A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: A meta-analysis of 2822 patients

The impact of pylorus preservation on the development of nonalcoholic fatty liver disease after pancreaticoduodenectomy: A historical cohort study

BACKGROUND/PURPOSE

The pathophysiology and associated factors of nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD) remain elusive. We aimed to investigate these factors, including the operation type, for NAFLD development after PD.

METHODS

This historical cohort study included 786 consecutive patients treated with either classic Whipple operation or pylorus-preserving pancreaticoduodenectomy (PPPD) in Korea between 2012 and 2018. De novo NAFLD was determined based on hepatic attenuation in nonenhanced computed tomography during follow-up.

RESULTS

Of the 786 patients, 216 (27.5%) had a newly developed NAFLD at 2 years after PD. The incidences of newly developed NAFLD at 0.5, 1, 1.5, and 2 years were 13 (1.7%), 41 (5.2%), 48 (6.1%), and 114 (14.5%), respectively. The Whipple group showed a significantly higher incidence of NAFLD than the PPPD group (40.3% vs 24.5%, P < .001). Seventeen patients (2.2%) had severe fatty liver with abnormal liver enzymes. Multivariable analysis revealed that Whipple operation (vs PPPD; adjusted odds ratio [AOR]: 1.92, P < .001) and high preoperative body mass index (vs normal; AOR: 1.71, P = .001) were independently associated with a higher risk of NAFLD.

CONCLUSION

The incidence of NAFLD was 27.5% at 2 years after PD. Undergoing Whipple operation and high preoperative body mass index were significantly associated with de novo NAFLD development.

A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading

BACKGROUND

Morbidity and mortality from post-pancreatectomy haemorrhage (PPH) remains high. The International Study Group of Pancreatic Surgery (ISGPS) published guidelines to standardise definitions of PPH severity, management and reporting. This study aimed to i) identify the number of studies reporting PPH using ISGPS guidelines (Grade A, B or C) and ii) describe treatment modality success by grade.

METHODS

A systematic literature review was performed, identifying studies reporting PPH by ISGPS Grade and their subsequent management.

RESULTS

Of 62 studies reporting on PPH management, 17 (27.4%) stratified by ISGPS guidelines and included 608 incidences of PPH: 48 Grade A, 274 Grade B (62 early, 166 late, 46 unspecified) and 286 Grade C. 96% of Grade A PPH were treated conservatively. Of 62 early Grade B, 54.8% were managed conservatively and 37.1% surgically. Late Grade B were managed non-operatively in 25.3% (42/166), with successful endoscopy in 90.9% (10/11) and angiography in 90.3% (28/31). In Grade C, endoscopic treatment was successful in 64.4% (29/45) and angiography in 90.8% (108/119). Surgical intervention was required in 43.5% early Grade B, 7.8% late Grade B and 33.2% Grade C.

CONCLUSION

PPH grading is underreported and despite guidelines, inconsistencies remain when using definitions and reporting of outcomes.

Risk Factors for Delayed Gastric Emptying After Pancreaticoduodenectomy

OBJECTIVES

Delayed gastric emptying (DGE) is a complication that affects the length of hospitalization and associated cost after pancreaticoduodenectomy (PD). The reported risk factors for DGE were controversial. This study aimed to identify risk factors for the development of DGE after PD.

METHODS

The patients who underwent PD between October 2010 and October 2020 were retrospectively examined. Multivariate analysis was performed to predict the variables causing DGE.

RESULTS

In total, 225 patients underwent PD. The pylorus preserving PD was applied to 151 patients (67%), whereas standard PD to 74 (33%). The DGE was detected in 26 patients (11.5%). The majority of cases were classified as grade A (57.7%), whereas 38.4% as grade B and 3.9% as grade C. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 3.48; 95% confidence interval [CI], 1.45-8.34; P = 0.05), the preoperative biliary stent (OR, 2.5; 95% CI, 1.04-5.99; P = 0.039), and the pylorus resection (OR, 3.05; 95% CI, 1.28-7.25; P = 0.012) were independently associated with DGE.

CONCLUSIONS

We demonstrated that implementation of the preoperative stent, pylorus resection, and diabetes mellitus are independent risk factors for DGE. Pylorus preservation should remain the standard of care in PD.

Korean Surgical Practice Guideline for Pancreatic Cancer 2021: A summary of evidence-based surgical approaches

Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related deaths in Korea. Despite the increasing incidence and high mortality rate of pancreatic cancer, there are no appropriate surgical practice guidelines for the current domestic medical situation. To enable standardization of management and facilitate improvements in surgical outcome, a total of 10 pancreatic surgical experts who are members of Korean Association of Hepato-Biliary-Pancreatic Surgery have developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. This is an English version of the Korean Surgical Practice Guideline for Pancreatic Cancer 2021. This guideline includes 13 surgical questions and 15 statements. Due to the lack of high-level evidence, strong recommendation is almost impossible. However, we believe that this guideline will help surgeons understand the current status of evidence and suggest what to investigate further to establish more solid recommendations in the future.

Surgery for chronic pancreatitis in Finland is rare but seems to produce good long-term results

BACKGROUND

Abdominal pain in chronic pancreatitis (CP) may require invasive interventions. Surgical procedures are rare, and little is known about the long-term results.

AIM

To study the nationwide frequency of pancreatic surgery for CP in Finland, and postoperative symptoms and quality of life (QoL).

METHODS

All patients in Finland with a diagnosis of CP who had undergone pancreatic surgery during 2000-2008 were selected from a national register. Only patients with CP as an indication for pancreatic surgery were included. Medical records were studied and questionnaires QLQ-C30, PAN26 and AUDIT, and symptom questionnaires were sent out.

RESULTS

During the 9-year period, pancreatic surgery for CP was performed on 30 patients [77% men, median age 45 (21-62) years]. Eighty-three percent underwent endoscopic procedures before surgery. Surgery was performed a median 2 (0-10) years after the original CP diagnosis, and 17% developed postoperative complications. Primary pain relief after surgery was reported in 70% of cases. Need for strong pain medication was lower after surgery. Eight of 21 (38%) returned the questionnaires and 88% reported that surgery had reduced their pain and 63% were almost or entirely pain-free at a median 14 (10-18) years after surgery. QoL results did not differ from those in our control Finnish CP group.

CONCLUSION

Surgery for CP is rare in Finland and most patients had prior endoscopic procedures. Patients who returned the questionnaires reported less pain and good QoL during the 14-year follow-up.

