Pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy: A meta-analysis of randomized control trials

Retrospective Comparative Analysis of POPF Using Fistula Risk Score According to Pancreaticoenterostomy Method

Background

The aim of this study is to examine whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is the better reconstructive method to reduce postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) according to the fistula risk.

Methods

An institutional database was reviewed for patients undergoing PD between January 2008 and August 2019. A total of 159 patients were stratified into 4 groups according to the Clinical Risk Score-Pancreatic Fistula. POPF according to 4 risk groups was compared between PJ and PG.

Results

Of the 159 patients, 82 underwent PG (51.6%) and 77 underwent PJ (48.4%) reconstruction. POPF rate was 17.1% (n = 14) in the PG group and 12.9% (n = 10) in the PJ group (P = 0.51). POPF rates were not different in intermediate, low, and negligible risks between 2 reconstructive methods. In the high-risk group (n = 47), there were 4 POPFs (22.2%) in PJ group and 9 (31.0%) in the PG group, respectively (P = 0.74).

Conclusion

In PD, there was no superior method of reconstruction with regard to POPF, even in high-risk glands.

The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: a network meta-analysis

INTRODUCTION

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile.

EVIDENCE ACQUISITION

A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistula(ISGPF) definition of POPF. The main outcomes were POPF and clinically relevant POPF.

RESULTS

Three techniques of pancreatic anastomosis following PD were directly compared in 16 RCTs comprising 2365 patients.

EVIDENCE SYNTHESIS

Overall, 929 patients underwent duct-to-mucosa pancreaticojejunostomy(PJ DTM), 760 patients invagination pancreaticojejunostomy(PJ Inv), and 676 patients underwent pancreatogastrostomy(PG). The results of comparisons of POPF, clinically relevant POPF, biliary leakage, delayed gastric emptying(DGE), in hospital mortality, internal hemorrhage, reoperation in our network meta-analysis suggested there were no significant differences among the 3 procedures.

CONCLUSIONS

There are no significant differences among PJ DTM, PJ Inv and PG in the prevention of POPF, clinically relevant POPF, biliary leakage, DGE, internal hemorrhage and reoperation. However, further randomized controlled trials should be undertaken to ascertain these findings.

Pancreatic fistula rates after internal and external stenting of the pancreatojejunostomy anastomosis following pancreatoduodenectomy

Background: This retrospective comparative case series study aims to analyze the pancreatic fistula rates of internal and external stenting of the pancreatojejunostomy (PJ) anastomosis in patients who underwent pancreatoduodenectomy (PD) for periampullary tumors.Methods: Ninety-eight patients with periampullary tumors who were operated between 2010 and 2017 were enrolled in this study. A classic open PD with Roux-en-Y PJ reconstruction was performed in all cases.Results: The PJ anastomosis of 53 patients (54%) were stented internally whereas in 45 patients (46%) external stenting was preferred. Pancreatic fistula was observed in 29 patients (29.6%). Internal stenting and soft pancreatic tissue were found to be related to higher pancreatic fistula rates with odds ratios of 3.27 (p = .024) and 3.4 (p = .017), respectively. When only grade B and grade C fistulas were taken into account, the type of stenting has lost its significance but the texture of the remnant pancreas was still associated with 'clinically important' pancreatic fistula.Conclusions: We concluded that the external stenting of the PJ anastomosis may be considered as an effective approach for reducing postoperative pancreatic leaks in PD-planned patients for periampullary tumors. Although our study was retrospectively designed, we used standard charts to gather patient data and compared two stenting methods among homogeneous patient groups.

Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature

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.

A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy

BACKGROUND

Many pancreatic anastomoses have been proposed to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, but a complete overview is lacking. This systematic review and meta-analysis aims to provide an online overview of all pancreatic anastomosis techniques and to evaluate the incidence of clinically relevant POPF in randomized controlled trials (RCTs).

METHODS

A literature search was performed to December 2017. Included were studies giving a detailed description of the pancreatic anastomosis after open pancreatoduodenectomy and RCTs comparing techniques for the incidence of POPF (International Study Group of Pancreatic Surgery [ISGPS] Grade B/C). Meta-analyses were performed using a random-effects model.

