
| | - Cristian Draghici
- Anaesthesia Intensive Care Unit, Colentina Clinical Hospital, 020125 Bucharest, Romania; (M.F.F.); (C.D.)
| | - Cristian Botezatu
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Dragos Cretoiu
- Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
- Department of Genetics, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania
| | - Valentin Nicolae Varlas
- Department of Obstetrics and Gynaecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
- Department of Obstetrics and Gynaecology, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania
| | - Angela Madalina Lazar
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
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Identification and Validation of Potentially Clinically Relevant CpG Regions within the Class 2 Tumor Suppressor Gene SFRP1 in Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15030683. [PMID: 36765639 PMCID: PMC9913221 DOI: 10.3390/cancers15030683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 01/25/2023] Open
Abstract
In pancreatic cancer treatment, tumor stage-dependent chemotherapies are used to prolong overall survival. By measuring DNA promoter hypermethylation in the plasma of patients with stage IV pancreatic cancer, it was recently shown that promoter DNA methylation of the tumor suppressor gene SFRP1 has a high value for predicting failure of drug treatment with gemcitabine. In this study, we therefore aimed to identify as precisely as possible the region in the SFRP1 promoter that is frequently hypermethylated in pancreatic cancer tissue. First, we used the TCGA data set to define CpG-rich regions flanking the SFRP1 transcription start site that were significantly more methylated in pancreatic cancer compared to normal pancreatic acinar tissue. A core CpG island was identified that exhibited abundant tumor DNA methylation and anti-correlation of SFRP1 mRNA expression. To validate our in silico results, we performed bisulfide conversion followed by DNA pyrosequencing of 28 matched formalin-fixed, paraffin-embedded (FFPE) pancreatic cancer cases and six pancreatic cancer cell lines. A defined block of seven CpG sites within the core CpG island was identified, which confirmed our in silico results by showing significantly higher SFRP1 methylation in pancreatic cancer specimens than in normal pancreatic tissue. By selecting this core CpG island, we were able to determine a median overall survival benefit for the low SFRP1 methylation group compared to the high SFRP1 methylation group (702 versus 517 days, p = 0.01) in the TCGA pancreatic cancer cohort. We propose a compact pyrosequencing assay that can be used in the future to further investigate the prognostic value of SFRP1 promoter hypermethylation in predicting pancreatic cancer chemoresistance. Therefore, instead of DNA analysis from blood (liquid biopsy), DNA easily extractable from cancer tissue blocks (FFPE material) could be used.
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A Blumgart Anastomosis-Based Half-Invagination Pancreaticoenterostomy with Better Applicability to Laparoscopy and Lower Incidence of Pancreatic Leakage. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2023; 2023:6304047. [PMID: 36873788 PMCID: PMC9981301 DOI: 10.1155/2023/6304047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 02/25/2023]
Abstract
Background The Blumgart anastomosis (BA) is one of the safest anastomoses for pancreatic stump reconstruction. The incidence of postoperative pancreatic fistula (POPF) and postoperative complications is low. However, how to make laparoscopic pancreaticoenterostomy easier and safer is still a topic to be discussed. Methods The data of patients who underwent laparoscopic pancreaticoduodenectomy (PD) from April 2014 to December 2019 were analyzed retrospectively. Results Half-invagination anastomosis was performed in 20 cases (HI group), and the Cattell-Warren anastomosis was carried out in 26 cases (CW group). The amount of intraoperative bleeding, operation time, and postoperative catheterization time in the HI group was significantly less than those in the CW group. Besides, the number of patients at the Clavien-Dindo grade III and above in the HI group was significantly less than that in the control group. Moreover, the incidence of POPF in the HI group was significantly lower than that in the CW group. Furthermore, fistula risk score (FRS) analysis showed that there was no high-risk group, and the highest risk in the medium-risk group was pancreatic leakage. In addition, the incidence of pancreatic leakage in the HI group and CW group was 7.7% and 46.67%, respectively, while the incidence of pancreatic leakage in the HI group was significantly lower than that in the CW group. Conclusions The half-invagination pancreaticoenterostomy based on the Blumgart anastomosis should have good applicability under laparoscopy and could effectively reduce the incidence of postoperative pancreatic leakage.
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Adhikari KM, Sharma D, Dahal R, Kandel BP, Lakhey PJ. Comparative Study of Perioperative Outcomes Between Modified Blumgart Duct to Mucosa and Dunking Pancreaticojejunostomy. Cureus 2023; 15:e34418. [PMID: 36874701 PMCID: PMC9978053 DOI: 10.7759/cureus.34418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Pancreaticojejunostomy (PJ) is the ''Achilles heel" of pancreaticoduodenectomy (PD) which affects perioperative as well as oncological outcomes. However, there is a lack of information about the superiority of the type of anastomosis in terms of overall morbidity and postoperative pancreatic fistula (POPF) after PD. Here, we compare the outcomes of modified Blumgart PJ with the dunking technique of PJ. METHODOLOGY A case-control study of a prospectively maintained database of 25 consecutive patients undergoing modified Blumgart PJ (study group) and 25 patients who underwent continuous dunking PJ (control group) between January 2018 to April 2021 was done. Between groups, comparisons were made for the duration of surgery, intraoperative blood loss, original fistula risk score, overall complications as graded by Clavien Dindo (CD), POPF, post pancreatectomy haemorrhage (PPH), delayed gastric emptying (DGE), and 30-day mortality at 95% confidence level. RESULTS Among 50 patients, 30 (60%) were male. The most common indication for PD was ampullary carcinoma (44% in the study group vs. 60% in the control group). The duration of surgery was approximately 41 minutes longer in the study group compared to the control (p = 0.02), while the intraoperative blood loss was similar between the two groups (496.00 ± 226.35 ml vs 508.00 ± 180.67 ml, p = 0.84). While there was no significant difference in mean fistula risk score between the two groups, the POPF (8% vs 32%, p = 0.03), PPH (0% vs 20%, p =0.02), and overall major complications (CD≥ III) according to CD Grading (12% vs 40%, p = 0.02) were significantly lower in the study group. Similarly, the duration of hospital stay in the study group was 4.64 days shorter than the control group (p = 0.001). However, there was no significant difference in the 30-day mortality between the two groups. CONCLUSIONS Modified Blumgart pancreaticojejunostomy has better perioperative outcomes in terms of procedure-specific complications like POPF, PPH, overall major postoperative complications, and duration of hospital stay.
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Affiliation(s)
- Krishna M Adhikari
- Department of Surgical Gastroenterology, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Deepak Sharma
- Department of Surgical Gastroenterology, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Romi Dahal
- Department of Surgical Gastroenterology, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Bishnu P Kandel
- Department of Surgical Gastroenterology, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, NPL
| | - Paleswan J Lakhey
- Department of Surgical Gastroenterology, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, NPL
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Dalgatov KD, Kurskov AO, Khalbaginov AA, Sazhin AV. [Pancreatodigestive anastomosis: from history to modernity]. Khirurgiia (Mosk) 2021:81-86. [PMID: 34608784 DOI: 10.17116/hirurgia202110181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This review is devoted to history of pancreatodigestive anastomoses (PDA), technique of the most popular PDA, causes of pancreatic fistula and its prevention. Contradictory data were obtained in randomized trials and meta-analyses devoted to pancreatic anastomoses. There is no optimal anastomosis excluding clinically significant postoperative pancreatic fistula. Therefore, further studies should be aimed at new approaches reducing the incidence of clinically significant postoperative pancreatic fistula.
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Affiliation(s)
- K D Dalgatov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A O Kurskov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Khalbaginov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Shinde RS, Acharya R, Chaudhari VA, Bhandare MS, Shrikhande SV. Pancreaticojejunostomy for Pancreatico-enteric Anastomosis after Pancreaticoduodenectomy: one procedure with multiple techniques. SURGERY IN PRACTICE AND SCIENCE 2020. [DOI: 10.1016/j.sipas.2020.100019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Cao Z, Luo W, Qiu J, Liu Y, Zheng L, Zhang T. Is Invagination Anastomosis More Effective in Reducing Clinically Relevant Pancreatic Fistula for Soft Pancreas After Pancreaticoduodenectomy Under Novel Fistula Criteria: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:1637. [PMID: 32974203 PMCID: PMC7471255 DOI: 10.3389/fonc.2020.01637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/27/2020] [Indexed: 12/20/2022] Open
Abstract
Objective: To define the effectiveness of different anastomosis on clinically relevant postoperative fistula in patients with soft pancreas using the newest version of the fistula definition and criteria. Background: Different criteria of clinically relevant postoperative pancreatic fistula (POPF) result in the optimal anastomosis technique remaining controversial. Methods: PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov were systematically searched up to 20 April 2020, and were evaluated by Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Randomized controlled trials comparing duct-to-mucosa anastomosis vs. invagination anastomosis in pancreatic surgery were included. Result: Seven studies involving 1,110 participants were included. Using the postoperative pancreatic fistula definition provided by the International Study Group of Pancreatic Surgery 2016, the incidence rate of grade B/C pancreatic fistula was significantly lower in patients experiencing invagination anastomosis than in those undergoing duct-to-mucosa anastomosis. Four of seven trials comparing invagination with duct-to-mucosa anastomosis in patients with a soft pancreas showed that invagination was significantly better than duct-to-mucosa anastomosis in controlling pancreatic fistula formation, but no significant difference was detected between the two anastomosis techniques in patients with a hard pancreas. No significant difference in the length of hospital stay or postoperative mortality rate was found between the two methods. Conclusion: This study demonstrated superiority of invagination anastomosis over duct-to-mucosa anastomosis in reducing the risk of Grade B/C postoperative pancreatic fistula using the ISGPS 2016 definition, but it does not significantly reduce the mortality rate or length of hospital stay. The effect of invagination in reducing pancreatic fistula formation is obvious in patients with a soft pancreas, but there is no significant difference between the two anastomosis techniques in patients with a hard pancreas. We found a lower rate of clinically relevant postoperative pancreatic fistula in the invagination group, in patients with a soft pancreas.