A Systematic Review and Network-Meta-Analysis of Gastro-Enteric Reconstruction Techniques Following Pancreatoduodenectomy to Reduce Delayed Gastric Emptying

INTRODUCTION

This network meta-analysis aimed to identify the reconstruction technique associated with lowest rates of DGE following pancreatoduodenectomy (PD) from randomised controlled trials (RCTs).

METHODS

A systematic literature search of PubMed, Embase and MEDLINE databases was carried out using the PRISMA framework to identify all RCTs comparing reconstruction techniques of gastrojejunostomy after PD, with overall DGE as the primary endpoint. The primary outcome measure was overall DGE. Secondary outcomes were grade B/C DGE, duration of nasogastric tube, time to solid food intake, overall and grade B/C pancreatic fistula, bile leaks, reoperation, length of hospital stay and in-hospital mortality.

RESULTS

The search strategy identified eight RCTs including 761 patients. Six RCTs compared antecolic (n = 291 patients) and retrocolic Billroth II (n = 289 patients) reconstruction (n = 6 studies), and two RCTs compared antecolic Billroth II (n = 92 patients) and Roux-en-Y (n = 89 patients) reconstruction. Overall, antecolic Billroth II ranked best for overall and grade B/C DGE, bile leak, surgical site infection, length of stay and in-hospital mortality. Roux-en-Y was best for overall and grade B/C pancreatic fistula.

CONCLUSION

Antecolic Billroth II gastroenteric reconstruction is associated with the lowest rates of delayed gastric emptying after PD amongst the currently available techniques of gastrojejunostomy reconstructions.

Clinical outcomes of pancreaticoduodenectomy for pancreatic ductal adenocarcinoma depending on preservation or resection of pylorus

Backgrounds/Aims

The comparative effectiveness of pylorus-resecting pancreaticoduodenectomy (PRPD) and pylorus-preserving pancreaticoduodenectomy (PPPD) in pancreatic head cancer is still disputed. The aim of this study was to analyze the data obtained from a large, single center with PPPD compared with PRPD in terms of postoperative outcomes, including blood glucose levels and survival in patients with pancreatic head cancer.

Methods

Between January 2007 and December 2016, a total of 556 patients with pancreatic head cancer underwent either PPPD or PRPD. We analyzed the clinicopathologic data to assess short- and long-term outcomes retrospectively.

Results

For underlying disease, patients with DM in PPPD were fewer than in PRPD (33.0% vs. 46.2%, p=0.002). The median value of CA19-9 was significantly higher in PRPD than in PPPD (129.36 vs. 86.47, p=0.037). The incidence of Clavien-Dindo grade III to V major complications in PPPD was significantly higher than in PRPD (20.4% vs. 13.4%, p=0.032). Resection of pylorus was shown to reduce complications in univariate and multivariate analyses (p=0.032 and = 0.021, respectively). The 5-year survival rates were 27.6% in the PPPD group and 22.4% in the PRPD group (p=0.015).

Conclusions

The results of PPPD and PRPD showed no significant differences from those reported conventionally in previous studies. Although further well-designed studies are needed, it is more important to select the range of surgical resection for the patient’s disease regardless of resection of pylorus.

PANCREATICODUODENECTOMY: IMPACT OF THE TECHNIQUE ON OPERATIVE OUTCOMES AND SURGICAL MORTALITY

BACKGROUND

Pancreaticoduodenectomy (PD) is a procedure associated with significant morbidity and mortality. Initially described as gastropancreaticoduodenectomy (GPD), the possibility of preservation of the gastric antrum and pylorus was described in the 1970s.

AIM

To evaluate the mortality and operative variables of PD with or without pyloric preservation and to correlate them with the adopted technique and surgical indication.

METHOD

Retrospective cohort on data analysis of medical records of individuals who underwent PD from 2012 through 2017. Demographic, anthropometric and operative variables were analyzed and correlated with the adopted technique (GPD vs. PD) and the surgical indication.

RESULTS

Of the 87 individuals evaluated, 38 (43.7%) underwent GPD and 49 (53.3%) were submitted to PD. The frequency of GPD (62.5%) was significantly higher among patients with pancreatic neoplasia (p=0.04). The hospital stay was significantly shorter among the individuals submitted to resection due to neoplasias of less aggressive behavior (p=0.04). Surgical mortality was 10.3%, with no difference between GPD and PD. Mortality was significantly higher among individuals undergoing resection for chronic pancreatitis (p=0.001).

CONCLUSION

There were no differences in mortality, surgical time, bleeding or hospitalization time between GPD and PD. Pancreas head neoplasm was associated with a higher indication of GPD. Resection of less aggressive neoplasms was associated with lower morbidity and mortality.

Randomized trial of two types of gastrojejunostomy after pancreatoduodenectomy and risk of delayed gastric emptying (PAUDA trial)

BACKGROUND

Delayed gastric emptying (DGE) is the most important cause of an extended hospital stay after pancreatoduodenectomy. Reports suggest that a Roux-en-Y gastroenteric anastomosis may have lower incidence of DGE than a Billroth II reconstruction. The primary aim of this RCT was to compare Billroth II (single loop) and Roux-en-Y (double loop) after pancreatoduodenectomy to determine whether Roux-en-Y reconstruction is associated with a lower incidence of DGE. Secondary endpoints were postoperative complications.

METHODS

This was a randomized unblinded single-centre trial without masked evaluation of the main outcome. Patients undergoing pancreatoduodenectomy between 2013 and 2015 were randomized to undergo one of two types of gastroenteric anastomosis for reconstruction.

RESULTS

A total of 80 patients were randomized, 40 in each group. The incidence of DGE was the same in patients undergoing Billroth II or Roux-en-Y gastroenteric anastomosis (both 18 of 40 patients; P = 1·000). The grade of DGE was also similar in the Billroth II and Roux-en-Y groups (grade A, both 10 of 40; grade B, 5 of 40 versus 6 of 40; grade C, 3 of 40 versus 2 of 40; P = 0·962). The mortality rate was 3 per cent, with no significant difference between the two groups. There were no differences in the overall rate of postoperative morbidity, relaparotomy rate or duration of hospital stay.

CONCLUSION

The incidence and severity of DGE does not differ between single- or double-loop gastroenteric anastomosis performed after pancreatoduodenectomy. Registration number: NCT00915863 (http://www.clinicaltrials.gov).

PANCREATODUODENECTOMY: BRAZILIAN PRACTICE PATTERNS

Background:

Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative.

Aim:

To understand the Brazilian practice patterns for pancreatoduodenectomy.

