Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized study

Techniques in Robotic Pancreatic Reconstruction for Pancreaticoduodenectomy: Tailoring Approaches to Different Situations

This "How I Do It" study provides an in-depth exploration of techniques for pancreatic reconstruction following pancreaticoduodenectomy. The study includes a video demonstration highlighting the step-by-step strategies and appropriate indications for each reconstruction method using the robotic system.

Pancreaticoduodenectomy with pancreaticogastrostomy and an external pancreatic stent in risky patients: a propensity score-matched analysis

BACKGROUND

There is an ongoing debate about the most appropriate method for reconstructing the pancreas after a pancreaticoduodenectomy (PD). This study assessed the impact of pancreaticogastrostomy (PG) with an external pancreatic stent on postoperative outcomes following PD in high-risk patients.

PATIENTS AND METHODS

This study involves a propensity score-matched analysis of high-risk patients who underwent PD with PG reconstruction. The primary outcome measure was the occurrence of Postoperative Pancreatic Fistula (POPF). Secondary outcomes included operative time, intraoperative blood loss, length of hospital stay, re-exploration rate, as well as postoperative morbidity and mortality rates.

RESULTS

The study included 78 patients; 26 patients underwent PD with Pancreatogastrostomy (PG) and an external pancreatic stent, while 52 underwent PG without a pancreatic stent. Blood loss and operative time did not significantly differ between the two groups. The overall postoperative morbidity was higher in the group without a stent than in the stented group (34.6% vs. 15.4%, P = 0.06). No patient in the pancreatic stent group developed a clinically relevant POPF; however, in the non-stented group of PG, 17.3% developed POPF. There were no cases of hospital mortality in the stented group. However, in the non-stented group, two hospital mortality happened (one case was due to the systemic inflammatory response syndrome (SIRS) secondary to POPF grade C, and the other was due to pulmonary embolism.

CONCLUSION

PG with an external pancreatic stent results in fewer clinically relevant pancreatic fistulas, a decrease in postoperative morbidities, and a non-existent mortality rate in high-risk patients.

Is duct-to-mucosa pancreaticojejunostomy necessary after pancreaticoduodenectomy: A meta-analysis of randomized controlled trials

The incidence of postoperative pancreatic fistula is influenced by the effectiveness of the pancreaticojejunostomy, and the most suitable pancreaticojejunostomy for pancreaticoduodenectomy remains uncertain. Since grade A postoperative pancreatic fistula is no longer considered a true fistula, the purpose of this meta-analysis was to compare the effectiveness of duct-to-mucosa anastomosis and invagination anastomosis in reducing the incidence of grade B/C postoperative pancreatic fistula. The meta-analysis was conducted using software Review Manager 5.3, and the fixed-effect model was employed for pooled statistic calculations. The Cochrane Collaboration Risk of Bias Tool was utilized for quality assessment. Ten randomized controlled trials from Embase, Web of Science, MEDLINE, and the Cochrane Library (1990.01-2022.10) including 1471 patients, met the inclusion criteria. This meta-analysis has been registered on PROSPERO with the registration number CRD42023491673. The incidence of grade B/C fistula was significantly lower in the invagination group (7.7 %) compared to the duct-to-mucosa group (12.8 %, mostly Cattell manner)(RR = 1.65, 95%CI: 1.14-2.39, P = 0.008; heterogeneity: P = 0.008, I2 = 68 %),heterogeneity among the results was addressed through sensitivity analysis. In patients with a soft pancreas, the incidence of grade B/C fistula was significantly lower in those who underwent invagination anastomosis (10 %) compared to those who underwent duct-to-mucosa anastomosis (41.9 %)(RR = 4.19, 95%CI: 1.33-13.25, P = 0.01).No significant differences were observed in terms of the occurrence of grade B/C fistula in firm pancreas, postoperative mortality, other major postoperative complications, anastomosis time, and postoperative bile leak. Therefore, we concluded that invagination anastomosis is significantly superior to duct-to-mucosa anastomosis in reducing the incidence of grade B/C fistula, especially in patients with a soft pancreas.

Safety and feasibility of modified duct-to-mucosa pancreaticojejunostomy during pancreatoduodenectomy: A retrospective cohort study

BACKGROUND

Pancreatoduodenectomy (PD) is the most effective surgical procedure to remove a pancreatic tumor, but the prevalent postoperative complications, including postoperative pancreatic fistula (POPF), can be life-threatening. Thus far, there is no consensus about the prevention of POPF.