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Affiliation(s)
- Zhe Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenhao Luo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiangdong Qiu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yueze Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lianfang Zheng
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Menonna F, Napoli N, Kauffmann EF, Iacopi S, Gianfaldoni C, Martinelli C, Amorese G, Vistoli F, Boggi U. Additional modifications to the Blumgart pancreaticojejunostomy: Results of a propensity score-matched analysis versus Cattel-Warren pancreaticojejunostomy. Surgery 2020; 169:954-962. [PMID: 32958267 DOI: 10.1016/j.surg.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula continues to occur frequently after pancreatoduodenectomy. METHODS We have described a modification of the Blumgart pancreaticojejunostomy. The modification of the Blumgart pancreaticojejunostomy was compared to the Cattel-Warren pancreaticojejunostomy in cohorts of patients matched by propensity scores based on factors predictive of clinically relevant postoperative pancreatic fistula, which was the primary endpoint of this study. Based on a noninferiority study design, 95 open pancreatoduodenectomies per group were needed. Feasibility of the modification of the Blumgart pancreaticojejunostomy in robotic pancreatoduodenectomy was also shown. All pancreaticojejunostomies were performed by a single surgeon. RESULTS Between October 2011 and May 2019, there were 415 pancreatoduodenectomies with either a Cattel-Warren pancreaticojejunostomy (n = 225) or a modification of the Blumgart pancreaticojejunostomy (n = 190). There was 1 grade C postoperative pancreatic fistula in 190 consecutive modification of the Blumgart pancreaticojejunostomies (0.5%). Logistic regression analysis showed that the rate of clinically relevant postoperative pancreatic fistula was not affected by consecutive case number. After exclusion of robotic pancreatoduodenectomies (the Cattel-Warren pancreaticojejunostomy: 82; modification of the Blumgart pancreaticojejunostomy: 66), 267 open pancreatoduodenectomies were left, among which the matching process identified 109 pairs. The modification of the Blumgart pancreaticojejunostomy was shown to be noninferior to the Cattel-Warren pancreaticojejunostomy with respect to clinically relevant postoperative pancreatic fistula (11.9% vs 22.9%; odds ratio: 0.46 [0.21-0.93]; P = .03), grade B postoperative pancreatic fistula (11.9% vs 18.3%; P = .18), and grade C postoperative pancreatic fistula (0 vs 4.6%; P = .05) as well as to all secondary study endpoints. The modification of the Blumgart pancreaticojejunostomy was feasible in 66 robotic pancreatoduodenectomies. In this subgroup with 1 conversion to open surgery (1.5%), a clinically relevant postoperative pancreatic fistula occurred after 9 procedures (13.6%) with no case of grade C postoperative pancreatic fistula and a 90-day mortality of 3%. CONCLUSION The modification of the Blumgart pancreaticojejunostomy described herein is noninferior to the Cattel-Warren pancreaticojejunostomy in open pancreatoduodenectomy. This technique is also feasible in robotic pancreatoduodenectomy.
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Affiliation(s)
- Francesca Menonna
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Emanuele F Kauffmann
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Sara Iacopi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Caterina Martinelli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliero Universitaria Pisana. University of Pisa, Italy.
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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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Baimas-George M, Watson M, Murphy KJ, Iannitti D, Baker E, Ocuin L, Vrochides D, Martinie JB. Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study. Surg Endosc 2020; 34:3644-3649. [PMID: 32328825 DOI: 10.1007/s00464-020-07564-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The robotic platform in pancreatic disease has gained popularity in the hepatobiliary community due to significant advantages it technically offers over conventional open and laparoscopic techniques. Despite promising initial studies, there remains scant literature on operative and oncologic outcomes of robotic pancreaticoduodenectomy (RPD) for pancreatic adenocarcinoma. METHODS A retrospective review evaluated all RPD performed for pancreatic adenocarcinoma from 2008 to 2019 in a single tertiary institution. RPD cases were matched to open cases (OPD) by demographic and oncologic characteristics and outcomes compared using Mann-Whitney U test, log rank tests, and Kaplan-Meier methods. RESULTS Thirty-eight RPD cases were matched to 38 OPD. RPD had significantly higher lymph node (LN) yield (21.5 vs 13.5; p = 0.0036) and no difference in operative time or estimated blood loss (EBL). RPD had significantly lower rate of delayed gastric emptying (DGE) (3% vs 32%; p = 0.0009) but no difference in leaks, infections, hemorrhage, urinary retention ,or ileus. RPD had significantly shorter length of stay (LOS) (7.5 vs. 9; p = 0.0209). There were no differences in 30- or 90-day readmissions or 90-day mortality. There was an equivalent R0 resection rate and LN positivity ratio. There was a trend towards improved median overall survival in RPD (30.4 vs. 23.0 months; p = 0.1105) and longer time to recurrence (402 vs. 284 days; p = 0.7471). OPD had two times the local recurrent rate (16% vs. 8%) but no difference in distant recurrence. CONCLUSIONS While the feasibility and safety of RPD has been demonstrated, the impact on oncologic outcomes had yet to be investigated. We demonstrate that RPD not only offers similar if not superior immediate post-operative benefit by decreasing DGE but more importantly may offer improved oncologic outcomes. The significantly higher LN yield and decreased inflammatory response demonstrated in robotic surgery may improve overall survival.
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Affiliation(s)
- Maria Baimas-George
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith J Murphy
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lee Ocuin
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA.
- Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28203, USA.
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Low TY, Koh YX, Goh BK. First experience with robotic pancreatoduodenectomy in Singapore. Singapore Med J 2019; 61:598-604. [PMID: 31535153 DOI: 10.11622/smedj.2019119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Recent studies reported that laparoscopic pancreatoduodenectomy (LPD) is associated with superior perioperative outcomes compared to the open approach. However, concerns have been raised about the safety of LPD, especially during the learning phase. Robotic pancreatoduodenectomy (RPD) has been reported to be associated with a shorter learning curve compared to LPD. We herein present our initial experience with RPD. METHODS A retrospective review of a single-institution prospective robotic hepatopancreaticobiliary (HPB) surgery database of 70 patients identified seven consecutive RPDs performed by a single surgeon in 2016-2017. These were matched at a 1:2 ratio with 14 open pancreatoduodenectomies (OPDs) selected from 77 consecutive pancreatoduodenectomies performed by the same surgeon between 2011 and 2017. RESULTS Seven patients underwent RPD, of which five were hybrid procedures with open reconstruction. There were no open conversions. Median operative time was 710.0 (range 560.0-930.0) minutes. Two major morbidities (> Grade 2) occurred: one gastrojejunostomy bleed requiring endoscopic haemostasis and one delayed gastric emptying requiring feeding tube placement. There were no pancreatic fistulas, reoperations or 90-day/in-hospital mortalities in the RPD group. Comparison between RPD and OPD demonstrated that RPD was associated with a significantly longer operative time. Compared to open surgery, there was no significant difference in estimated blood loss, blood transfusion, postoperative stay, pancreatic fistula rates, morbidity and mortality rates, R0 resection rates, and lymph node harvest rates. CONCLUSION Our initial experience demonstrates that RPD is feasible and safe in selected patients. It can be safely adopted without any compromise in patient outcomes compared to the open approach.