RESULTS

A total of 61 different anastomoses were found and summarized in 19 subgroups (www.pancreatic-anastomosis.com). In 6 RCTs, the POPF rate was 12% after pancreaticogastrostomy (n = 69/555) versus 20% after pancreaticojejunostomy (n = 106/531) (RR0.59; 95%CI 0.35-1.01, P = 0.05). Six RCTs comparing subtypes of pancreaticojejunostomy showed a pooled POPF rate of 10% (n = 109/1057). Duct-to-mucosa and invagination pancreaticojejunostomy showed similar results, respectively 14% (n = 39/278) versus 10% (n = 27/278) (RR1.40, 95%CI 0.47-4.15, P = 0.54).

CONCLUSION

The proposed online overview can be used as an interactive platform, for uniformity in reporting anastomotic techniques and for educational purposes. The meta-analysis showed no significant difference in POPF rate between pancreatic anastomosis techniques.

Strategies for pancreatic anastomosis after pancreaticoduodenectomy: What really matters?

BACKGROUND

The postoperative pancreatic fistula rate remains approximately 10-20% even in institutions treating a high-volume of pancreatic cases. The best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate.

DATA SOURCES

Studies were identified by searching PubMed for studies published between January 1934 (when pancreaticogastrostomy was technically feasible) and December 2016. The following search terms were used: "duct-to-mucosa", "invagination", "pancreaticojejunostomy", "pancreaticogastrostomy," and "pancreaticoduodenectomy". The search was limited to English publications.

RESULTS

Many technical methods have been developed and optimized to restore pancreaticoenteric continuity, including pancreaticojejunostomy, pancreaticogastrostomy, and stented drainage of the pancreatic duct, among other modifications. Researchers have also attempted to decrease the postoperative pancreatic fistula after pancreaticoduodenectomy by using fibrin glue and somatostatin analogues. However, no significant decrease in postoperative pancreatic fistula has been observed in most of these studies, and only an external pancreatic duct stent has been found to decrease the leakage rate of pancreatic anastomosis after pancreaticojejunostomy.

CONCLUSION

Pancreatic surgeons should choose a suitable technique according to the characteristics of individual cases.

Modified Blumgart anastomosis without pancreatic duct-to-jejunum mucosa anastomosis for pancreatoduodenectomy: a feasible and safe novel technique

Objective

This study proposed a modified Blumgart anastomosis (m-BA) that uses a firm ligation of the main pancreatic duct with a supporting tube to replace the pancreatic duct-to-jejunum mucosa anastomosis, with the aim of simplifying the complicated steps of the conventional BA (c-BA). Thus, we observe if a difference in the risk of postoperative pancreatic fistula (POPF) exists between the two methods.

Methods

The m-BA anastomosis method has been used since 2010. From October 2011 to October 2015, 147 patients who underwent pancreatoduodenectomy (PD) using BA in Tianjin Medical University Cancer Institute and Hospital were enrolled in this study. According to the type of pancreatojejunostomy (PJ), 50 patients underwent m-BA and 97 received c-BA. The two patient cohorts were compared prospectively to some extent but not randomized, and the evaluated variables were operation time, the incidence rate of POPF, and other perioperative complications.

Results

The operation time showed no significant difference (P > 0.05) between the two groups, but the time of duct-to-mucosa anastomosis in the m-BA group was much shorter than that in the c-BA group ( P < 0.001). The incidence rate of clinically relevant POPF was 12.0% (6/50) in the modified group and 10.3% (10/97) in the conventional group ( P > 0.05), which means that the modified anastomosis method did not cause additional pancreatic leakage. The mean length of postoperative hospital stay of the m-BA group was 23 days, and that of the c-BA group was 22 days ( P > 0.05).

Conclusions

Compared with the conventional BA, we suggest that the modified BA is a feasible, safe, and effective operation method for P J of PD with no sacrifice of surgical quality. In the multivariate analysis, we also found that body mass index (≥ 25 kg/m²) increased the risk of POPF.

Tailored pancreatic reconstruction after pancreaticoduodenectomy: a single-center experience of 892 cases

BACKGROUND

Pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debatable even for pancreatic surgeons. Ideally, pancreatic reconstruction after PD should reduce the risk of postoperative pancreatic fistula (POPF) and its severity if developed with preservation of both exocrine and endocrine pancreatic functions. It must be tailored to control the morbidity linked to the type of reconstruction. This study was to show the best type of pancreatic reconstruction according to the characters of pancreatic stump.