Method:

A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery.

Results:

A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube.

Conclusion:

Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

Comparison of long-term benefits of organ-preserving pancreatectomy techniques for benign or low-grade malignant tumors at the pancreatic head

The aim of this article was to investigate and emphasize the clinical benefits of organ-preserving surgeries by comparing the pancreatic head resection with segmental duodenectomy (PHRSD), pylorus-preserving pancreatoduodenectomy (PPPD), and classic pancreatoduodenectomy (PD).A retrospective analysis of PHRSD (20 patients), PPPD (42 patients), and PD (92 patients) with benign lesions, low-grade malignancies, or early-stage carcinomas at the pancreatic head was performed since 2008. The intraoperative and postoperative courses and a long-term statuses were compared.The overall average age of the patients in 3 groups was 48.82 years old (range 12-76). The mean operative time and the blood loss were significantly less in the PHRSD and PPPD groups than that in the PD group (P < .05), but there were no differences between the PHRSD and PPPD groups. The possibilities of postoperative complications were equivalent in all 3 groups. During an average follow-up time of 61.1 months, there were no recurrence or distant metastasis happened. Patients in the PHRSD and PPPD groups had a better long-term nutritional status because they had less body weight loss (P < .01), and suffered less from long-term diarrhea (P < .001) than that in the PD group. However, the results in the PPPD group seemed to be better than that in the PHRSD group.PHRSD and PPPD are ideal procedures of organ-preserving pancreatectomy to fulfill the curative goals of benign lesions, low-grade malignancies, or early-stage carcinomas at the pancreatic head. It was proved to be operative safe and could bring patients with a better nutritional status and quality of life after surgery. However, PHRSD was more difficult with no better long-term benefits than PPPD, which asked a comprehensive consideration when made the surgical choice.

Our contrivances to diminish complications after pylorus-preserving pancreaticoduodenectomy

The objective of this study is to diminish postoperative complications after pylorus-preserving pancreaticoduodenectomy. Pylorus-preserving pancreaticoduodenectomy is still associated with major complications, especially leakage at pancreatojejunostomy and delayed gastric emptying. Traditional pylorus-preserving pancreaticoduodenectomy was performed in group A, while the novel procedure, an antecolic vertical duodenojejunostomy and internal pancreatic drainage with omental wrapping, was performed in group B (n = 40 each). We compared the following characteristics between the 2 groups: operation time, blood loss, time required before removal of nasogastric tube and resumption of food intake, length of hospital stay, and postoperative complications. The novel procedure required less time and was associated with less blood loss (both P < 0.0001). In the comparison of the 2 groups, group B showed less time for removal of nasogastric tubes and resumption of food intake, shorter hospital stays, and fewer postoperative complications (all P < 0.0001). The novel procedure appears to be a safe and effective alternative to traditional pancreaticoduodenectomy techniques.

A Study on the Dietary Intake and the Nutritional Status among the Pancreatic Cancer Surgical Patients

The adequate dietary intake is important to maintain the nutritional status of the patients after pancreatic cancer surgery. This prospective study was designed to investigate the dietary intake and the nutritional status of the patients who had pancreatic cancer surgery. Thirty-one patients (15 men, 16 women) were enrolled and measured body weight, body mass index (BMI), nutritional risk index (NRI), and Malnutrition Universal Screening Tool (MUST). Actual oral intake with nutritional impact symptoms recorded on the clinical research foam at every meal and medical information were collected from electronic medical charts. The rates of malnutrition at admission were 45.1% (14/31) and 28.9% (9/31) by NRI and MUST method, respectively, but those were increased to 87% (27/31) and 86.6% (26/31) after operation on discharge. The median values of daily intake of energy, carbohydrates, fat, and protein were 588.1 kcal, 96.0 g, 11.8 g, and 27.0 g, respectively. Most patients (n = 20, 64.5%) experienced two or more symptoms such as anorexia, abdominal bloating and early satiety. There were negative correlations between C-reactive protein (CRP) levels and the intake of total energy, protein, fat, and zinc. The rates of malnutrition were increased sharply after surgery and the dietary intake also influenced the inflammatory indicators. The results suggested that need of considering special therapeutic diets for the patients who received pancreatic surgery.

Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting, with or without replacement, is preferable. This is an update of a systematic review.

OBJECTIVES

To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and four major Chinese biomedical databases up to November 2015. We also searched several major trials registers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents, replacement versus no replacement following pancreaticoduodenectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. We showed the results as risk ratio (RR) or mean difference (MD), with 95% confidence interval (CI). We assessed the quality of evidence using GRADE (http://www.gradeworkinggroup.org/).

MAIN RESULTS

We included eight studies (1018 participants). The average age of the participants ranged from 56 to 68 years. Most of the studies were conducted in single centers in Japan (four studies), China (two studies), France (one study), and the USA (one study). The risk of bias was low or unclear for most domains across the studies. Stents versus no stentsThe effect of stents on reducing pancreatic fistula in people undergoing pancreaticoduodenectomy was uncertain due to the low quality of the evidence (RR 0.67, 95% CI 0.39 to 1.14; 605 participants; 4 studies). The risk of in-hospital mortality was 3% in people who did receive stents compared with 2% (95% CI 1% to 6%) in people who had stents (RR 0.73, 0.28 to 1.94; 605 participants; 4 studies; moderate-quality evidence). The effect of stents on reoperation was uncertain due to wide confidence intervals (RR 0.67, 0.36 to 1.22; 512 participants; 3 studies; moderate-quality evidence). We found moderate-quality evidence that using stents reduces total hospital stay by just under four days (mean difference (MD) -3.68, 95% CI -6.52 to -0.84; 605 participants; 4 studies). The risk of delayed gastric emptying, wound infection, and intra-abdominal abscess was uncertain (gastric emptying: RR 0.75, 95% CI 0.24 to 2.35; moderate-quality evidence) (wound infection: RR 0.73, 95% CI 0.40 to 1.32; moderate-quality evidence) (abscess: RR 1.38, 0.49 to 3.85; low-quality evidence). Subgroup analysis by type of stent provided limited evidence that external stents lead to lower risk of fistula compared with internal stents. External versus internal stentsThe effect of external stents on the risk of pancreatic fistula, reoperation, delayed gastric emptying, and intra-abdominal abscess compared with internal stents was uncertain due to low-quality evidence (fistula: RR 1.44, 0.94 to 2.21; 362 participants; 3 studies) (reoperation: RR 2.02, 95% CI 0.38 to 10.79; 319 participants; 3 studies) (gastric emptying: RR 1.65, 0.66 to 4.09; 362 participants; 3 studies) (abscess: RR 1.91, 95% CI 0.80 to 4.58; 362 participants; 3 studies). The rate of in-hospital mortality was lower in studies comparing internal and external stents than in those comparing stents with no stents. One death occurred in the external-stent group (RR 0.33, 0.01 to 7.99; low-quality evidence). There were no cases of pancreatitis in participants who had internal stents compared with three in those who had external stents (RR 0.15, 0.01 to 2.73; low-quality evidence). The difference between internal and external stents on total hospital stay was uncertain due to the wide confidence intervals around the average effect of 1.7 days fewer with internal stents (9.18 days fewer to 5.84 days longer; 262 participants; 2 studies; low-quality evidence). The analysis of wound infection could not exclude a protective effect with either approach (RR 1.41, 0.44 to 4.48; 319 participants; 2 studies; moderate-quality evidence). Operative replacement of pancreatic juice versus not replacing pancreatic juice There was insufficient evidence available from a small trial to ascertain the effect of replacing pancreatic juice.