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Affiliation(s)
- Tze-Yi Low
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian Kp Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
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Xiang Y, Wu J, Lin C, Yang Y, Zhang D, Xie Y, Yao X, Zhang X. Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature. Expert Rev Gastroenterol Hepatol 2019; 13:797-806. [PMID: 31282769 DOI: 10.1080/17474124.2019.1640601] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Postoperative pancreatic fistula is the most troublesome complication after pancreaticoduodenectomy, and is an on-going area of concern for pancreatic surgeons. The specific pancreatic reconstruction technique is an important factor influencing the development of postoperative pancreatic fistula after pancreaticoduodenectomy. Areas covered: In this paper, we briefly introduced the definition and relevant influencing factors of postoperative pancreatic fistula. We performed a search of all meta-analyses published in the last 5 years and all published randomized controlled trials comparing different pancreatic anastomotic techniques, and we evaluated the advantages and disadvantages of different techniques. Expert opinion: No individual anastomotic method can completely avoid postoperative pancreatic fistula. Selecting specific techniques tailored to the patient's situation intraoperatively may be key to reducing the incidence of postoperative pancreatic fistula.
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Affiliation(s)
- Yien Xiang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Jiacheng Wu
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Chao Lin
- b Department of Hepatobiliary and Pancreatic Surgery, Jilin University Third Affiliated Hospital , Changchun , Jilin , CN
| | - Yongsheng Yang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Dan Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Yingjun Xie
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xiaoxiao Yao
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xuewen Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
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16
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Lee CM, Suh YJ, Yoon SY. Retrograde installation of percutaneous transhepatic negative-pressure biliary drainage stabilizes pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective cohort study. World J Surg Oncol 2019; 17:101. [PMID: 31196100 PMCID: PMC6567420 DOI: 10.1186/s12957-019-1645-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Leakage from the pancreatoenteric anastomosis has been one of the major complications of pancreaticoduodenectomy (PD). The aim of this study was to investigate the feasibility of retrograde installation of percutaneous transhepatic negative-pressure biliary drainage (RPTNBD), as part of which the drainage tube is intraoperatively inserted into the bile duct and afferent loop by surgical guidance to reduce pancreaticoenteric leakage after PD. METHODS We retrospectively reviewed the medical records of the patients who underwent pylorus-preserving PD or Whipple's operation for a malignant disease between June 2012 and August 2016. We performed intraoperative RPTNBD to decompress the biliopancreatic limb in all patients and compared their clinical outcomes with those of internal controls. RESULTS Twenty-one patients were enrolled in this study. The operation time was 412.0 ± 92.8 min (range, 240-600 min). The duration of postoperative hospital stay was 39.4 ± 26.4 days (range, 13-105 days). Ten patients (47.6%) experienced morbidities of Clavien-Dindo grade > II, and 2 patients (9.5%) experienced pancreaticojejunostomy-related complications. The internal controls showed a higher incidence rate of pancreaticojejunostomy-related complications than the study participants (P = 0.020). Mortality occurred only in the internal controls. CONCLUSION For stabilizing the pancreaticoenteric anastomosis after PD for a malignant disease, RPTNBD is a feasible and effective procedure. When PD is combined with technically demanding procedures, including hepatectomy or vascular reconstruction, RPTNBD could prevent fulminant anastomotic failure.
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Affiliation(s)
- Chang Min Lee
- Department of Surgery, Korea University Medical Center Ansan Hospital, Ansan, 15355, Korea
| | - Yong Joon Suh
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang, 14068, Korea
| | - Sam-Youl Yoon
- Department of Surgery, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang, 14068, Korea.
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Sunagawa M, Yokoyama Y, Yamaguchi J, Ebata T, Sugawara G, Igami T, Mizuno T, Nagino M. Is constant negative pressure for external drainage of the main pancreatic duct useful in preventing pancreatic fistula following pancreatoduodenectomy? Pancreatology 2019; 19:602-607. [PMID: 30967345 DOI: 10.1016/j.pan.2019.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study sought to investigate the utility of constant negative pressure for external drainage of the main pancreatic duct in preventing postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. METHODS Only patients with soft pancreas were included. In the former period (July 2013 to May 2015), gravity dependent drainage was applied (gravity dependent drainage group), and in the latter period (June 2015 to November 2016), constant negative pressure drainage (negative pressure drainage group) was applied to the main pancreatic duct stent. RESULTS There were 37 patients in the gravity dependent drainage group and 39 patients in the negative pressure drainage group. Clinically relevant POPF occurred in 21 patients (56.8%) in the gravity dependent drainage group and 13 patients (33.3%) in the negative pressure drainage group (p = 0.040). The incidence rate of major complications (Clavien-Dindo grade > III) was significantly lower in the negative pressure drainage group (13.2%) compared to the gravity dependent drainage group (48.7%) (p = 0.001). In-hospital stay was also significantly shorter in the negative pressure drainage group compared to the gravity dependent drainage group (median 25 vs. 33 days, p = 0.024). Multivariate analysis demonstrated that the gravity dependent drainage was one of the independent risk factors for the incidence of POPF (odds ratio, 3.33; p = 0.032). CONCLUSIONS In patients with soft pancreas, the incidence rate of clinically relevant POPF may be reduced by applying constant negative pressure to the pancreatic duct stent. It also has a potential to reduce overall incidence of major complications and shorten in-hospital stay after pancreatoduodenectomy.
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Affiliation(s)
- Masaki Sunagawa
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan; Division of Perioperative Medicine, Department of Surgery, Nagoya University Graduate School of Medicine, Japan.
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Japan
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18
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Yen HH, Ho TW, Wu CH, Kuo TC, Wu JM, Yang CY, Tien YW. Late acute pancreatitis after pancreaticoduodenectomy: incidence, outcome, and risk factors. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:109-116. [PMID: 30623589 DOI: 10.1002/jhbp.606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The pancreatoenteric anastomotic stricture (PEAS) is a common long-term complication after pancreaticoduodenectomy (PD), some of which present as acute pancreatitis requiring emergency care. This important topic has never been reported. In this study, we focus on the incidence, radiological features, clinical outcome, and risk factors of late-occurring acute pancreatitis (LAP) after PD. METHODS We retrospectively reviewed a prospectively collected database of 539 patients who underwent PD at a single tertiary referral center between June 2005 and December 2014. Only patients with at least 3 years of follow-up and available pre- and post-operative images were included. RESULTS Of the 539 patients, 23 (15 [65%] with and eight [35%] without PEAS) were diagnosed with LAP after PD. The cumulative incidence of LAP was 3.6% (1-year), 4.4% (2-year), and 5.1% (5-year). The median time to the first LAP episode was 22 months (range 8-38 months) after PD. All the first and recurrent LAP events were mild in severity and resolved after conservative treatment. Multivariate analysis showed that a history of acute pancreatitis before PD (P = 0.001, HR 5.24, 95% CI 1.95-14.10) and PEAS (P = 0.047, HR 2.75, 95% CI 1.01-7.49) were two significant risk factors. CONCLUSIONS We propose using a more conservative treatment for patients who experience LAP after PD.
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Affiliation(s)
- Hung-Hsuan Yen
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Te-Wei Ho
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Chien-Hui Wu
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Ting-Chun Kuo
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Jin-Ming Wu
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Ching-Yao Yang
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Yu-Wen Tien
- Division of General Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7 Chung-Shan South Road, Taipei, 10002, Taiwan
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Lavu H, McCall N, Keith SW, Kilbane EM, Parmar AD, Hall BL, Pitt HA. Leakage of an Invagination Pancreaticojejunostomy May Have an Influence on Mortality. J Pancreat Cancer 2018; 4:45-51. [PMID: 30631858 PMCID: PMC6145537 DOI: 10.1089/pancan.2018.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose: No consensus exists regarding the most effective form of pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD). Methods: Data were gathered through the American College of Surgeons-National Surgical Quality Improvement Program, Pancreatectomy Demonstration Project. A total of 1781 patients underwent a PD at 43 institutions. After appropriate exclusions, 890 patients were analyzed. Patients were divided into duct-to-mucosa (n = 734, 82%) and invagination (n = 156, 18%) groups and were compared by unadjusted analysis. Type of PJ was included in eight separate morbidity and mortality multivariable analyses. Results: Invagination patients had higher serum albumin (p < 0.01) and lower body mass index (p < 0.01), were less likely to have a preoperative biliary stent (p < 0.01), and were more likely to have a soft gland (p < 0.01). PJ anastomosis type was not associated with morbidity but was associated with mortality (duct-to-mucosa vs. invagination, odds ratio = 0.22, p < 0.01). Among patients who developed a clinically relevant pancreatic fistula, none of the 119 duct-to-mucosa, compared with 5 of 21 invagination, patients died (p < 0.01). Conclusion: Patients who undergo a PJ by duct-to-mucosa or invagination differ with respect to preoperative and intraoperative variables. When an invagination PJ leaks, there may be a greater influence on mortality than when a duct-to-mucosa PJ leaks.