METHODS

We studied all patients who underwent PD in our center from January 1993 to December 2015. Patients were categorized into three groups depending on the presence of risk factors of postoperative complications: low-risk group (absent risk factor), moderate-risk group (presence of one risk factor) and high-risk group (presence of two or more risk factors).

RESULTS

A total of 892 patients underwent PD for resection of periampullary tumor. BMI >25 kg/m², cirrhotic liver, soft pancreas, pancreatic duct diameter <3 mm, and pancreatic duct location from posterior edge <3 mm are risk variables for development of postoperative complications. POPF developed in 128 (14.3%) patients. Delayed gastric emptying occurred in 164 (18.4%) patients, biliary leakage developed in 65 (7.3%) and pancreatitis presented in 20 (2.2%). POPF in low-, moderate- and high-risk groups were 26 (8.3%), 65 (15.7%) and 37 (22.7%) patients, respectively. Postoperative morbidity and mortality were significantly lower with pancreaticogastrostomy (PG) in high-risk group, while pancreaticojejunostomy (PJ) decreases incidence of postoperative steatorrhea in all groups.

CONCLUSIONS

Selection of proper pancreatic reconstruction according to the risk factors of patients may reduce POPF and postoperative complications and mortality. PG is superior to PJ as regards short-term outcomes in high-risk group but PJ provides better pancreatic function in all groups and therefore, PJ is superior in low- and moderate-risk groups.

Is pancreaticogastrostomy safer than pancreaticojejunostomy after pancreaticoduodenectomy? A meta-regression analysis of randomized clinical trials

OBJECTIVE

To evaluate the clinically relevant POPF rate between Pancreatogastrostomy (PG) and pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). To evaluate the confounding factors affecting meta-analytic results.

METHODS

A systematic literature search of randomized clinical trials (RCTs) comparing PG to PJ with an International Study Group of Pancreatic Fistula (ISGPF) definition of postoperative pancreatic fistula (POPF). Risk difference (RD) and number needed to treat or harm (NNT and NNH) were used. Fixed and random-effect models were applied. Impact of confounding covariates on the meta-analytic results was evaluated using meta-regression analysis, reporting β coefficient ± standard error (SE).

RESULTS

Seven RCTs were identified involving 1184 patients: 603 PG and 581 PJ. RD in the fixed model of clinically relevant POPFs suggested that PG was superior to PJ (RD-0.07; 95% CI: -0.11 to -0.03) with an NNT of 14 (95% CI: 9 to 33). In random model, PG was not superior to PJ (RD-0.06; 95% CI: -0.13 to 0.01) with an NNT of 17 and a possibility of harm in some cases (NNH = 100). Meta-regression suggested that the increase in the proportion of "soft pancreas" in the PG arm corresponded to a more positive value of RD (β = 0.47 ± 0.19; P value: 0.045 ± 0.003).

CONCLUSION

A PG could be slightly superior to PJ in the prevention of clinically relevant POPF. The presence of high risk pancreatic remnant remains the main limitation of PG.

Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015

BACKGROUND

Pancreatoduodenectomy (PD) is one of the most technically demanding operations challenging surgeons, and a postoperative pancreatic fistula (POPF) can complicate an otherwise uneventful postoperative (PO) course. This review examined the methods and procedures used to prevent postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD).

METHODS

A comprehensive systematic search of the literature was performed using PubMed (Medline), Embase, Web of science, and the Cochrane databases for studies published between January 1, 1990 and December 31, 2015. English language articles involving at least 100 patients undergoing PDs carried out in centers performing at least 10 PDs/y were screened for data regarding the Grade of any POPFs according to the definition of the International Study Group on Pancreatic Fistula (ISGPF) and the overall rate of PO mortality related to POPF.