AIM

To determine possible prognostic factors and investigate the clinical effects of modified duct-to-mucosa pancreaticojejunostomy (PJ) on POPF development.

METHODS

We retrospectively collected and analyzed the data of 215 patients who underwent PD between January 2017 and February 2022 in our surgery center. The risk factors for POPF were analyzed by univariate analysis and multivariate logistic regression analysis. Then, we stratified patients by anastomotic technique (end-to-side invagination PJ vs modified duct-to-mucosa PJ) to conduct a comparative study.

RESULTS

A total of 108 patients received traditional end-to-side invagination PJ, and 107 received modified duct-to-mucosa PJ. Overall, 58.6% of patients had various complications, and 0.9% of patients died after PD. Univariate and multivariate logistic regression analyses showed that anastomotic approaches, main pancreatic duct (MPD) diameter and pancreatic texture were significantly associated with the incidence of POPF. Additionally, the POPF incidence and operation time in patients receiving modified duct-to-mucosa PJ were 11.2% and 283.4 min, respectively, which were significantly lower than those in patients receiving traditional end-to-side invagination PJ (27.8% and 333.2 minutes).

CONCLUSION

Anastomotic approach, MPD diameter and pancreatic texture are major risk factors for POPF development. Compared with traditional end-to-side invagination PJ, modified duct-to-mucosa PJ is a simpler and more efficient technique that results in a lower incidence of POPF. Further studies are needed to validate our findings and explore the clinical applicability of our technique for laparoscopic and robotic PD.

Application of split pancreatic duct stent in laparoscopic pancreaticoduodenectomy

Laparoscopic pancreaticoduodenectomy (LPD) is a classic surgical method for diseases, such as tumors at the lower end of the common bile duct, pancreatic head, and benign and malignant tumors of the duodenum. Postoperative pancreatic fistula (POPF) is one of the most serious complications of LPD. To reduce the incidence of grade B or C POPF and other complications after LPD, we applied a split pancreatic duct stent combined with the characteristics of internal and external stent drainage. Between September 2020 and September 2022,12 patients underwent placement of the Split pancreatic duct stent during LPD. Data on basic characteristics of patients, surgical related indicators and postoperative POPF incidence were collected and analyzed. The results showed that the average operation time was 294.2 ± 36 minutes, average time for pancreaticojejunostomy was 35.9 ± 4.1 minutes, and average estimated blood loss was 204.2 ± 58.2 mL. Biochemical leakage occurred in 2 patients (16.7%), whereas no grade B or C POPF, 1 case (8.3%) had postoperative bleeding, and no death occurred within 30 days after the operation. Preliminary experience shows that the split pancreatic duct stent can effectively reduce the incidence of complications after LPD, especially grade B or C POPF.

Outcomes of Duct-to-Mucosa vs. Invagination Pancreatojejunostomy: Toward a Personalized Approach for Distal Pancreatic Stump Anastomosis in Central Pancreatectomy?

(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ) and distal pancreatic invagination into jejunum anastomoses (PJ) after CP. (2) Methods: All patients with CP and jejunal anastomoses (between 1 January 2002 and 31 December 2022) were retrospectively assessed and compared. (3) Results: 29 CP were analyzed: WJ-12 patients (41.4%) and PJ-17 patients (58.6%). The operative time was significantly higher in the WJ vs. PJ group of patients (195 min vs. 140 min, p = 0.012). Statistically higher rates of patients within the high-risk fistula group were observed in the PJ vs. WJ group (52.9% vs. 0%, p = 0.003). However, no differences were observed between the groups regarding the overall, severe, and specific postpancreatectomy morbidity rates (p values ≥ 0.170). (4) Conclusions: The WJ and PJ anastomoses after CP were comparable in terms of morbidity rates. However, a PJ anastomosis appeared to fit better for patients with high-risk fistula scores. Thus, a personalized, patient-adapted technique for the distal pancreatic stump anastomosis with the jejunum after CP should be considered. At the same time, future research should explore gastric anastomoses' emerging role.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.

DATA SOURCES

A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.

RESULTS

A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.