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Affiliation(s)
- Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Neal McCall
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scott W Keith
- Department of Biostatistics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Bruce L Hall
- Washington University, School of Medicine, St. Louis, Missouri
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, Surgery, Philadelphia, Pennsylvania
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Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis. Oncotarget 2018; 8:46449-46460. [PMID: 28521286 PMCID: PMC5542280 DOI: 10.18632/oncotarget.17503] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 04/11/2017] [Indexed: 12/12/2022] Open
Abstract
Objective We aimed to compare the two most commonly used pancreatico-jejunostomy reconstruction techniques—duct-to-mucosa and invagination. Methods Databases, including MEDLINE, EMBASE, Cochrane Library, and several clinical trial registration centers were searched. Randomized controlled trials that compared duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were included and analyzed. Results In total, seven RCTs were included, involving 850 patients. The difference in postoperative pancreatic fistula rate between the duct-to-mucosa and invagination pancreaticojejunostomy was not significant (RR = 1.03, 95% CI = 0.76-1.39, P = 0.86). There was no significant difference in clinically relevant postoperative pancreatic fistula between the two groups (RR = 0.78, 95% CI = 0.15-3.96, P = 0.77). The overall morbidity, overall mortality, delayed gastric emptying, intra-abdominal collection, reoperation rate, and length of hospital stay between the two groups were not significantly different. Sensitivity analysis showed that the meta-analysis was stable. Further, no significant publication bias was seen. Conclusions Duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were comparable in terms of postoperative pancreatic fistula incidence and other parameters.
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Li B, Xu C, Qiu ZQ, Liu C, Yi B, Luo XJ, Jiang XQ. An end-to-side suspender pancreaticojejunostomy: A new invagination pancreaticojejunostomy. Hepatobiliary Pancreat Dis Int 2018; 17:163-168. [PMID: 29567046 DOI: 10.1016/j.hbpd.2018.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 12/20/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a severe complication of the pancreaticoduodenectomy (PD). Recently, we introduced a method of suspender pancreaticojejunostomy (PJ) to the PD. In this study, we retrospectively analyzed various risk factors for complications after PD. We also introduced and assessed the suspender PJ to demonstrate its advantages. METHODS Data from 335 patients with various periampullary lesions, who underwent the Whipple procedure (classic Whipple procedure or pylorus-preserving) PD by either traditional end-to-side invagination PJ or suspender PJ, were analyzed. The correlation between either perioperative or postoperative complications and corresponding PD approaches was evaluated by univariate analysis. RESULTS A total of 147 patients received the traditional end-to-side invagination PJ, and 188 patients were given the suspender PJ. Overall, 51.9% patients had various complications after PD. The mortality rate was 2.4%. The POPF incidence in patients who received the suspender PJ was 5.3%, which was significantly lower than those who received the traditional end-to-side invagination PJ (18.4%) (P < 0.001). Univariate analysis showed that PJ approach and the pancreas texture were significantly associated with the POPF incidence rate (P < 0.01). POPF was a risk factor for both postoperative abdominal cavity infection (OR = 8.34, 95% CI: 3.99-17.42, P < 0.001) and abdominal cavity hemorrhage (OR = 4.86, 95% CI: 1.92-12.33, P = 0.001). CONCLUSIONS Our study showed that the impact of the pancreas texture was a major risk factor for pancreatic leakage after a PD. The suspender PJ can be easily accomplished and widely applied and can effectively decrease the impact of the pancreas texture on pancreatic fistula after a PD and leads to a lower POPF incidence rate.
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Affiliation(s)
- Bin Li
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Chang Xu
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Zhi-Quan Qiu
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Chen Liu
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Bin Yi
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Xiang-Ji Luo
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China
| | - Xiao-Qing Jiang
- Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, 225 Changhai Road, Shanghai 200438, China.
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Pancreatic parenchymal injection of ethanol and octreotide to induce focal pancreatic fibrosis in rats: Strategies to eliminate postoperative pancreatic fistula. Hepatobiliary Pancreat Dis Int 2018; 17:81-85. [PMID: 29428110 DOI: 10.1016/j.hbpd.2018.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 08/11/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is more likely to occur in a soft pancreas compared to a hard pancreas in which fibrosis has progressed. There is almost no leakage at the anastomosis site or cut surface of a hard pancreas. The aim of this study was to induce localized fibrosis at the cut surface of the pancreas in a rat model. METHODS Thirty-six rats were divided into three groups (group S: normal saline group; group E: ethanol group; and group O: octreotide group). Each rat was directly injected with a particular compound at the duodenal lobe of the pancreatic parenchyma. Each group was divided into three subgroups according to the time of post-injection sacrifice (1, 2, or 4 weeks). The hardness, suture holding capacity (SHC), and histological fibrosis grade of each pancreas were measured. RESULTS The hardness, SHC, and fibrosis grade of groups E and O were increased at week 1, with greater increases in group E (all P < 0.001). In a subgroup comparison, the hardness, SHC, and fibrosis grade of group E tended to decrease gradually over time, with no regular pattern evident in group O. A comparison between the injected site (duodenal lobe) and non-injected site (splenic lobe) of the pancreas revealed increases in the three parameters of group E only in the duodenal lobe, with increases in group O at both the duodenal and splenic lobes. CONCLUSIONS Parenchymal injection of ethanol and octreotide increased pancreatic fibrosis. Unlike octreotide, ethanol provoked localized fibrosis that was maintained over time. It is expected that ethanol injection could eliminate POPF during pancreatic surgery.
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Senda Y, Shimizu Y, Natsume S, Ito S, Komori K, Abe T, Matsuo K, Sano T. Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy. Br J Surg 2017; 105:48-57. [PMID: 29265404 DOI: 10.1002/bjs.10727] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/23/2017] [Accepted: 09/18/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy. METHODS Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay. RESULTS Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028). CONCLUSION This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).
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Affiliation(s)
- Y Senda
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Japan
| | - Y Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Japan
| | - S Natsume
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Japan
| | - S Ito
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Japan
| | - K Komori
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Japan
| | - T Abe
- Department of Gastroenterological Surgery, Aichi Cancer Centre Hospital, Nagoya, Japan
| | - K Matsuo
- Division of Molecular Medicine, Aichi Cancer Centre Research Institute, Nagoya, Japan
| | - T Sano
- Department of Gastroenterological Surgery, Aichi Medical University Hospital, Aichi, Japan
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Zijah R, Jasmin H, Amra M, Emir A, Amir T, Goran I. http://www.ijhpd.com/archive/2016-archive/100060IJHPDRZ2016-zijah/100060IJHPDRZ2016-zijah-full-text.php. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2017. [DOI: 10.5348/ijhpd-2016-59-oa-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Aims: The most demanding anastomosis of cephalic pancreaticoduodenectomy is pancreaticojejunostomy. In order to reduce the number of complications of pancreatico- jejunostomy, we worked to improve the technique of creating the anastomosis by modification of several aspects of the already standardized technique of creating a pancreaticojejunostomy.
Materials and Methods: Observational cohort study was conducted on 50 patients who had undergone a cephalic pancreaticoduo-denectomy due to a periampullary carcinoma in the period from January 2011 to March 2016. We analyzed the effect of the presented technique on postoperative morbidity and mortality.
Results: Of the 50 surgical patients, 31 (62%) were male. The mean age of the surgical patients was 58.8±10.08 years. Postoperative morbidity of 28% was lower than figures from literatures, which range from 35–43% (p > 0.05). Postoperative mortality was 6%, and in line with the figures from literature. Postoperative pancreatic fistula occurred in 6% of patients, which is also lower than 12.9% found in literature (p > 0.05).
Conclusion: Postoperative morbidity in patients in whom a pancreaticojejunostomy was created with presented technique, including the incidence of a postoperative pancreatic fistula, was lower, although the difference was not statistically significant.
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Affiliation(s)
- Rifatbegović Zijah
- MD, University Clinical Centre Tuzla, Department of Surgery, Tuzla, Bosnia and Herzegovina
| | - Hasanović Jasmin
- MD, University Clinical Centre Tuzla, Department of Surgery, Tuzla, Bosnia and Herzegovina
| | - Meštrić Amra
- MD, University of Tuzla, School of Medicine, Tuzla, Bosnia and Herzegovina
| | - Ahmetašević Emir
- MD, University Clinical Centre Tuzla, Department of Surgery, Tuzla, Bosnia and Herzegovina
| | - Tursunović Amir
- MD, University Clinical Centre Tuzla, Department of Surgery, Tuzla, Bosnia and Herzegovina
| | - Imamović Goran
- MD, University of Tuzla, School of Medicine, Tuzla, Bosnia and Herzegovina
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Kim M, Shin WY, Lee KY, Ahn SI. An intuitive method of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: use of one-step circumferential interrupted sutures. Ann Hepatobiliary Pancreat Surg 2017; 21:39-47. [PMID: 28317044 PMCID: PMC5353904 DOI: 10.14701/ahbps.2017.21.1.39] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/08/2017] [Accepted: 01/19/2017] [Indexed: 12/28/2022] Open
Abstract
Pancreaticoenteric anastomosis is the origin of postoperative pancreatic fistula (POPF). Although a variety of methods have been proposed to decrease the POPF rate, randomized controlled trials performed so far have failed to demonstrate superiority of any particular method to the others. Cattell-Warren duct-to-mucosa pancreaticojejunostomy (PJ) is a widely practiced procedure. Their method is challenging, especially when the pancreatic duct is small. We assumed that the difficulty resides in the pancreatic duct becoming difficult to access when the posterior row is tied before suturing the anterior row. We have modified the duct-to-mucosa PJ so that the entire circumference of the inner layer can be sutured and tied in one-step by anchoring and retracting the anterior row. The jejunal roux-limb and pancreatic stump are positioned spatially apart, allowing enough space for free needle work. During a 13-year period, 151 patients underwent pancreaticoduodenectomy with this method, and the cumulative POPF and mortality rates were 37.1% and 4.6%, respectively. These rates were stable throughout the study period, implicating a relative independence from surgeons' experience. We believe that our method is intuitive, easy to grasp, and can be readily adopted even by surgeons not accustomed to pancreaticoduodenectomy.