RESULTS

We reviewed 7119 references through the major databases, and an additional 841 studies were identified by cross-checking the bibliographies of the full-text articles retrieved. After excluding 7379 out of 7960 studies, because they did not meet the eligibility criteria, the full texts of 581 articles were examined; 96 studies were excluded at this point, because they concerned partially or totally duplicate data that had already been reported. The remaining 485 articles were screened carefully for POPF-related mortality and POPF Grades as defined by the ISGPF. Of the 485 articles, 208 reported the POPF-related PO mortality rate and 162 the Grades (A, B, and C) of POPFs in 60,739 and 54,232 patients, respectively. The POPF-related mortality rates after pancreatojejunostomy and pancreatogastrostomy were similar but were less (0.5% vs. 1%; P = .014) when an externally draining, trans-anastomotic stent was placed intraoperatively. The incidence of the different Grades of POPF Grade was quite variable, but Grade C POPFs were associated with a PO mortality rate of 25.7% (range 0-100%).

CONCLUSIONS

The POPF-related mortality rate has remained at approximately 1% over the past 25 years. Only externally draining, trans-anastomotic stents decreased the POPF-related mortality rate. However, adequately designed venting drains were never tested in randomized controlled trials (RCTs).

A Novel Reconstruction Technique During Pancreaticoduodenectomy After Roux-En-Y Gastric Bypass: How I do It

The altered anatomy in patients after bariatric surgery who have undergone a Roux-en-Y gastric bypass may pose a technical challenge for surgical removal of the pancreatic head. We treat patients with pancreas cancer with multimodality therapy in a neoadjuvant fashion followed by pancreaticoduodenectomy (PD). In patients with Roux-en-Y gastric bypass anatomy, the gastric remnant is preserved and used for pancreaticogastrostomy reconstruction and subsequently drained by the same jejunal limb used for the hepaticojejunostomy. This method of reconstruction takes advantage of the previous surgically altered anatomy and avoids the morbidity of a gastric remnant resection at the time of PD.

Minimally Invasive Surgery for Pancreatic Disease - Current Status

Laparoscopic procedures have advanced to represent the new gold standard in many surgical fields. Although application in pancreatic surgery is hampered by the friable nature of the gland and the difficulty of its exposure, advanced technology and surgeons' experience are leading to an expansion of minimally invasive pancreatic surgery. Addressing the whole range of main operative procedures, this review analyzes the literature data so far to give an overview about the current status of minimally invasive pancreatic surgery, its indications and limitations. In acute pancreatitis, a step-up approach from percutaneous drainage to retroperitoneoscopic necrosectomy seems beneficial. Transgastric necrosectomy also preserves the retroperitoneal compartment in contrast to the laparoscopic approach, which has widely been abandoned. In tumor pathology, laparoscopic access is adequate for small benign lesions in the pancreatic tail and body. Oncological outcome shows to be at least equal to the open procedure. Concerning laparoscopic pancreaticoduodenectomy, there is no evidence for a patients' benefit currently although several studies prove that it can be done.

Pancreaticojejunostomy is comparable to pancreaticogastrostomy after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials

PURPOSE

To perform an up-to-date meta-analysis of randomized controlled trials (RCTs) comparing pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) in order to determine the safer anastomotic technique. Compared to existing meta-analysis, new RCTs were evaluated and subgroup analyses of different anastomotic techniques were carried out.

METHODS

We conducted a bibliographic research using the National Library of Medicine's PubMed database from January 1990 to July 2015 of RCTs. Only RCTs, in English, that compared PG versus all types of PJ were selected. Data were independently extracted by two authors. We performed a quantitative systematic review following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A random-effect model was applied. Statistical heterogeneity was assessed using the I (2) and χ (2) tests. Primary outcomes were rate of overall and clinically significant pancreatic fistula (POPF).

RESULTS

Ten RCTs were identified including 1629 patients, 826 undergoing PG and 803 undergoing PJ. RCTs showed significant heterogeneity regarding definitions of POPF, perioperative management, and characteristics of pancreatic gland. No significant differences were found in the rate of overall and clinically significant POPF, morbidity, mortality, reoperation, and intra-abdominal sepsis when PG was compared with all types PJ or when subgroup analysis (double-layer PG with or without anterior gastrotomy versus duct to mucosa PJ and single-layer PG versus single-layer end-to-end/end-to-side PJ) were analyzed.