CONCLUSIONS

Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Application of purse string suture pancreaticojejunostomy for undilated pancreatic duct in total laparoscopic pancreaticoduodenectomy

Background

To investigate the feasibility of purse string suture pancreaticojejunostomy in complete laparoscopic pancreaticoduodenectomy for patients with an undilated pancreatic duct.

Methods

We retrospectively reviewed a database of 113 patients with undilated pancreatic ducts who had undergone laparoscopic pancreaticoduodenectomy (LPD) with purse string suture pancreaticojejunostomy to analyze the perioperative outcomes.

Results

One hundred thirteen patients underwent successful LPD. The surgery time was 353 ± 41 min, the time required for pancreaticojejunostomy was 27 ± 5 min, and the hospital stay after surgery was 16 ± 8 days. Fifteen patients suffered postoperative complications, including twelve patients with pancreatic fistula, one with bile leakage, one with gastroparesis (complicated with abdominal infection), and one with abdominal bleeding. No perioperative death occurred.

Conclusions

Purse string suture pancreaticojejunostomy is safe and feasible for patients with an undilated pancreatic duct.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01640-w.

Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain.

OBJECTIVES

To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques.

SEARCH METHODS

We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021).

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes.

MAIN RESULTS

We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.

Invaginated duct to mucosa pancreaticojejunostomy reduce postoperative pancreatic leakage: A matched case-controlled study

Postoperative pancreatic leakage is an obstacle in pancreaticoduodenectomy, which always follows pancreaticojejunostomy (PJ) failure. Dozens of PJ procedures have been reported, and none have shown superiority over others. Therefore, the present study is conducted to assess the potential advantages of invaginated duct-to-mucosa (D-M) PJ.We retrospectively analyze the related data from patients who underwent pancreaticodedunostomy due to malignant tumors at the First Affiliated Hospital of Henan University of Science and Technology from January 2017 to August 2019. According to the different PJ procedures, the patients are divided into custom D-M group and invaginated D-M group. Matching by sex, age, pancreatic duct size, and pancreatic texture is performed. Pancreatic leakage and other complications are compared, and SPSS 16.0 is employed for analysis.A total of 48 pairs of patients are included. Patients in both groups has almost the same baseline characteristics in terms of sex (P = 1.000), age (P = .897), American Society of Anesthesiologists status (P = .575), body mass index (P = .873), pancreatic duct size (P = .932), pancreatic texture (P = 1.000) and tumor origin (P = .686). No significant difference is observed in operative outcomes, such as operative duration (P = .632), PJ duration (P = .748), blood loss (P = .617) and number of required transfusions (P = .523). Pancreatic leakage is significantly decreased in the invaginated D-M group (P = .005). The differences in other complications, such as bleeding (P = .617), biliary leakage (P = .646), pneumonia (P = .594) and thrombosis (P = .714), do not reach statistical significance. The postoperative hospitalization duration is almost the same for both groups (P = .764).Invaginated D-M PJ may reduce pancreatic leakage following pancreaticoduodenectomy.

A novel anastomosis technique facilitates pancreaticojejunostomy in total laparoscopic pancreaticoduodenectomy (with video)

BACKGROUND

While the best technique for pancreatic anastomosis during Whipple's procedure remains controversial, laparoscopic pancreaticoduodenectomy (LPD) has been rapidly increasing in popularity. Because of their feasibility and reliability, new pancreatic anastomosis techniques may have vital roles when adapted for LPD. Here, we describe a new pancreaticojejunostomy (PJ) technique using three sutures (termed the "three sutures" PJ technique), which facilitates pancreatic anastomosis during total LPD.

METHODS

A total of 149 patients who underwent LPD using the "three sutures" PJ technique at three hospitals were included in this study (81 patients at Guangdong Provincial People's Hospital [GDPH], 60 patients at Sun Yat-Sen Memorial Hospital [SMH], and 8 patients at Affiliated Hospital of Guangdong Medical University [AHGMU]). Data on the demographic characteristics, operative outcomes, and postoperative results (pancreatic fistula rate, mortality rate, and length of hospital stay) of these patients were collected and analyzed.