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Affiliation(s)
- Moonwhan Kim
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Woo Young Shin
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Keon-Young Lee
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Seung-Ik Ahn
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
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26
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Seo JW, Hwang HK, Lee M, Kim KW, Kang CM, Kim MJ, Chung YE. Normal Postoperative Computed Tomography Findings after a Variety of Pancreatic Surgeries. Korean J Radiol 2017; 18:299-308. [PMID: 28246510 PMCID: PMC5313518 DOI: 10.3348/kjr.2017.18.2.299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/14/2016] [Indexed: 12/12/2022] Open
Abstract
Pancreatic surgery remains the only curative treatment for pancreatic neoplasms, and plays an important role in the management of medically intractable diseases. Since the original Whipple operation in the 20th century, surgical techniques have advanced, resulting in decreased postoperative complications and better clinical outcomes. Normal postoperative imaging findings vary greatly depending on the surgical technique used. Radiologists are required to be familiar with the normal postoperative imaging findings, in order to distinguish from postoperative complications or tumor recurrence. In this study, we briefly review a variety of surgical techniques for the pancreas, and present the normal postoperative computed tomography findings.
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Affiliation(s)
- Ji Won Seo
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Ho Kyoung Hwang
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Minwook Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Ki Whang Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Chang Moo Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Myeong-Jin Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Yong Eun Chung
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul 03722, Korea
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27
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Imbedding pancreaticojejunostomy used in pure laparoscopic pancreaticoduodenectomy for nondilated pancreatic duct. Surg Endosc 2017; 31:1986-1992. [DOI: 10.1007/s00464-016-4805-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 02/03/2016] [Indexed: 02/01/2023]
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28
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Sun X, Zhang Q, Zhang J, Lou Y, Fu Q, Zhang X, Liang T, Bai X. Meta-analysis of invagination and duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: An update. Int J Surg 2016; 36:240-247. [PMID: 27826046 DOI: 10.1016/j.ijsu.2016.11.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/30/2016] [Accepted: 11/03/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Duct-to-mucosa and invagination are two commonly used techniques of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy. Previously, we conducted a systematic review comparing the safety and efficacy of the two PJ techniques. Here, we added new evidence and updated our previous conclusion. METHODS We systematically searched multiple databases and included randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination techniques of PJ. The quality of evidence was assessed using Jadad score, and reporting bias was evaluated using funnel plots. Meta-analysis was performed using a random-effects model. Risk ratio (RR) and 95% confidence interval (CI) were calculated. The primary outcome was pancreatic fistula, and the secondary outcomes included mortality, reoperation, morbidity and postoperative hospital stay. Trial sequential analysis was performed to calculate the required information size. RESULTS Seven RCTs with 850 participants were included. No significant difference was detected in the rates of pancreatic fistula (RR 0.98, 95% CI 0.63 to 1.53), mortality (RR 0.94, 95% CI 0.40 to 2.18), reoperation (RR 1.23, 95% CI 0.69 to 2.20) and morbidity (RR 0.98, 95% CI 0.82 to 1.16) between the two groups. However, patients who underwent duct-to-mucosa PJ had a significantly shorter postoperative hospital stay (mean difference -2.80, 95% CI -5.08 to -0.52). Trial sequential analysis showed that another 279 participants were needed for conclusive results. CONCLUSIONS Given the current evidence, duct-to-mucosa PJ did not decrease the rates of pancreatic fistula and other adverse events as compared to invagination PJ; however, it did reduce postoperative hospital stay. Further RCTs are needed.
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Affiliation(s)
- Xu Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of General Surgery, Huzhou Central Hospital, Zhejiang University Huzhou Hospital, Huzhou, China
| | - Qi Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - JingYing Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu Lou
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - QiHan Fu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - XingLong Zhang
- The Second Department of General Surgery, People's Hospital of Kaihua, Quzhou, China
| | - TingBo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - XueLi Bai
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Khajanchee YS, Johnston WC, Cassera MA, Hansen PD, Hammill CW. Characterization of Pancreaticojejunal Anastomotic Healing in a Porcine Survival Model. Surg Innov 2016; 24:15-22. [DOI: 10.1177/1553350616674638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Anastomotic leak after pancreaticoduodenectomy is the most important cause of postoperative morbidity and mortality. Histological studies of bowel anastomoses have provided valuable insights regarding causes of anastomotic failure. However, this crucial information is lacking for pancreatico-enteric anastomoses. Methods: Pancreaticoduodenectomy was performed in a porcine model. Animals were survived up to 10 days and then the pancreatico-enteral anastomosis specimen was resected en bloc. Anastomotic bursting pressure was measured and histological sections of the anastomoses were examined. Results: Six out of 8 animals had excellent healing of the anastomoses. One animal developed a clinically significant leak at the pancreaticoduodenal anastomosis (12.5%) and one animal had a subclinical duodeno-duodenal leak discovered on necropsy (12.5%). Both anastomoses that failed had a collagen-to-tissue ratio less than 40%. In contrast, none of the anastomoses with a ratio greater than 40% showed any evidence of disruption. Conclusion: Our results indicate that quantitative measurement of collagen deposition at the pancreatic anastomosis provides objective assessment of healing of the pancreatic anastomosis. A survival porcine model of pancreaticoduodenectomy results in a similar leak rate to published data on pancreaticoduodenectomy in humans and will be useful for future studies assessing novel pharmacologic or technical interventions aimed at improving outcomes.
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Affiliation(s)
| | | | - Maria A. Cassera
- Providence Portland Medical Center, Portland, OR, USA
- The Oregon Clinic, Portland, OR, USA
| | - Paul D. Hansen
- Providence Portland Medical Center, Portland, OR, USA
- The Oregon Clinic, Portland, OR, USA
| | - Chet W. Hammill
- Providence Portland Medical Center, Portland, OR, USA
- The Oregon Clinic, Portland, OR, USA
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30
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Oda T, Hashimoto S, Miyamoto R, Shimomura O, Fukunaga K, Kohno K, Ohshiro Y, Akashi Y, Enomoto T, Ohkohchi N. The Tight Adaptation at Pancreatic Anastomosis Without Parenchymal Laceration: An Institutional Experience in Introducing and Modifying the New Procedure. World J Surg 2016; 39:2014-22. [PMID: 25894407 DOI: 10.1007/s00268-015-3075-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Among the types of pancreatic anastomosis used after pancreatoduodenectomy (PD), Blumgart type reconstruction has rapidly been distributed for its theoretical reasonableness, including secure tight adaptation of jejunal wall and pancreatic parenchyma without cause of parenchymal laceration. The clinical appropriateness of our modified Blumgart method was demonstrated by comparing to that of Kakita method. METHODS Retrospective analysis of 156 patients underwent elective open PD, reconstructed former 78 patients with the Kakita method, utilizing a full-thickness penetrating suture for tight stump adhesion. The later 78 patients were treated with the modified Blumgart method, which involved clamping the pancreatic parenchymal stump by the jejunal seromuscular layers with horizontal mattress-type penetration sutures. Evaluated variables were the rate of pancreatic fistula (PF) and the length of postoperative hospital stay (POHS). RESULTS The rate of ISGPF grade B+C PF was 29/78 (37.2%) in the Kakita group and 16/78 (20.5%) in the Blumgart group (P=0.033). The median POHS for the Kakita group was 23 days, whereas that for the Blumgart group was 16 days (P<0.001), one of the shortest value among Japanese high-volume centers. There was no perioperative intensive hemorrhage or deaths in either group. CONCLUSION A unique concept of Blumgart pancreatic anastomosis, i.e., utilizing the jejunum as an interstitial cushion to prevent pancreatic laceration at the knot site, has become realistic through a simple "one step" modification. This technique, also providing flexible handling space at main pancreatic duct anastomosis, should contribute to the improved PF prevention and shortening the POHS.