AUTHORS' CONCLUSIONS

This systematic review has identified limited evidence on the effects of stents. We have not been able to identify convincing direct evidence of superiority of external over internal stents. We found a limited number of RCTs with small sample sizes. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.

Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma

BACKGROUND

Pancreatic cancer is the fourth-leading cause of cancer death for both, men and women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, postoperative mortality, complications, and quality of life.

OBJECTIVES

The objective of this systematic review was to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region.

SEARCH METHODS

We conducted searches on 28 March 2006, 11 January 2011, 9 January 2014, and 18 August 2015 to identify all randomised controlled trials (RCTs), while applying no language restrictions. We searched the following electronic databases on 18 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) from the Cochrane Library (2015, Issue 8); MEDLINE (1946 to August 2015); and EMBASE (1980 to August 2015). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010); we did not update this part of the search for the 2014 and 2015 updates because the prior searches did not contribute any additional information. We identified two additional trials through the updated search in 2015.

SELECTION CRITERIA

RCTs comparing CW versus PPW including participants with periampullary or pancreatic carcinoma.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included trials. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs), and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included trials according to the standards of The Cochrane Collaboration.

MAIN RESULTS

We included eight RCTs with a total of 512 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Postoperative mortality (OR 0.64, 95% confidence interval (CI) 0.26 to 1.54; P = 0.32), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P = 0.29), and morbidity showed no significant differences, except of delayed gastric emptying, which significantly favoured CW (OR 3.03, 95% CI 1.05 to 8.70; P = 0.04). Furthermore, we noted that operating time (MD -45.22 minutes, 95% CI -74.67 to -15.78; P = 0.003), intraoperative blood loss (MD -0.32 L, 95% CI -0.62 to -0.03; P = 0.03), and red blood cell transfusion (MD -0.47 units, 95% CI -0.86 to -0.07; P = 0.02) were significantly reduced in the PPW group. All significant results were associated with low-quality evidence based on GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria.

AUTHORS' CONCLUSIONS

Current evidence suggests no relevant differences in mortality, morbidity, and survival between the two operations. However, some perioperative outcome measures significantly favour the PPW procedure. Given obvious clinical and methodological heterogeneity, future high-quality RCTs of complex surgical interventions based on well-defined outcome parameters are required.

[No-touch pancreatectomy and radical antegrade modular pancreatosplenectomy: a systematic review]

AIM

To summarize the data of 'no-touch isolation technique' (NIT) for pancreatoduodenectomy and radical antegrade modular pancreato-splenectomy (RAMPS) for pancreatic malignancies.

MATERIAL AND METHODS

We looked through Pubmed and Cochrane databases for scientific papers published from January 2000 until September 2014.

RESULTS

Eight studies were included. There were 7 retrospective cohort studies and one randomized controlled trial (RCT). Mean operation time and blood loss were 267 min (198-386 min) and 132 ml (331-744 ml) respectively. Mean morbidity rate was 35% (17-58%). There was no 30-day mortality. Mean incidence of R0-resection varied from 50% to 97% with average value 84%. Median survival was reported in 3 studies (17, 18 and 26 months). Five-year actuarial overall survival was reported in 4 studies (31, 36, 40 and 53%).

CONCLUSION

Positive results of NIT and RAMPS might justify further evaluation of the method in pancreatic cancer. Prospective randomized controlled trials needs to be done to demonstrate the oncological value of this novel surgical technique.

Delayed Gastric Emptying After Pancreaticoduodenectomy: Is Subtotal Stomach Preserving Better or Pylorus Preserving?

BACKGROUND

Delayed gastric emptying (DGE) is one of the main complications after pancreaticoduodenectomy (PD). Literature review and meta-analysis were used to evaluate whether subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) may have less incidence than pylorus-preserving pancreaticoduodenectomy (PPPD).

METHODS

Online search for studies comparing PPPD to SSPPD was done. Primary outcome was DGE. Quality of included studies was evaluated and heterogeneity was assessed. Relative risk (RR) and 95% confidence intervals (CI) were calculated from pooled data in RCTs and retrospective studies.

RESULTS

Eight studies met our selection criteria, with a total of 663 patients undergoing pancreaticoduodenectomy; 309 underwent PPPD and 354 underwent SSPPD. Median age was 66 years. Average male/female ratio was 57 vs. 43%, respectively. There was lower incidence of DGE with SSPPD (RR 0.527; 95% CI 0.363-0.763; p < 0.001) and less nasogastric tube days with SSPPD (RR -0.544; 95% CI -876 to -0.008; p = 0.047). Operative blood loss was more in SSPPD (RR 0.285; 95% CI 0.071-0.499; p = 0.009). There was no statistical difference between the two groups regarding length of hospital stay, incidence of pancreatic fistula, abscesses, overall morbidity, or postoperative mortality.

CONCLUSION

SSPPD was associated with less DGE than PPPD. Larger prospective randomized studies are needed to investigate the association of this result with other complications in more depth.

Meta-analysis of subtotal stomach-preserving pancreaticoduodenectomy vs pylorus preserving pancreaticoduodenectomy

AIM: To investigate the differences in outcome following pylorus preserving pancreaticoduodenectomy (PPPD) and subtotal stomach-preserving pancreaticoduodenectomy (SSPPD).