RESULTS

A surgical video showing the details of the "three sutures" PJ method was included. The mean operation times at GDPH, SMH, and AHGMU were 4.08 ± 0.99 h, 4.65 ± 1.53 h, and 4.67 ± 0.64 h, respectively, and the average PJ times were 17.96 ± 3.49 min, 18.19 ± 2.63 min, and 22.5 ± 3.96 min, respectively. The numbers of grade B pancreatic fistulas were 9 (11.11%), 2 (3.33%), and 1 (12.50%), respectively, and two patients had grade C fistulas, one each at GDPH and SMH. The numbers of clinically relevant postoperative pancreatic fistula (CR-POPF) were 10 (12.35%), 3 (5.00%), and 1 (12.50%) in each center, respectively. The overall rate of CR-POPF was 9.40% (14/149) among patients of all three centers. The perioperative mortality rate was 0%.

CONCLUSIONS

The "three sutures" PJ technique for total LPD is a safe and reliable method, with a low risk of pancreatic fistula, short anastomosis time, and steep learning curve.

Wrapping double-mattress anastomosis for pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy can significantly reduce postoperative pancreatic fistula rate compared with conventional pancreaticojejunostomy in open surgery: An analysis of a propensity score-matched sample

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD.

METHODS

The current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group.

RESULTS

The patients' preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004).

CONCLUSION

The novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.

[Pylorus-Preserving Pancreaticoduodenectomy (PPPD) with Segmental Portal Vein Resection]

INTRODUCTION

Pylorus-preserving partial pancreatoduodenectomy is a complex visceral operation, especially when simultaneous resection and reconstruction of the portal venous axis is necessary. Pancreatic anastomosis plays a decisive role in this procedure, since postoperative pancreatic fistula (POPF) is a frequent complication, with serious consequences (morbidity and mortality) for the affected patient. Various techniques are available for anastomosing the residual pancreas: the duct-to-mucosa pancreaticojejunostomy, invaginating pancreatojejunostomy, Blumgart anastomosis and pancreatogastrostomy.

INDICATION

Adenocarcinoma of the pancreatic head with portal vein infiltration.

PROCEDURE

Pylorus-preserving pancreaticoduodenectomy (PPPD) with portal vein resection.

CONCLUSION

A standardised and structured approach to pylorus-preserving partial pancreatoduodenectomy helps the surgeon to perform this procedure safely. Performing a simultaneous portal vein resection increases the complexity of the procedure, but nonetheless, if infiltration of the portal venous axis is suspected, the indication for en-bloc resection should be given generously, as intraoperatively it is not possible to differentiate reliably between inflammatory adherence and tumour infiltration and portal vein/V.-mesenterica-superior-resection does not increase morbidity and mortality. The choice of the surgical technique for anastomosing the residual pancreas should be made by the surgeon on the basis of his expertise and, if necessary, adapted to the patient's situs, since the most important pancreatic anastomosis techniques appear to be equivalent according to the current evidence.

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.

Landmark Series in Pancreatic Tumors: Anastomotic Techniques and Route of Reconstruction

INTRODUCTION

Pancreaticoduodenectomy is one of the more complicated operations that exists in surgery, and is fraught with potential morbidity, the most well-known, and dreaded, of which is the pancreatic leak. While much of the risk associated with pancreatic leak is inherent to the operation, there have been no shortage of techniques employed by surgeons to try to mitigate that risk.

METHODS

We focused on four topics of greatest conjecture with regard to reconstruction after pancreaticoduodenectomy: (1) the type of anastomosis, (2) the enteral organ to which the pancreas is sewn, (3) whether to preserve the pylorus and (4) whether or not to use anastomotic silastic stents. We identified the most relevant randomized control trials on each topic, which were appropriately powered.

RESULTS

We identified a total of 15 studies for evaluation, (type of anastomosis: n = 4; enteral organ to which the pancreas is sewn: n = 4; whether to preserve the pylorus, n=3; and whether or not to use anastomotic silastic stents, n = 4). In each group of comparisons, there was no definitive conclusion to be made on superiority of reconstruction.

CONCLUSION

While clear consensus on how best to reconstruct the anatomy after pancreaticoduodenectomy has not yet been reached, we present the following review in the hope of providing some understanding of the literature for the pancreatic surgeon.

A propensity score analysis of over 12,000 pancreaticojejunal anastomoses after pancreaticoduodenectomy: does technique impact the clinically relevant fistula rate?

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) remains a major cause of morbidity in patients undergoing pancreatic surgery. Controversy exists as to whether there is any difference in CR-POPF with a Duct-to-Mucosa (DTM) versus an Invagination (IG) pancreaticojejunostomy (PJ).