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Affiliation(s)
- Tatsuya Oda
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan,
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Gangl O, Fröschl U, Langer RM, Függer R. Single-layer versus duct-to-mucosa pancreaticojejunostomy in pyloruspreserving pancreatoduodenectomy for ductal adenocarcinoma—an analysis of a single surgeon’s series. Eur Surg 2015. [DOI: 10.1007/s10353-015-0373-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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32
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Hua J, He Z, Qian D, Meng H, Zhou B, Song Z. Duct-to-Mucosa Versus Invagination Pancreaticojejunostomy Following Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis. J Gastrointest Surg 2015; 19:1900-9. [PMID: 26264363 DOI: 10.1007/s11605-015-2913-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 08/03/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most common complications after pancreaticoduodenectomy (PD). The ideal choice of pancreaticojejunostomy (PJ) anastomosis remains a matter of debate. METHODS A meta-analysis of randomized controlled trials (RCTs) comparing duct-to-mucosa with invagination PJ following PD was performed. Pooled odds ratio (OR) with 95 % confidence intervals (CI) were calculated using fixed-effects or random-effects models. RESULTS In total, five RCTs involving 654 patients were included. Meta-analysis revealed no significant difference in POPF rate between the duct-to-mucosa and invagination PJ techniques (OR = 1.23, 95 % CI = 0.78-1.93; P = 0.38). Two of five trials applied the POPF definition proposed by the International Study Group of Pancreatic Surgery (ISGPS). Using this definition, the incidence of clinically relevant POPF was lower in patients undergoing invagination PJ than in those undergoing duct-to-mucosa PJ (OR = 2.94, 95 % CI = 1.31-6.60; P = 0.009). There was no significant difference in terms of delayed gastric emptying, intra-abdominal collection, overall morbidity and mortality, reoperation rate, and length of hospital stay between the two groups. CONCLUSION Invagination PJ is not superior to duct-to-mucosa PJ in terms of POPF and other complications but appears to reduce clinically relevant POPF. Further well-designed RCTs that use ISGPS definition are still required before strong evidence-based recommendations can be formulated.
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Affiliation(s)
- Jie Hua
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Zhigang He
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Daohai Qian
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Hongbo Meng
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Bo Zhou
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Zhenshun Song
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Middle Road, Shanghai, 200072, China.
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Oda T, Hashimoto S, Shimomura O, Yamada K, Ohara Y, Fukunaga K, Oshiro Y, Akashi Y, Enomoto T, Ohkohchi N. Inter-Anastomosis Drainage Tube Between the Pancreas and Jejunum: A Novel Technique for Preventing Pancreatic Fistula after Pancreaticoduodenectomy. J Am Coll Surg 2015. [PMID: 26195249 DOI: 10.1016/j.jamcollsurg.2015.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Tatsuya Oda
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Shinji Hashimoto
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Osamu Shimomura
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Keiichi Yamada
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yusuke Ohara
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kiyoshi Fukunaga
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yukio Oshiro
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoshimasa Akashi
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tsuyoshi Enomoto
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Clinical Sciences, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Lee JY, Kim EY, Lee JS, Lee SH, Na GH, Hong TH, You YK, Kim DG. A novel pancreaticogastrostomy method using only two transpancreatic sutures: early postoperative surgical results compared with conventional pancreaticojejunostomy. Ann Surg Treat Res 2015; 88:299-305. [PMID: 26029674 PMCID: PMC4443260 DOI: 10.4174/astr.2015.88.6.299] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/18/2014] [Accepted: 12/06/2014] [Indexed: 12/12/2022] Open
Abstract
Purpose To evaluate the surgical outcomes of pancreaticogastrostomy (PG) using two transpancreatic sutures with a buttress method through an anterior gastrostomy (PGt), and compare these results with our previous experience with pancreaticojejunostomy (PJ) including the dunking and duct to mucosa methods after pancreaticoduodenectomy (PD). Methods In this study, 171 patients who had undergone PD between January 2005 and April 2013 were classified into three groups according to the method of the pancreaticoenteric anastomosis: dunking PJ (PJu group; n = 67, 39.1%), duct to mucosa PJ (PJm group; n = 41, 23.9%), and PGt (PGt group; n = 63, 36.8%). We retrospectively analyzed patient characteristics, perioperative outcomes, and surgical results. Results Both groups had comparable demographics and pathology, and there were no significant differences in operative time, estimated blood loss, or postoperative hospital stay. Within the two groups, morbidities occurred in 49 cases (10.7%), and were not significantly different between the two groups, excepting postoperative pancreatic fistula (POPF). The PGt group had a lower rate of POPF (18/63, 28.6%) than the PJu and PJm groups (21/67, 31.3% and 19/41, 46.3%; P = 0.048), especially in terms of grades B and C POPF (4/63 [6.3%] in the PGt group vs. 7/67 [10.4%] in the PJu group and 9/41 [22.0%] in the PJm group, P = 0.049). Conclusion The PGt method showed feasible outcomes for POPF and had advantages over dunking PJ and duct to mucosa PJ with respect to immediate postoperative results. PGt may be a promising technique for pancreaticoenteric anastomosis after PD.
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Affiliation(s)
- Jeong Yeon Lee
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Eun Young Kim
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jun Suh Lee
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Soo Ho Lee
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Gun Hyung Na
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Tae Ho Hong
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Young Kyoung You
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dong Goo Kim
- Department of Hepatobiliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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El Nakeeb A, El Hemaly M, Askr W, Abd Ellatif M, Hamed H, Elghawalby A, Attia M, Abdallah T, Abd ElWahab M. Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized study. Int J Surg 2015; 16:1-6. [PMID: 25682724 DOI: 10.1016/j.ijsu.2015.02.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD. METHODS Consecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions. RESULTS One hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively. CONCLUSION Invagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. CLINICAL TRIALS. GOV ID NCT02142517.
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Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt.
| | - Mohamed El Hemaly
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | - Waleed Askr
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | | | - Hosam Hamed
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | - Ahmed Elghawalby
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | - Mohamed Attia
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
| | - Tallat Abdallah
- Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt
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Kang CM, Lee SH, Chung MJ, Hwang HK, Lee WJ. Laparoscopic pancreatic reconstruction technique following laparoscopic pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:202-10. [PMID: 25546026 DOI: 10.1002/jhbp.193] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the advance of laparoscopic experiences and techniques, it is carefully regarded that laparoscopic pancreaticoduodenectomy (lap-PD) is feasible and safe in managing perimapullary pancreatic pathology. Especially, laparoscopic management of remnant pancreas can be a critical step toward completeness of minimally invasive PD. According to available published reports, there is a wide range of technical differences in choosing surgical options in managing remnant pancreas after lap-PD. For the evidence-based surgical approach, it would be ideal to test potential techniques by randomized controlled trials, but, currently, it is thought to be very difficult to expect those clinical trials to be successful because there are still a lack of expert surgeons with sound surgical techniques and experience. In addition, lap-PD is so complicated and technically demanding that many surgeons are still questioning whether this surgical approach could be standardized and popular like laparoscopic cholecystectomy. In general, surgical options are usually chosen based on following question: (1) Is it simple? (2) Is it easy and feasible? (3) Is it secure and safe? (4) Is there any supporting scientific evidence? It would be interesting to estimate which surgical technique would be appropriate in managing remnant pancreas under these considerations. It is hoped that a well standardized multicenter-based randomized control study would be successful to test this fundamental issues based on sound surgical techniques and scientific background.
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Affiliation(s)
- Chang Moo Kang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Ludlow Faculty Research Building #203, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea; Pancreaticobiliary Cancer Clinic, Yonsei Cancer Center, Institute of Gastroenterology, Severance Hospital, Seoul, Korea
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Zhang RC, Xu XW, Zhou YC, Wu D, Ajoodhea H, Chen K, Mou YP. A rare case of mixed mucinous cystadenoma with serous cystadenoma of the pancreas treated by laparoscopic central pancreatectomy. World J Surg Oncol 2014; 12:318. [PMID: 25319107 PMCID: PMC4203968 DOI: 10.1186/1477-7819-12-318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 10/01/2014] [Indexed: 12/29/2022] Open
Abstract
Mixed mucinous cystadenoma with serous cystadenoma of the pancreas is rare. There have been only two previous case reports in the English-language literature. We present a case of a 46-year-old woman who was diagnosed with mixed mucinous cystadenoma with serous cystadenoma of the pancreas. Computed tomography and magnetic resonance imaging showed a cystic neoplasm in the dorsal/proximal body of the pancreas with a clear-margin multilocular cavity and enhanced internal septum. The patient underwent laparoscopic central pancreatectomy. The diagnosis of mixed mucinous cystadenoma with serous cystadenoma of the pancreas was confirmed by pathological examination. The patient was followed up for 3 months and there were no signs of recurrence, or pancreatic exocrine or endocrine insufficiency. To the best of our knowledge, this is the first reported case treated by laparoscopic central pancreatectomy.