METHODS: Major databases including PubMed (Medline), EMBASE and Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched for comparative studies between patients with PPPD and SSPPD published between January 1978 and July 2014. Studies were selected based on specific inclusion and exclusion criteria. The primary outcome was delayed gastric emptying (DGE). Secondary outcomes included operation time, intraoperative blood loss, pancreatic fistula, postoperative hemorrhage, intraabdominal abscess, wound infection, time to starting liquid diet, time to starting solid diet, period of nasogastric intubation, reinsertion of nasogastric tube, mortality and hospital stay. The pooled odds ratios (OR) or weighted mean difference (WMD) with 95% confidence intervals (95%CI) were calculated using either a fixed-effects or random-effects model.

RESULTS: Eight comparative studies recruiting 650 patients were analyzed, which include two RCTs, one non-randomized prospective and 5 retrospective trial designs. Patients undergoing SSPPD experienced significantly lower rates of DGE (OR = 2.75; 95%CI: 1.75-4.30, P < 0.00001) and a shorter period of nasogastric intubation (OR = 2.68; 95%CI: 0.77-4.58, P < 0.00001), with a tendency towards shorter time to liquid (WMD = 2.97, 95%CI: -0.46-7.83; P = 0.09) and solid diets (WMD = 3.69, 95%CI: -0.46-7.83; P = 0.08) as well as shorter inpatient stay (WMD = 3.92, 95%CI: -0.37-8.22; P = 0.07), although these latter three did not reach statistical significance. PPPD, however, was associated with less intraoperative blood loss than SSPPD [WMD = -217.70, 95%CI: -429.77-(-5.63); P = 0.04]. There were no differences in other parameters between the two approaches, including operative time (WMD = -5.30, 95%CI: -43.44-32.84; P = 0.79), pancreatic fistula (OR = 0.91; 95%CI: 0.56-1.49; P = 0.70), postoperative hemorrhage (OR = 0.51; 95%CI: 0.15-1.74; P = 0.29), intraabdominal abscess (OR = 1.05; 95%CI: 0.54-2.05; P = 0.89), wound infection (OR = 0.88; 95%CI: 0.39-1.97; P = 0.75), reinsertion of nasogastric tube (OR = 1.90; 95%CI: 0.91-3.97; P = 0.09) and mortality (OR = 0.31; 95%CI: 0.05-2.01; P = 0.22).

CONCLUSION: SSPPD may improve intraoperative and short-term postoperative outcomes compared to PPPD, especially DGE. However, these findings need to be further ascertained by well-designed randomized controlled trials.

[Surgery for pancreatic cancer: Evidence-based surgical strategies]

Pancreatic cancer surgery represents a challenge for surgeons due to its technical complexity, the potential complications that may appear, and ultimately because of its poor survival. The aim of this article is to summarize the scientific evidence regarding the surgical treatment of pancreatic cancer in order to help surgeons in the decision making process in the management of these patients .Here we will review such fundamental issues as the need for a biopsy before surgery, the type of pancreatic anastomosis leading to better results, and the need for placement of drains after pancreatic surgery will be discussed.

The effect of pylorus removal on delayed gastric emptying after pancreaticoduodenectomy: a meta-analysis of 2,599 patients

BACKGROUND

Delayed gastric emptying is a serious complication of pancreaticoduodenectomy. The effect of pylorus removal on delayed gastric emptying has not been well evaluated.

STUDY DESIGN

We searched five databases (PubMed, EMBASE and the Cochrane Central Register of Controlled Trials, Scopus and Web of Science) up to July 2014. The meta-regression analysis was performed to evaluate any factors accountable for the heterogeneity. Publication bias was assessed by Egger's test, and corrected by Duval's trim and fill method. Subgroup analyses were conducted for different surgical techniques of pyloric removal. Other intraoperative and postoperative parameters were compared between two groups.

RESULTS

We included 27 studies involving 2,599 patients, with a moderate-high heterogeneity for primary outcome (I(2) = 63%). Meta-regression analysis showed that four variables primarily contributed to the heterogeneity, namely nasogastric tube intubation time, solid food start time, preoperative diabetes percentage and the number of patients in pylorus-preserving group. After excluding four studies, the remaining twenty-three studies showed reduced heterogeneity (I(2) = 51%). Then we used Duval's trim and fill method to correct publication bias. The corrected MH odds ratio was 0.78 (95% CI: 0.52-1.17). A subgroup analysis showed that pylorus removal tends to reduce delayed gastric emptying incidence for subtotal stomach-preserving pancreaticoduodenectomy or pylorus-resecting pancreaticoduodenectomy, compared with pylorus-preserving group. However, standard Whipple procedure failed to show any significant reduction of DGE compared with pylorus-removal group. No significant differences were observed in terms of length of hospital stay, infection and pancreatic fistula; however, pylorus removal resulted in longer operation time, more blood loss and higher mortality.

CONCLUSION

The pylorus removal does not significantly reduce the overall incidence of delayed gastric emptying. Subtotal stomach-preserving pancreaticoduodenectomy or pylorus-resecting pancreaticoduodenectomy tends to reduce delayed gastric emptying incidence, but needs further validation.

Intraoperative Schnellschnittuntersuchungen parapylorischer Lymphknoten bei der pyloruserhaltenden Pankreaskopfresektion: Gibt es eine klinische Relevanz?

Hintergrund

Die pyloruserhaltende Pankreaskopfresektion (PPPD) ist als onkologisches Standardverfahren etabliert. Lokal fortgeschrittene Tumoren können eine erweiterte Resektion erforderlich machen. Ebenso soll früheren Arbeiten zufolge bei Tumornachweis in den parapylorischen Lymphknoten (PLK) eine distale Magenresektion im Sinne einer klassischen Whipple-Operation indiziert sein. Entsprechend diesen Empfehlungen haben wir intraoperative Schnellschnittuntersuchungen der PLK in unseren Routineablauf integriert. Im Rahmen dieser Studie haben wir die klinische Relevanz dieses Vorgehens hinterfragt.

Methoden

Bei 105 onkologischen Patienten im Zeitraum von 2006-2012 bestand die Indikation zur PPPD. In allen Fällen erfolgte eine intraoperative Schnellschnittuntersuchung der PLK. Die Patienten wurden bezüglich Primärtumor, Anzahl der untersuchten Lymphknoten (LK) (gesamt und parapylorisch) sowie Auswirkungen auf das operative Konzept untersucht. Es handelt sich um eine retrospektive Studie, die auf prospektiv erhobenen Daten unserer Pankreasdatenbank basiert.