METHODS

Demographic, perioperative, intraoperative, and postoperative data were captured from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2014-2017 databases. Potential confounders were included in a logistic regression and a propensity score model. The primary outcome was CR-POPF.

RESULTS

A total of 12,361 pancreaticojejunal anastomoses were performed with 11,168 patients undergoing DTM (90%) and 1193 undergoing IG (10%) after pancreaticoduodenectomy. Amongst all patients, there was no significant difference in CR-POPF between DTM and IG on multivariate (OR = 0.95, p = 0.64) or propensity score analysis (OR = 0.99, p = 0.93). After stratification by pancreatic gland texture and duct size, there was a decrease in CR-POPF with DTM amongst patients with duct size greater than 6 mm on multivariate analysis (OR = 0.35, p = 0.009) and propensity score analysis (OR = 0.40, p = 0.018). There were no significant differences in any other strata.

CONCLUSION

DTM or IG technique are not associated with CR-POPF for patients with average size pancreatic ducts; however, DTM is preferable in patients with large pancreatic duct diameter (>6 mm).

Is Invagination Anastomosis More Effective in Reducing Clinically Relevant Pancreatic Fistula for Soft Pancreas After Pancreaticoduodenectomy Under Novel Fistula Criteria: A Systematic Review and Meta-Analysis

Objective: To define the effectiveness of different anastomosis on clinically relevant postoperative fistula in patients with soft pancreas using the newest version of the fistula definition and criteria.

Background: Different criteria of clinically relevant postoperative pancreatic fistula (POPF) result in the optimal anastomosis technique remaining controversial.

Methods: PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov were systematically searched up to 20 April 2020, and were evaluated by Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Randomized controlled trials comparing duct-to-mucosa anastomosis vs. invagination anastomosis in pancreatic surgery were included.

Result: Seven studies involving 1,110 participants were included. Using the postoperative pancreatic fistula definition provided by the International Study Group of Pancreatic Surgery 2016, the incidence rate of grade B/C pancreatic fistula was significantly lower in patients experiencing invagination anastomosis than in those undergoing duct-to-mucosa anastomosis. Four of seven trials comparing invagination with duct-to-mucosa anastomosis in patients with a soft pancreas showed that invagination was significantly better than duct-to-mucosa anastomosis in controlling pancreatic fistula formation, but no significant difference was detected between the two anastomosis techniques in patients with a hard pancreas. No significant difference in the length of hospital stay or postoperative mortality rate was found between the two methods.

Conclusion: This study demonstrated superiority of invagination anastomosis over duct-to-mucosa anastomosis in reducing the risk of Grade B/C postoperative pancreatic fistula using the ISGPS 2016 definition, but it does not significantly reduce the mortality rate or length of hospital stay. The effect of invagination in reducing pancreatic fistula formation is obvious in patients with a soft pancreas, but there is no significant difference between the two anastomosis techniques in patients with a hard pancreas. We found a lower rate of clinically relevant postoperative pancreatic fistula in the invagination group, in patients with a soft pancreas.

Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence

BACKGROUND

Despite advancements in operative technique and improvements in postoperative managements, postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD). There are some reports to predict POPF preoperatively or intraoperatively, but the accuracy of those is questionable. Artificial intelligence (AI) technology is being actively used in the medical field, but few studies have reported applying it to outcomes after PD.

AIM

To develop a risk prediction platform for POPF using an AI model.

METHODS

Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016. A total of 38 variables were inserted into AI-driven algorithms. The algorithms tested to make the risk prediction platform were random forest (RF) and a neural network (NN) with or without recursive feature elimination (RFE). The median imputation method was used for missing values. The area under the curve (AUC) was calculated to examine the discriminative power of algorithm for POPF prediction.

RESULTS

The number of POPFs was 221 (12.5%) according to the International Study Group of Pancreatic Fistula definition 2016. After median imputation, AUCs using 38 variables were 0.68 ± 0.02 with RF and 0.71 ± 0.02 with NN. The maximal AUC using NN with RFE was 0.74. Sixteen risk factors for POPF were identified by AI algorithm: Pancreatic duct diameter, body mass index, preoperative serum albumin, lipase level, amount of intraoperative fluid infusion, age, platelet count, extrapancreatic location of tumor, combined venous resection, co-existing pancreatitis, neoadjuvant radiotherapy, American Society of Anesthesiologists’ score, sex, soft texture of the pancreas, underlying heart disease, and preoperative endoscopic biliary decompression. We developed a web-based POPF prediction platform, and this application is freely available at http://popfrisk.smchbp.org.