CONCLUSIONS

PG is not superior to PJ in the prevention of POPF. Current RCTs have major methodological limitations with significant heterogeneity in regard to surgical techniques, definition of POPF/complications, and perioperative management.

Pancreaticojejunostomy Versus Pancreaticogastrostomy After Pancreaticoduodenectomy: An Up-to-date Meta-Analysis

BACKGROUND

The reconstruction of the pancreas after pancreaticoduodenectomy (PD) is a crucial factor in preventing postoperative complications as pancreatic anastomosis failure is associated with a high morbidity rate and contributes to prolonged hospitalization and mortality. Several techniques have been described for the reconstruction of pancreatic digestive continuity in the attempt to minimize the risk of a pancreatic fistula. The aim of this study was to compare the results of pancreaticogastrostomy and pancreaticojejunostomy after PD.

METHODS

A systematic review and meta-analysis were conducted of randomized controlled trials (RCTs) published up to January 2015 comparing patients with pancreaticogastrostomy (PG group) versus pancreaticojejunostomy (PJ group). Two reviewers independently assessed the eligibility and quality of the studies. The meta-analysis was conducted using either the fixed-effect or the random-effect model.

RESULTS

Eight RCTs describing 1,211 patients were identified for inclusion in the study. The meta-analysis shows that the PG group had a significantly lower incidence rate of postoperative pancreatic fistulas [OR 0.64 (95% confidence interval 0.46-0.86), p = .003], intra-abdominal abscesses [OR 0.53 (95% CI, 0.33-0.85), p = .009] and length of hospital stay [MD -1.62; (95% CI 2.63-0.61), p = .002] than the PJ group, while biliary fistula, mortality, morbidity, rate of delayed gastric emptying, reoperation, and bleeding did not differ between the two groups.

CONCLUSION

This meta-analysis suggests that the most effective treatment for reconstruction of pancreatic continuity after pancreatoduodenectomy is pancreaticogastrostomy. However, the advantage of the latter could potentially be demonstrated through further RCTs, including only patients at high risk of developing pancreatic fistulas.

Is there comparable morbidity in pylorus-preserving and pylorus-resecting pancreaticoduodenectomy? A meta-analysis

Pancreaticoduodenectomy (PD) is the most effective treatment for patients with pancreatic head or periampullary lesions. Two major strategies exist: pylorus-preserving pancreaticoduodenectomy (PPPD) and pylorus-resecting pancreaticoduodenectomy (PRPD). However, it is yet unclear regarding the morbidity after PPPD and PRPD. This study analyzed the morbidity after PPPD and PRPD to determine the optimal surgical treatment of masses in the pancreatic head or periampullary region. A systematic search of databases identifying randomized controlled trials (RCTs) from the Cochrane Library, PubMed, EMBASE and Web of Science was performed. Outcome was compared by postoperative morbidity including overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding, biliary leakage, ascites and delayed gastric emptying (DGE) rate between PPPD and PRPD. The DGE rate in the PRPD subgroups (conventional PD [CPD] and subtotal stomach-preserving PD [SSPPD], respectively) was also analyzed. The results showed that 9 RCTs including 722 participants were included for meta-analysis. Among these RCTs, 7 manuscripts described PRPD as CPD, and 2 manuscripts described PRPD as SSPPD. There were no significant differences in the overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding, or biliary leakage between PPPD and PRPD. There was a lower rate of DGE with PRPD than that with PPPD (RR=2.15, P=0.03, 95% CI, 1.09-4.23). Further subgroup analysis indicated a comparable DGE rate for the CPD but a lower DGE rate for the SSPPD group than the PPPD group. However, the result did not indicate any difference between CPD and SSPPD regarding the DGE rate (P=0.92). It is suggested that PPPD is comparable to PRPD in overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding and biliary leakage. The current data are not sufficient to draw a conclusion regarding which surgical procedure is associated with a lower postoperative DGE rate. Our conclusions were limited by the available data. Further evaluations of RCTs are needed.

Systematic review on the use of matrix-bound sealants in pancreatic resection

BACKGROUND

Pancreatic fistula is a potentially life-threatening complication after a pancreatic resection. The aim of this systematic review was to evaluate the role of matrix-bound sealants after a pancreatic resection in terms of preventing or ameliorating the course of a post-operative pancreatic fistula.