Ergebnisse

Die Primärtumoren waren 72 Pankreaskopfkarzinome und 33 extrapankreatische Karzinome (Gallengangskarzinom, Ampullenkarzinom, Duodenalkarzinom). 73 Patienten waren nodalpositiv. Insgesamt wurden 2391 LK untersucht, von denen 325 parapylorisch lokalisiert waren. Die intraoperative Schnellschnittuntersuchung erbrachte lediglich bei 4 Patienten mit Pankreaskopfkarzinom jeweils einen positiven PLK; daraufhin erfolgte eine distale Magenresektion. In keinem der distalen Magenresektate waren Tumorresiduen nachweisbar. Lokale chirurgisch-technische Probleme im Sinne von Durchblutungsstörungen des Magens ergaben sich durch die regionale Lymphadenektomie nicht. PLK waren nur beim Pankreaskarzinom positiv. In der Subgruppe der nodalpositiven Patienten mit Pankreaskopfkarzinom hatten 8% der Patienten einen positiven PLK.

Schlussfolgerung

Die regionale parapylorische Lymphadenektomie ist beim Pankreaskarzinom in einigen (5%) Fällen onkologisch sinnvoll. Der Nutzen einer intraoperativen Schnellschnittuntersuchung mit nachfolgender Konsequenz für eine etwaige distale Magenresektion ist anhand unserer Daten nicht belegbar.

Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date, there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting is preferable.

OBJECTIVES

To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ISI Web of Science and four major Chinese biomedical databases were searched up to February 2011. We also searched four major trials registers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents following pancreaticoduodenectomy.

DATA COLLECTION AND ANALYSIS

Two authors extracted the data independently. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. The results were shown as relative risk (RR) with 95% confidence interval (CI).

MAIN RESULTS

A total of 656 patients were included in the systematic review. Overall, the use of stents (both external and internal) was not associated with a statistically significant change in any of the studied outcomes. In a subgroup analysis, it was found that the use of external, but not internal, stents is associated with a significant reduction in the incidence of pancreatic fistulae (RR 0.33; 95% CI 0.11 to 0.98, P = 0.04), the incidence of complications (RR 0.48; 95% CI 0.25 to 0.92, P = 0.03) and length of hospital stay (RR -0.57; 95% CI -0.94 to -0.21, P = 0.002). In RCTs on the use of internal versus external stents, no statistically significant difference was found in terms of any of the studied outcomes.

AUTHORS' CONCLUSIONS

This systematic review suggests that the use of external stents following pancreaticoduodenectomy may be beneficial. However, only a limited number of RCTs with rather small sample sizes were available. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.

Pancreatic surgery: indications, complications, and implications for nutrition intervention

Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.

Proposal for splenectomy-omitting radical distal pancreatectomy in well-selected left-sided pancreatic cancer: multicenter survey study

BACKGROUND

When distal pancreatectomy is carried out for left-sided pancreatic cancer, splenectomy is usually performed not only for margin-negative resection but also for effective clearance of the splenic hilar lymph nodes (LNs). However, the incidence of splenic hilar LN metastasis in these patients has not been definitively determined.

METHODS

From April 2010 to June 2011, in a pilot study, we analyzed the medical records of twelve patients who had undergone radical antegrade modular pancreatosplenectomy. Potential remnant soft tissue around the splenic hilum, which would be left following an extended Warshaw's procedure, was dissected and sent to a pathologist. Three Japanese medical centers conducted a retrospective survey of splenic hilar lymph node metastasis in left-sided pancreatic cancer to support our study.

RESULTS

In the pilot study, all twelve patients had adenocarcinoma with a median tumor size of 2 cm. Six patients had LN metastasis and a median number of 4 splenic hilar LNs were evaluated; however, no splenic hilar LN metastasis was noted. In the Japanese multicenter survey (n = 85), only four patients had splenic LN metastasis. Small (<3 cm) and proximal (neck/body) left-sided pancreatic cancer might not be associated with splenic hilar LN metastasis (P < 0.05).

CONCLUSIONS

In well-selected left-sided pancreatic cancer, the incidence of splenic hilar LN metastasis is low enough that splenectomy-omitting radical distal pancreatectomy would be feasible. The rationale for routine splenectomy should be re-evaluated, and the oncologic effects of the preserved spleen need to be investigated further.

Classic Whipple versus pylorus-preserving pancreaticoduodenectomy in the ACS NSQIP

BACKGROUND

The classic Whipple operation carries substantial risk of complications. A pylorus-preserving pancreaticoduodenectomy might confer the benefit of decreased perioperative morbidity, but existing data comparing both techniques are inconclusive.

METHODS

Using a propensity score model to adjust for potentially confounding differences in patient characteristics, 30-d mortality, operative time, red blood cell transfusion requirements, major complications, and length of hospital stay were compared between both techniques in the American College of Surgeons' National Surgical Quality Improvement Program database. Separate analyses were carried out for underlying malignancy or benign disease, as defined by International Classification of Diseases, Ninth Revision codes.

RESULTS

A total of 6988 pancreaticoduodenectomies from 2005 through 2010 were included. In 5424 patients (77.6%) with underlying malignancy, there were no significant differences for 30-d mortality (2.4% versus 2.8%, P = 0.33) and major organ system complications (all P > 0.10). Patients undergoing the classic Whipple operation had a significantly longer operative time (389 versus 366 min, P < 0.01), longer length of hospital stay (13.1 versus 12.0 days, P < 0.01), and higher red blood cell transfusion requirements (1.0 versus 0.8 units, P < 0.01). Results were similar for 1564 patients (22.4%) with underlying benign disease, except for a higher occurrence of postoperative pulmonary (P = 0.02) and renal (P = 0.05) complications in patients undergoing the classic Whipple operation.

CONCLUSIONS

Short-term outcomes after classic and pylorus-preserving pancreaticoduodenectomy in this large, multicenter database are excellent, without significant differences in postoperative mortality and most major organ system complications. However, small advantages in resource and blood utilization may be accomplished with the pylorus-preserving technique.