CONCLUSION

This study is the first to predict POPF with multiple risk factors using AI. This platform is reliable (AUC 0.74), so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.

The Effect of Fibrinogen/Thrombin-Coated Collagen Patch (TachoSil®) Application in Pancreaticojejunostomy for Prevention of Pancreatic Fistula After Pancreaticoduodenectomy: A Randomized Clinical Trial

BACKGROUND

Fibrin sealants and topical glue have been studied to reduce the incidence of postoperative pancreatic fistulas (POPF) after pancreatico-enteric anastomosis, but a definitive innovation is still needed. We aim to evaluate the effectiveness of fibrin sealant patch applied to pancreatico-enteric anastomosis to reduce postoperative complications, including POPF.

METHODS

This study was a single-center, prospective, randomized, phase IV trial involving three pancreaticobiliary surgeons. The primary outcome was POPF; secondary outcomes included complications, drain removal days, hospital stay, readmission rate, and cost. Risk factors for POPF were identified by logistic regression analysis.

RESULTS

A total of 124 patients were enrolled. Biochemical leakage (BL) or POPF occurred in 16 patients (25.8%) in the intervention group and 23 patients (37.1%) in the control group (no statistical significance). Clinically relevant POPF occurred in 4 patients (6.5%) in both the intervention and control groups (p = 1.000). Hospital stay (11.6 days vs. 12.1 days, p = 0.585) and drain removal days (5.7 days vs. 5.3 days, p = 0.281) were not statistically different between two groups. Complication rates were not different between the two groups (p = 0.506); nor were readmission rates (12.9% vs. 11.3%, p = 1.000) or cost ($13,549 vs. $15,038, p = 0.103). In multivariable analysis, age and soft pancreas texture were independent risk factors for BL or POPF in this study. Applying fibrin sealant patch is not a negative risk factor, but the p value may indicate a likelihood of reducing the incidence of BL (p = 0.084).

CONCLUSIONS

Fibrin sealant patches after pancreaticojejunostomy did not reduce the incidence of POPF or other postoperative complications. This study was registered at clinicaltrials.gov (NCT03269955).

Critical appraisal of the techniques of pancreatic anastomosis following pancreaticoduodenectomy: A network meta-analysis

BACKGROUND

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.

METHODS

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 primary outcome was clinically relevant POPF.

RESULTS

Five techniques of pancreatic anastomosis following PD were directly compared in 15 RCTs comprising 2428 patients. Panreatojejunostomy (PJ) end-to-side invagination vs. PJ end-to-side duct-to-mucosa was the most frequent comparison (n = 7). Overall, 971 patients underwent PJ end-to-side duct-to-mucosa, 791 patients PJ end-to-side invagination, 505 patients pancreatogastrostomy (PG) end-to-side invagination, 98 patients PG end-to-side duct-to-mucosa, and 63 patients PJ end-to-side single layer. PG duct-to-mucosa was associated with the lowest rates of clinically relevant POPF, delayed gastric emptying, intra-abdominal abscess, all postoperative morbidity and postoperative mortality, the shortest operative time and postoperative hospital stay and the lowest volume of intra-operative blood loss.

CONCLUSION

Duct-to-mucosa pancreaticogastrostomy was associated with the lowest rates of clinically relevant POPF and had the best outcome profile among all techniques of pancreatico-anastomosis following PD.

Modified Blumgart Mattress Suture Versus Conventional Interrupted Suture in Pancreaticojejunostomy During Pancreaticoduodenectomy: Randomized Controlled Trial

Objective:

This study used a randomized controlled trial (RCT) to evaluate whether mattress suture of pancreatic parenchyma and the seromuscular layer of jejunum (modified Blumgart method) during pancreaticojejunostomy (PJ) decreases the incidence of clinically relevant postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD).

Background:

Several studies reported that mattress suture of Blumgart anastomosis in PJ could reduce POPF rate. This, however, is the first RCT.

Methods:

Between June, 2013 and May, 2017, 224 patients scheduled for PD were enrolled in this study in Wakayama Medical University Hospital. Enrolled patients were randomized to either interrupted suture or modified Blumgart mattress suture. The primary endpoint was the incidence of grade B/C POPF based on the International Study Group on Pancreatic Fistula criteria. This RCT was registered with ClinicalTrials.gov (NCT01898780).