METHODS

A systematic search was performed in the literature from May 2005 to April 2015. Included were clinical studies using matrix-bound sealants after a pancreatic resection, reporting a post-operative pancreatic fistula (POPF) according to the International Study Group on Pancreatic Fistula classification, in which grade B and C fistulae were considered clinically relevant.

RESULTS

Two were studies on patients undergoing pancreatoduodenectomy (sealants n = 67, controls n = 27) and four studies on a distal pancreatectomy (sealants n = 258, controls n = 178). After a pancreatoduodenectomy, 13% of patients treated with sealants versus 11% of patients without sealants developed a POPF (P = 0.76), of which 4% versus 4% were clinically relevant (P = 0.87). After a distal pancreatectomy, 42% of patients treated with sealants versus 52% of patients without sealants developed a POPF (P = 0.03). Of these, 9% versus 12% were clinically relevant (P = 0.19).

CONCLUSIONS

The present data do not support the routine use of matrix-bound sealants after a pancreatic resection, as there was no effect on clinically relevant POPF. Larger, well-designed studies are needed to determine the efficacy of sealants in preventing POPF after a pancreatoduodenectomy.

Preoperative Computed Tomography to Predict and Stratify the Risk of Severe Pancreatic Fistula After Pancreatoduodenectomy

The aim of this article is to assess whether measures of abdominal fat distribution, visceral density, and antropometric parameters obtained from computed tomography (CT) may predict postoperative pancreatic fistula (POPF) occurrence.We analyzed 117 patients who underwent pancreatoduodenectomy (PD) and had a preoperative CT scan as staging in our center. CT images were processed to obtain measures of total fat volume (TFV), visceral fat volume (VFV), density of spleen, and pancreas, and diameter of pancreatic duct. The predictive ability of each parameter was investigated by receiver-operating characteristic (ROC) curves methodology and assessing optimal cutoff thresholds. A stepwise selection method was used to determine the best predictive model.Clinically relevant (grades B and C) POPF occurred in 24 patients (20.5%). Areas under ROC-curves showed that none of the parameters was per se significantly predictive. The multivariate analysis revealed that a VFV >2334 cm, TFV >4408 cm, pancreas/spleen density ratio <0.707, and pancreatic duct diameter <5 mm were predictive of POPF. The risk of POPF progressively increased with the number of factors involved and age.It is possible to deduce objective information on the risk of POPF from a simple and routine preoperative radiologic workup.

Pancreaticogastrostomy in pure laparoscopic pancreaticoduodenectomy--A novel pancreatic-gastric anastomosis technique

Background

Although many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not commonly performed because of the technical difficulty of pancreatic resection and the associated reconstruction procedures. Several pancreatic-enteric anastomosis techniques for LPD have been reported, but most are adaptations of open procedures. To accomplish pure LPD, we consider it necessary to establish new pancreatic-enteric anastomosis techniques that are specifically developed for LPD and are safe and feasible to perform.

Results

One patient developed a postoperative pancreatic fistula (International Study Group of Pancreatic Fistula criteria, grade B) and subsequent postoperative delayed gastric emptying (International Study Group of Pancreatic Surgery criteria, grade C). No other major complications occurred. We developed a novel pancreatic-gastric anastomosis technique that enabled us to safely perform pure LPD. The main pancreatic duct was stented with a 4-Fr polyvinyl catheter during pancreatic resection. A small hole was created in the posterior wall of the stomach and was bluntly dilated. A 5-cm incision was made in the anterior stomach, and the pancreatic drainage tube was passed into the stomach through the hole in the posterior wall. The remnant pancreas was pulled into the stomach, and was easily positioned and secured in place with only four to six sutures between the pancreatic capsule and the gastric mucosa. We used this technique to perform pure LPD in five patients between December 2012 and July 2013.

Conclusions

Our new technique is technically easy and provides secure fixation between the gastric wall and the pancreas. This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized. Although this technique requires further investigation as it may increase the risk of delayed gastric emptying, it may be a useful method of performing pancreaticogastrostomy in pure LPD.

Trial registration

ISRCTN16761283. Registered 16 January 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12893-015-0061-x) contains supplementary material, which is available to authorized users.