Minimalinvasive Chirurgie bei Malignomen des Gastrointestinaltrakts: Pankreas - Kontra-Position

<b><i>Hintergrund: </i></b>Für eine Vielzahl von Erkrankungen der Bauchspeicheldrüse gilt die chirurgische Resektion als die Therapie der Wahl. In den vergangenen Jahren wurden die offenen Operationsmethoden für Pankreaserkrankungen zunehmend standardisiert und können mittlerweile mit hoher Sicherheit durchgeführt werden. Unabhängig davon wird zunehmend über laparoskopische Pankreasresektionen berichtet. <b><i>Methode: </i></b>In diesem Artikel stellen wir die aktuelle Literatur zur minimalinvasiven Chirurgie der Bauchspeicheldrüse vor, um sie mit offenen Operationsverfahren zu vergleichen. Besondere Berücksichtigung finden laparoskopische und roboterassistierte Duodenopankreatektomien sowie laparoskopische Pankreasschwanzresektionen bei Patienten mit chronischer Pankreatitis sowie mit gutartigen und bösartigen Tumoren. <b><i>Ergebnisse: </i></b>Laparoskopische und roboterassistierte Pankreaskopfresektionen sollten nur in ausgewählten Fällen angewandt werden und gelten als technisch äußerst anspruchsvoll - mit einer erhöhten Inzidenz von Pankreasfisteln. Laparoskopische Pankreasschwanzresektionen sind sichere Verfahren mit einem Trend zu einer kürzeren Krankenhausaufenthaltsdauer, sollten jedoch nur für gutartige Tumoren in Betracht gezogen werden. Im Rahmen der onkologischen Chirurgie sollte die offene Pankreasresektion bevorzugt werden. Werden onkologische Eingriffe laparoskopisch durchgeführt, ist eine ausgezeichnete präoperative Diagnostik und gegebenenfalls der Einsatz eines intraoperativen laparoskopischen Ultraschalls notwendig. <b><i>Schlussfolgerungen: </i></b>Obwohl laparoskopische Pankreasresektionen in ausgewählten Fällen von Nutzen sein können, werden sie zukünftig wohl eher die Ausnahme darstellen. Eine allgemeine Umstellung auf laparoskopische Pankreasschwanzresektionen wird aufgrund des Mangels an eindeutigen Vorteilen gegenüber dem offenen Verfahren höchstwahrscheinlich nicht stattfinden.

Pancreaticoduodenectomy for invasive pancreatic cancer (with video)

Pancreaticoduodenectomy (PD) is the only treatment option that potentially provides a cure for pancreatic head cancer. Various arrangements and modifications have been proposed to achieve pathological margin negative (R0) resection safely. In this article, we introduce a standard procedure for PD, including pancreaticogastrostomy with invagination and mattress sutures (video clip provided), for invasive ductal carcinoma of the pancreatic head, with a description of the need-to-know pitfalls for Board-certified HBP surgeons in Japan. The important points in performing PD for pancreatic cancer are: (1) While dissecting connective tissue and nerve plexus as well as lymph nodes, maintain a dissection plane to expose the surfaces of vessels or other organs to be preserved to achieve R0 resection: i.e., while dissecting the anterior surface of the inferior vena cava and the right side of the superior mesenteric artery, these vessels should be completely exposed with the connective tissue and nerve plexuses being attached to the resection side. (2) There should be early interruption of the afferent blood supply via the inferior pancreaticoduodenal artery to reduce blood loss by avoiding congestion of the pancreatic head and to increase the operative safety (video clip provided). (3) Eligibility for PD should be carefully evaluated because there are many "resectable" but not many "curable" cases. In addition, the clinical significance of various modifications of the surgical techniques used for PD are also discussed.

Preservation of the pyloric ring has little value in surgery for pancreatic head cancer: a comparative study comparing three surgical procedures

BACKGROUND

Pylorus-preserving pancreatoduodenectomy (PPPD) has replaced conventional pancreatoduodenectomy with a distal gastrectomy (cPD) as the most commonly performed procedure. However, there has been no evidence from prospective studies to indicate the overwhelming superiority of PPPD over cPD. A recent report revealed that resection of the pyloric ring reduced the incidence of delayed gastric emptying (DGE) in a randomized controlled trial.

METHODS

In 158 patients with pancreatic head cancer, the perioperative outcomes and long-term nutritional consequences were retrospectively compared among three types of pancreatoduodenectomy: cPD; PPPD; and subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pyloric ring and duodenum were removed and more than 90% of the stomach was preserved.

RESULTS

The incidence of DGE was significantly higher in the PPPD group than in the cPD and SSPPD groups (27.3 vs. 5.8 and 5.4%, respectively; P = 0.0012). The serum albumin concentration and total lymphocyte count at 1 year postoperatively were significantly higher in the SSPPD group than in the PPPD group (P = 0.0303 and P = 0.0203, respectively). The patients in the SSPPD group showed longer survival times than the patients in the cPD and PPPD groups (median survival times, 21.3, 17.1, and 17.7 months, respectively), although the differences did not reach statistical significance.

CONCLUSIONS

Our results suggest that preservation of the pyloric ring without vagal innervation has little significance, and that SSPPD with better perioperative and long-term outcomes is more suitable as a standard procedure for patients with pancreatic head cancer.

Comparison of pancreatic head resection with segmental duodenectomy and pylorus-preserving pancreatoduodenectomy for benign and low-grade malignant neoplasms of the pancreatic head

OBJECTIVE

The aim of this study was to investigate the clinical benefits of pancreatic head resection with segmental duodenectomy (PHRSD) with a particular emphasis on the long-term outcome.

METHODS

A retrospective analysis of PHRSD (77 patients) and pylorus-preserving pancreatoduodenectomy (PPPD; 55 patients) was performed for benign and low-grade malignant neoplasms of the pancreatic head. The zintraoperative and postoperative courses and long-term nutritional statuses were compared.

RESULTS

The mean operative time and blood loss were significantly less in the PHRSD group than in the PPPD group (351 vs 395 minutes, P = 0.005; and 474 vs 732 mL, P < 0.0001, respectively). Fewer overall postoperative complications occurred in the PHRSD group than in the PPPD group (33.8% vs 52.7%, respectively, P = 0.03). Postoperative weight loss and changes in the serum total protein and albumin levels were significantly milder in the PHRSD group than in the PPPD group (P = 0.04, P = 0.04, and P = 0.046, respectively). The overall recurrence-free survival rates in patients with noninvasive intraductal papillary mucinous neoplasms were equivalent in both groups.

CONCLUSIONS

The present results suggest that PHRSD fulfills the operative safety, long-term nutritional status, and curative goals and could be the best option for patients with benign or low-grade malignant pancreatic lesions.

Increased hepcidin production impairs iron metabolism after pancreatoduodenectomy

BACKGROUND

The duodenum is a central organ for iron absorption. This study was performed to evaluate changes in body iron concentration and other iron-related molecules sequentially, in patients undergoing pancreatoduodenectomy (PD).