Results:

Patients were randomized to either interrupted suture (103 patients) or modified Blumgart mattress suture (107 patients) and were analyzed by intention-to-treat. Grade B/C POPF occurred in 7 patients (6.8%) in the interrupted suture group and 11 (10.3%) in the mattress suture group (P = 0.367). Mortality within 90 days was 0 in both groups. There were no significant differences in all postoperative complications between the interrupted suture group and the modified Blumgart mattress suture group.

Conclusions:

Mattress suture of pancreatic parenchyma and the jejunal seromuscular layer during PJ (modified Blumgart technique) did not reduce clinically relevant POPF compared with interrupted suture.

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.

Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.

Modified Pancreatojejunostomy in Pancreaticoduodenectomy for the Treatment of Periampullary Tumor: 8 Years of Surgical Experience

Background

We modified the anastomosis surgical method based on the Blumgart anastomosis in pancreaticoduodenectomy. This study aimed to compare patient outcomes with regards to clinically relevant postoperative pancreatic fistula (CR-POPF) and other postoperative complications among patients receiving traditional anastomosis, classical Blumgart anastomosis, and our modified-Blumgart anastomosis.

Material/Methods

Data were reviewed from 229 consecutive patients with periampullary tumors who underwent pancreaticoduodenectomy administered by a single surgeon at the Tianjin Medical University Cancer Institute and Hospital between January 2010 and December 2017. Subsequently, clinical factors potentially associated with CR-POPF were analyzed.

Results

During the study period, the incidence of overall CR-POPF was 31 out of 229 patients (13.5%). Using Blumgart anastomosis (BA), the incidence of CR-POPF was lower at 15 out of 148 patients (10.1%), significantly lower than that of traditional anastomosis (invagination technique or “duct-to-mucosa” anastomosis) (15 out of 148 patients versus 16 out of 81 patients, P=0.042). Compared with classical Blumgart anastomosis (c-B), our modified-Blumgart anastomosis (m-BA) method had similar outcomes in terms of CR-POPF (9 out of 73 patients versus 6 out of 75 patients, P=0.383), CR-POPF-related intra-abdominal hemorrhage rate (0 out of 73 patients versus 1 out of 75 patients, P=0.322), and median length of postoperative hospital stay (19 days versus 19 days, P=0.752). There were no fatalities as a result of CR-POPF in the BA group.

Conclusions

Upon review of a single surgeon’s experience over 8 years, Blumgart anastomosis might be more effective in the prevention of CR-POPF than traditional anastomosis. Our modified-Blumgart anastomosis method maintained a low rate of morbidity and mortality but with simplified procedures that can be easily put into practice. This technique can be used widely with excellent safety for pancreatojejunostomy as a part of pancreaticoduodenectomy.

Comparison of Different Techniques of Pancreatic Stump Management in Robot-Assisted Pancreaticoduodenectomy

Background

Various technical improvements have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined. The aim of this study was to identify the risk factors and incidence of POPF with different types of pancreatic stump management after robot-assisted pancreaticoduodenectomy (RAPD).

Materials and Methods

This study is a retrospective review of consecutive patients who underwent RAPD at the University of Illinois Hospital and Health Sciences System between September 2007 and January 2016. The cohort was divided based on the type of pancreatic stump management: pancreatic duct occlusion with cyanoacrylate glue (CG), pancreaticojejunostomy (PJ), posterior pancreaticogastrostomy (PPG), and transgastric pancreaticogastrostomy (TPG).

Results

The cohort included 69 patients: pancreatic duct occlusion with CG (n = 18), PJ (n = 12), PPG (n = 11), and TPG (n = 28). Pancreatic duct diameter < 3 mm and duct occlusion with CG were identified as risk factors for POPF (p < 0.05). The incidence of POPF was lower when TPG and PJ were performed (p < 0.001).

Conclusions

Reconstruction with PJ and TPG had better results compared to pancreatic duct occlusion with CG and PPG. However, TPG was the technique of choice and showed comparable results to PJ.

Characterization and Optimal Management of High-risk Pancreatic Anastomoses During Pancreatoduodenectomy

OBJECTIVE

The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy.