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Affiliation(s)
| | | | | | | | | | | | - Yi-ping Mou
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou 310016, Zhejiang Province, China.
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Schoellhammer HF, Fong Y, Gagandeep S. Techniques for prevention of pancreatic leak after pancreatectomy. Hepatobiliary Surg Nutr 2014; 3:276-87. [PMID: 25392839 PMCID: PMC4207840 DOI: 10.3978/j.issn.2304-3881.2014.08.08] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/21/2014] [Indexed: 12/12/2022]
Abstract
Pancreatic resections are some of the most technically challenging operations performed by surgeons, and post-operative pancreatic fistula (POPF) are not uncommon, developing in approximately 13% of pancreaticoduodenectomies and 30% of distal pancreatectomies. Multiple trials of various operative techniques in the creation of the pancreatic ductal anastomosis have been conducted throughout the years, and herein we review the literature and outcomes data regarding these techniques, although no one technique of pancreatic ductal anastomosis has been shown to be superior in decreasing rate of POPF. Similarly, we review the literature regarding techniques of pancreatic closure after distal pancreatectomy. Again, no one technique has been shown to be superior in preventing POPF; however the use of buttressing material on the pancreatic staple line in the future may be a successful means of decreasing POPF. We review adjunctive techniques to decrease POPF such as pancreatic ductal stenting, the use of various topical biologic glues, and the use of somatostatin analogue medications. We conclude that future trials will need to be conducted to find optimal techniques to decrease POPF, and meticulous attention to intra-operative details and post-operative care by surgeons is necessary to prevent POPF and optimally care for patients undergoing pancreatic resection.
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Affiliation(s)
- Hans F Schoellhammer
- Division of Surgical Oncology, Department of Surgery; City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Division of Surgical Oncology, Department of Surgery; City of Hope National Medical Center, Duarte, CA, USA
| | - Singh Gagandeep
- Division of Surgical Oncology, Department of Surgery; City of Hope National Medical Center, Duarte, CA, USA
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Evaluation of a new modification of pancreaticogastrostomy after pancreaticoduodenectomy: anastomosis of the pancreatic duct to the gastric mucosa with invagination of the pancreatic remnant end into the posterior gastric wall for patients with cancer head of pancreas and periampullary carcinoma in terms of postoperative pancreatic fistula formation. Int J Surg Oncol 2014; 2014:490386. [PMID: 25302117 PMCID: PMC4181776 DOI: 10.1155/2014/490386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 08/10/2014] [Accepted: 08/27/2014] [Indexed: 01/23/2023] Open
Abstract
Background/Objectives. Postoperative pancreatic fistula (POPF) remains the main problem after pancreaticoduodenectomy and determines to a large extent the final outcome. We describe a new modification of pancreaticogastrostomy which combines duct to mucosa anastomosis with suturing the pancreatic capsule to posterior gastric wall and then invaginating the pancreatic remnant into the posterior gastric wall. This study was designed to assess the results of this new modification of pancreaticogastrostomy. Methods. The newly modified pancreaticogastrostomy was applied to 37 consecutive patients after pancreaticoduodenectomy for periampullary cancer (64.86%) or cancer head of the pancreas (35.14%). Eighteen patients (48.65%) had a soft pancreatic remnant, 13 patients (35.14%) had firm pancreatic remnant, and 6 patients (16.22%) had intermediate texture of pancreatic remnant. Rate of mortality, early postoperative complications, and hospital stay were also reported. Results. Operative mortality was zero and morbidity was 29.73%. Only three patients (8.11%) developed pancreatic leaks; they were treated conservatively. Eight patients (16.1%) had delayed gastric emptying, one patient (2.70%) had minor hemorrhage, one patient (2.70%) had biliary leak, and four patients (10.81%) had superficial wound infection. Conclusions. The new modified pancreatogastrostomy seems safe and reliable with low rate of POPF. However, further prospective controlled trials are essential to support these results.
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Pezzilli R, Falconi M, Zerbi A, Casadei R, Morselli-Labate AM. Different reconstruction techniques after pancreatoduodenectomy do not affect clinical and patient reported outcomes. Adv Med Sci 2014; 59:151-5. [PMID: 25323749 DOI: 10.1016/j.advms.2014.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/29/2014] [Accepted: 04/01/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate the quality of life in a 2-year follow-up study in consecutive subjects who underwent pancreaticoduodenectomy with different reconstruction techniques: pancreaticojejunostomy or pancreaticogastrostomy. PATIENTS/METHODS One hundred and ninety-seven consecutive patients were studied: 164 (83.2%) had malignant and 33 (16.8%) had benign disease. The EORTC QLQ-C30 questionnaire was administered at 5 different time points for evaluation: before surgery, and 6, 12, 18 and 24 months after discharge. RESULTS Pancreaticojejunostomy was performed in 189 patients (95.9%) and pancreaticogastrostomy in 8 patients (4.1%). In the follow-up evaluation, the quality of life significantly improved using the various surgical approaches; improvement over time was not significantly different among the various reconstruction techniques. CONCLUSIONS In clinical practice, different surgical reconstruction techniques are equally effective in improving the quality of life after pancreaticoduodenectomy.
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Harada N, Ishizawa T, Inoue Y, Aoki T, Sakamoto Y, Hasegawa K, Sugawara Y, Tanaka M, Fukayama M, Kokudo N. Acoustic radiation force impulse imaging of the pancreas for estimation of pathologic fibrosis and risk of postoperative pancreatic fistula. J Am Coll Surg 2014; 219:887-94.e5. [PMID: 25262282 DOI: 10.1016/j.jamcollsurg.2014.07.940] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/17/2014] [Accepted: 07/30/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND We sought to evaluate whether pancreatic elasticity, measured using acoustic radiation force impulse (ARFI) imaging, can determine the degree of pancreatic fibrosis and risk of pancreatic fistula (PF) in patients undergoing pancreatic resection. Although soft pancreatic texture is a reliable predictor of postoperative PF, noninvasive, quantitative methods of assessing pancreatic hardness have not been established. STUDY DESIGN Shear wave velocity (SWV) of the pancreas was preoperatively measured by ARFI imaging in 62 patients undergoing pancreatic resection. Correlations of SWV with pathologic degree of fibrosis in the resected pancreas, exocrine function of the remnant pancreas, and the incidence of postoperative PF were determined. RESULTS The SWV was positively correlated with the degree of pancreatic fibrosis (Spearman's rank correlation coefficient [ρ] = 0.660, p < 0.001) and inversely correlated with postoperative amylase concentrations and daily output of pancreatic juice. The incidence of postoperative PF was significantly higher in the 32 patients with soft (SWV < 1.54 m/s) than in the 30 with hard (SWV ≥ 1.54 m/s) pancreata (63% vs 17%, p < 0.001). Multivariate analysis showed that a soft pancreas (SWV < 1.54 m/s) was an independent predictor of postoperative PF (odds ratio 38.3; 95% CI 5.82 to 445; p = 0.001). CONCLUSIONS Pancreatic elasticity on preoperative ARFI imaging accurately reflected the pathologic degree of fibrosis and exocrine function of the pancreas, enabling surgeons to adopt appropriate surgical procedures according to the risk of postoperative PF in each patient undergoing pancreatic resection.
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Affiliation(s)
- Nobuhiro Harada
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yosuke Inoue
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taku Aoki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuhiko Sugawara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masashi Fukayama
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Lee KF. Management of the pancreatic stump after pancreaticoduodenectomy. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kit-Fai Lee
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
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Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study. J Gastrointest Surg 2014; 18:1108-15. [PMID: 24733259 DOI: 10.1007/s11605-014-2523-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 03/31/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the main cause of fatal complications after pancreatoduodenectomy. There is still no universally accepted technique for pancreaticoenterostomy, especially in patients with soft pancreas. METHODS Between July 2008 and June 2013, 240 patients who underwent pancreatoduodenectomy were enrolled in this single-institution matched historical control study. To approximate the pancreatic parenchyma to the jejunal seromuscular layer, 120 patients underwent anastomosis using the Kakita method (three or four interrupted penetrating sutures) and 120 underwent anastomosis using the modified Blumgart anastomosis (m-BA) method (one to three transpancreatic/jejunal seromuscular sutures to completely cover the pancreatic stump with jejunal serosa). RESULTS The rate of clinically relevant POPF formation was significantly lower in the m-BA group than that in the Kakita group (2.5 vs 36 %; p < 0.001). The duration of drain placement and the length of postoperative hospital stay were significantly shorter in the m-BA group. Multivariate analysis showed that m-BA was an independent predictor of non-formation of POPF (hazard ratio, 0.02; 95 % confidence interval, 0.01-0.08; p < 0.001). CONCLUSION The m-BA method is safe and simple and improves postoperative outcomes. We suggest that the m-BA is suitable for use as a standard method of pancreaticojejunostomy after pancreatoduodenectomy.