METHODS

Twenty-one patients who had undergone PD at our department were enrolled in the study. Measurements of serum iron (sFe), total iron-binding capacity (TIBC), serum ferritin (sFer), C-reactive protein (CRP), interleukin-6 (IL-6), hemoglobin (Hb), hematocrit (Ht), and serum hepcidin (sHep) were performed before surgery (Pre), and on postoperative days 3 (D3), 7 (D7), and 14 (D14).

RESULTS

The median values of sFe on Pre, D3, D7, and D14 were 73.0, 30.0, 33.0, and 41.0 microg/ dL, respectively (P < 0.05), and those of TIBC were 276.0, 160.0, 176.0, and 165.0 microg/ dL, respectively (P < 0.05). CRP and IL-6 became maximal on D3. The median values of sHep on Pre, D3, D7, and D14 were 18.9, 42.9, 25.7, and 21.2 mg/dL, respectively (P < 0.05). Hb and Ht reached minimum values on D3 and remained low until D14. The median values of sFer on Pre, D3, D7, and D14 were 135, 301, 267, and 233 ng/ dL, respectively.

CONCLUSIONS

Hepcidin production is increased after pancreatoduodenectomy. Because hepcidin is known to divert iron to storage-type ferritin rather than to erythropoiesis, iron administration intended for erythropoiesis during this period may be ineffective.

Pylorus preserving pancreaticoduodenectomy for peri-ampullary carcinoma, is it a good option?

Pancreaticoduodenectomy (PD) is the standard surgical treatment for resectable peri-ampullary tumors. It can be performed with or without pylorus preservation. Many surgeons have a negative opinion of pylorus preserving PD (PPPD) and consider it an inferior operation, especially from an oncological point of view. This article reviews the various aspects of PD in the context of operative factors like blood loss and operation time, complications such as delayed gastric emptying and anastomotic leaks, and the impact on quality of life and survival. We aim to show that PPPD is at least as good as classic PD, if not better in some aspects.

Estimated glomerular filtration rate is superior to measured creatinine clearance for predicting postoperative renal dysfunction in patients undergoing pancreatoduodenectomy

OBJECTIVE

A retrospective study was conducted to compare measured creatinine clearance (Ccr) with estimated glomerular filtration rate (eGFR) as a preoperative renal function test in patients undergoing pancreatoduodenectomy.

METHODS

The records of 139 patients undergoing pancreatoduodenectomy were enrolled, and preoperative Ccr, a 3-variable equation for eGFR (eGFR3) and a 5-variable equation for eGFR (eGFR5) were estimated. The maximum increases in the postoperative serum creatinine and urea nitrogen levels were compared between the groups with normal and abnormal levels relative to Ccr, eGFR3, and eGFR5.

RESULTS

There were 30 patients with abnormal Ccr levels, 17 with abnormal eGFR3 levels, and 16 with abnormal eGFR5 levels. Postoperative serum creatinine and urea nitrogen levels were significantly higher in patients with eGFR3 and eGFR5 abnormal levels than in patients with eGFR3 and eGFR5 normal levels. Postoperative serum creatinine and urea nitrogen levels tended to be higher in patients with Ccr abnormal level. The sensitivity and specificity of eGFR3 and eGFR5 for postoperative renal dysfunction were better than those of Ccr, and multivariate analysis showed that eGFR5 was the only independent predictive factor for postoperative renal dysfunction.

CONCLUSIONS

The eGFR5 and eGFR3, rather than the Ccr, are recommended as preoperative renal function test in patients undergoing pancreatoduodenectomy.

Impact of hospital volume on outcomes for pancreaticoduodenectomy: a single UK HPB centre experience

BACKGROUND

High hospital volume has a favorable impact on outcomes for complex procedures including pancreaticoduodenectomy (PD); however, the temporal relationship has not been evaluated in a single centre.

AIM

To evaluate the impact of UK cancer outcome guidelines (COG) on outcomes for PD in a single UK HPB specialist centre.

PATIENTS AND METHODS

All patients with pancreatic pathologies undergoing surgery at our institution from 1999 to 2006 were identified, of which 140 underwent PD. The annual caseload for PD and corresponding outcomes for length of hospital stay, morbidity, mortality and survival were analysed during the period around the implementation of UK COG with an increase in the surgical workload correlating with catchment's population increase from 1.6 to 3.1 million.

RESULTS

Between January 1999 and December 2006, 140 patients underwent a PD (M:F 1.06:1; median age 64 (range 34-84) years). Median hospital stay was 16 days (range 7-318). The 30-day mortality was 2.8%, in-hospital mortality was 6.4% and morbidity was 37.1%. Pancreatic leak/fistula rate was 8.6%. Over the 7-year period, PDs per year increased 5.3 fold from 6 procedures in 1999 to 32 in 2006. Analysis of the data for 1999-2002-(pre-COG) and 2003-2006-(post-COG) showed a trend towards decrease in mortality (from 9.7% to 5.0%, p = 0.448: OR = 2.74 (95% CI, 0.58-12.88); Fisher's exact test) and morbidity (from 41.6% to 35.3%; OR = 1.29 (95% CI, 0.74-3.56); p = 0.565).

CONCLUSION

With COG implementation within a single UK pancreatic unit, the PD volume and staffing levels increased with a trend towards decreased morbidity and mortality.

How to assess difficulty and the possibility of pancreatoduodenectomy

Pancreatoduodenectomy has wide use and also puts high technical requirements with more postoperative complications. How to assess the difficulty and the possibility of pancreatoduodenectomy and to avoid negative laparotomy has been a question that concerns people. The aim of this paper is to introduce some of our experience dealing with pancreatoduodenectomy.

Pancreatoduodenectomy with or without pyloric preservation: a clinical outcomes comparison

Pyloric preservation (PP) can frequently be performed at the time of pancreatoduodenectomy (PD), although some reports have linked it to inferior outcomes such as delayed gastric emptying (DGE). We reviewed records in a single-surgeon practice to assess outcomes after PD with or without PP. There were 133 PDs with 67 PPPDs and 66 PDs. Differences between PPPD and PD groups included cancer frequency, tumor size, OR time, blood loss, and transfusion rate. However, postoperative morbidity rate and grade, NG tube duration, NGT reinsertion rate, DGE, and length of stay were similar. There was no difference among patients with pancreatic cancer. No detrimental outcomes are associated with pyloric preservation during PD. Greater intraoperative ease and superior survival in the PPPD group are due to confounding, tumor-related variables in this nonrandomized comparison. Nevertheless, we intend to continue the use of PP with our technique in patients who meet the stated criteria.