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Laparoscopic intussuscepting pancreaticojejunostomy. J Gastrointest Surg 2014; 18:208-12. [PMID: 23929187 DOI: 10.1007/s11605-013-2308-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 07/29/2013] [Indexed: 01/31/2023]
Abstract
Perhaps the greatest barrier to adoption of laparoscopic pancreaticoduodenectomy by experienced pancreatic surgeons is the technical challenge of constructing the pancreaticojejunostomy (PJ). The authors present a less demanding PJ technique they have developed that creates an end-to-end intussuscepting anastomosis using a running monofilament suture. This method reduces technical complexity and operative time while producing acceptably comparable outcomes.
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Zhang B, Xu J, Liu C, Long J, Liu L, Xu Y, Wu C, Luo G, Ni Q, Li M, Yu X. Application of "papillary-like main pancreatic duct invaginated" pancreaticojejunostomy for normal soft pancreas cases. Sci Rep 2013; 3:2068. [PMID: 23797701 PMCID: PMC3691567 DOI: 10.1038/srep02068] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 06/03/2013] [Indexed: 01/13/2023] Open
Abstract
Pancreaticojejunostomy is the key procedure of pancreaticoduodenectomy. Our study introduced a new pancreaticojejunal (PJ) anastomosis named “papillary-like main pancreatic duct invaginated” pancreaticojejunostomy. Nighty-two patients underwent pancreaticojejunostomy with either conventional duct-to-mucosa pancreaticojejunostomy or the new “papillary-like main pancreatic duct invaginated” techniques were analyzed retrospectively from January 2010 to September 2012. The incidence of pancreatic fistula was 15.7% (8/51) for the “papillary-like main pancreatic duct invaginated” group and 19.5% (8/41) for the duct-to-mucosa fashion respectively. It is noteworthy that the rate of grade B/C postoperative pancreatic fistula (POPF) in the “papillary-like main pancreatic duct invaginated” group was significantly lower than that of the duct-to-mucosa group (P = 0.039). There were no differences in the incidence of postoperative morbidity and mortality such as postoperative hemorrhage, delayed gastric emptying or remnant pancreatitis. The “papillary-like main pancreatic duct invaginated” pancreaticojejunostomy could provide a feasible option to pancreatic surgeons for patients with normal soft pancreas.
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Affiliation(s)
- Bo Zhang
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China
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Zhang R, Xu X, Yan J, Wu D, Ajoodhea H, Mou Y. Laparoscopic central pancreatectomy with pancreaticojejunostomy: preliminary experience with 8 cases. J Laparoendosc Adv Surg Tech A 2013; 23:912-8. [PMID: 24093934 DOI: 10.1089/lap.2013.0269] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Central pancreatectomy has been accepted as an alternative procedure for treating benign or low-grade malignant tumors in the pancreatic neck or proximal body of the pancreas, which preserves pancreatic parenchyma and function. In this study, we present our experience of laparoscopic central pancreatectomy with pancreaticojejunostomy. PATIENTS AND METHODS From April 2011 to February 2013, 8 patients underwent laparoscopic central pancreatectomy with a Roux-en-Y modified "dunking" or duct-to-mucosa pancreaticojejunostomy for benign or low-grade malignant tumors in the pancreatic neck or proximal body of the pancreas at the Department of General Surgery, Sir Run Run Shaw Hospital, Hangzhou, China. Surgical procedure, postoperative course, and follow-up data were collected. RESULTS Laparoscopic central pancreatectomy was performed successfully in all the patients. The pancreaticojejunostomy was executed with a modified "dunking" pancreaticojejunostomy (n=7) or duct-to-mucosa pancreaticojejunostomy (n=1). The mean operative time was 286±27 minutes (range, 250-330 minutes), with a mean blood loss of 57±21 mL (range, 30-100 mL). Mortality was 0%, and perioperative morbidity was 37.5% (pancreatic fistula [grade A], bleeding of a splenic vein branch, and retroperitoneal infection). The median postoperative hospital stay was 10 days (range, 6-38 days). At a median follow-up of 7.5 months (range, 2-24 months), all patients were alive without any exocrine or endocrine insufficiency or recurrence. CONCLUSIONS Laparoscopic central pancreatectomy is feasible and safe. The modified "dunking" pancreaticojejunostomy can be performed safely in this approach.
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Affiliation(s)
- Renchao Zhang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University , Hangzhou, Zhejiang Province, China
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Kadowaki S, Miura F, Amano H, Toyota N, Wada K, Shibuya M, Maeno S, Takada T, Sano K. Whereabouts of an internal short stent placed across the pancreaticojejunostomy following pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 19:566-77. [PMID: 22869100 DOI: 10.1007/s00534-012-0533-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND/PURPOSE It is generally thought that an internal short stent placed across the pancreaticojejunostomy (PJ) following pancreatoduodenectomy (PD) usually passes spontaneously through the rectum thereafter; however, we experienced some patients who presented with pancreatitis and cholangitis owing to delayed defecation of the stent. The purpose of this study was to clarify when the stent eventually became detached from the PJ and how it passed through the body until it was finally defecated. In addition, we also investigated the factors that may prevent such detachment and defecation. METHODS This study retrospectively analyzed 57 patients who had had internal short stents placed across the PJ following PD. Defecation from the body, detachment from the PJ, and distal migration of the stent was confirmed by X-ray or computed tomography (CT) during the postoperative course. The cumulative rates of defecation and detachment of the stents, complications in relation to delayed defecation of the stents, and factors predictive of the delayed defecation, delayed detachment, and distal migration of the stents were analyzed. RESULTS Defecation of the stent was confirmed in 35 patients. The median time to defecation after PD and the cumulative defecation rate at 1 year were 454 days and 41 %, respectively. Acute pancreatitis occurred in 2 patients with the stent remaining in the pancreatic duct. One patient experienced acute cholangitis owing to migration of the stent to the bile duct. Multivariate analysis showed that ≥5 stitches in the duct-to-mucosa anastomosis, stent size of ≥5 Fr, and pancreatic fistula classified as either Grade B or C were independent predictive factors for delayed defecation of the stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed detachment of the stent. A stent size of ≥5 Fr was a risk factor for distal migration of the stent. CONCLUSION In more than half of the study patients, internal short stents were not defecated within 1 year. Retrieval of the stent should be considered following the migration of an internal short stent. A stent size of ≥5 Fr was an independent predictive factor for delayed defecation and distal migration of a stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed defecation and detachment of a stent.
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Affiliation(s)
- Susumu Kadowaki
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan
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Ansorge C, Strömmer L, Andrén-Sandberg Å, Lundell L, Herrington MK, Segersvärd R. Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy. Br J Surg 2012; 99:1076-1082. [DOI: 10.1002/bjs.8784] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Abstract
Background
The morbidity rate after pancreaticoduodenectomy remains high (20–50 per cent) and postoperative pancreatic fistula (POPF) is a major underlying factor. POPF has been reported to be associated with pancreatic consistency (PC) and pancreatic duct diameter (PDD). The aim was to quantify the risk of pancreaticojejunostomy-associated morbidity (PJAM) by means of a structured intraoperative assessment of both characteristics.
Methods
This single-centre prospective observational study included pancreaticoduodenectomies performed between 2008 and 2010 with a standardized duct-to-mucosa end-to-side pancreaticojejunostomy. PC and PDD were assessed during surgery and classified into four grades each (from very hard to very soft, and from larger than 4 mm to smaller than 2 mm, respectively). PJAM was defined as POPF (grade B or C in International Study Group on Pancreatic Fistula classification) or symptomatic peripancreatic collection of either abscess or fluid. PJAM of at least Clavien grade IIIb was considered severe.
Results
PJAM and POPF were observed in 24 (21·8 per cent) and 17 (15·5 per cent) of 110 patients respectively. Softer PC and smaller PDD were risk factors for POPF (both P < 0·001), symptomatic peripancreatic collections (P = 0·071 and P = 0·015) and PJAM (both P < 0·001). Combining consistency and duct characteristics in a composite classification the PJAM risk was stratified as ‘high’ (both risk factors, PJAM incidence 51 per cent), ‘intermediate’ (softer PC or smaller PDD, PJAM 26 per cent) or ‘low’ (no risk factors, PJAM 2 per cent). Severe PJAM was observed only in patients with smaller PDD.
Conclusion
A high-risk pancreatic gland had a 25-fold higher risk of PJAM after pancreaticoduoden- ectomy than a low-risk gland. This simple classification can contribute to more individualized patient management and allow stratification of study cohorts with homogeneous POPF risk.
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Affiliation(s)
- C Ansorge
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - L Strömmer
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - Å Andrén-Sandberg
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - M K Herrington
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
- Department of Biology, Adams State College, Alamosa, Colorado, USA
| | - R Segersvärd
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
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