BACKGROUND

The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circumstances of the anastomosis. The Fistula Risk Score (FRS) identifies a distinct high-risk cohort (FRS 7 to 10) that demonstrates substantially worse clinical outcomes. The value of various fistula mitigation strategies in these particular high-stakes cases has not been previously explored.

METHODS

This multinational study included 5323 PDs performed by 62 surgeons at 17 institutions. Mitigation strategies, including both technique related (ie, pancreatogastrostomy reconstruction; dunking; tissue patches) and the use of adjuvant strategies (ie, intraperitoneal drains; anastomotic stents; prophylactic octreotide; tissue sealants), were evaluated using multivariable regression analysis and propensity score matching.

RESULTS

A total of 522 (9.8%) PDs met high-risk FRS criteria, with an observed CR-POPF rate of 29.1%. Pancreatogastrostomy, prophylactic octreotide, and omission of externalized stents were each associated with an increased rate of CR-POPF (all P < 0.001). In a multivariable model accounting for patient, surgeon, and institutional characteristics, the use of external stents [odds ratio (OR) 0.45, 95% confidence interval (95% CI) 0.25-0.81] and the omission of prophylactic octreotide (OR 0.49, 95% CI 0.30-0.78) were independently associated with decreased CR-POPF occurrence. In the propensity score matched cohort, an "optimal" mitigation strategy (ie, externalized stent and no prophylactic octreotide) was associated with a reduced rate of CR-POPF (13.2% vs 33.5%, P < 0.001).

CONCLUSIONS

The scenarios identified by the high-risk FRS zone represent challenging anastomoses associated with markedly elevated rates of fistula. Externalized stents and omission of prophylactic octreotide, in the setting of intraperitoneal drainage and pancreaticojejunostomy reconstruction, provides optimal outcomes.

Surgical Loupe at 4.0× Magnification in Pancreaticoduodenectomy-Does It Affect the Surgical Outcomes? A Propensity Score-Matched Study

BACKGROUND

There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD.

PATIENTS AND METHOD

This is a propensity score-matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay.

RESULTS

The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to oral intake, total amount of drainage, and time of nasogastric tube removal. Univariate and multivariate analyses demonstrated 3 independent factors of development of postoperative pancreatic fistula: pancreatic duct <3 mm, body mass index >25, and soft pancreas.

CONCLUSION

Surgical loupes 4.0× added no advantage in surgical outcomes of PD with regard to improvement of postoperative complications rate or mortality rate.

Modified duct-to-mucosa versus conventional pancreaticoenterostomy for pancreaticoduodenectomy: a retrospective cohort study based on propensity score matching analysis

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the most common neopathy after pancreatoduodenectomy (PD). An ideal pancreaticoenterostomy (PE) which can effectively reduce the incidence of CR-POPF and its potential neopathy is needed. We aimed to assess the efficacy of our modified duct-to-mucosa PE in the PD.

METHOD

From January 2011 to December 2017, 233 consecutive patients with PD were retrospectively included from Shenzhen People's Hospital. After propensity score matching (PSM), there were 82 patients in both the modified duct-to-mucosa PE group (group A) and the conventional end-to-side inserting PE group (group B), respectively. The clinical course and the incidence of postoperative neopathy were compared between groups. Logistic regression method was utilized to analyze the association between PE approach and CR-POPF.

RESULTS

The PE time was shorter in group A (9.3 ± 1.8 min vs. 21.5 ± 2.8 min, P < 0.001). The group A had significantly lower incidence of severe neopathy (Clavien-Dindo grade > II) [7.3% (5/82) vs. 17.1% (14/82), P = 0.028] and incidence of CR-POPF [1.2% (1/82) vs. 19.5% (12/82), P < 0.001] than the group B. Our modified duct-to-mucosa PE technique was associated with a reduced risk for CR-POPF (OR, 0.11 [95% CI, 0.02-0.57]; P = 0.009) as compared with the conventional end-to-side inserting PE.

CONCLUSION

Compared with conventional end-to-side inserting PE, our modified duct-to-mucosa PE technique can effectively reduce the incidences of postoperative neopathy and CR-POPF.

TRIAL REGISTRATION

Researchregistry3877 . Registered 24 March 2018. Retrospectively registered.

WITHDRAWN: A personal technical experience and results of a modified end-to-side technique of pancreatojejunostomy: A 350 patients retrospective cohort study

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Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture

BACKGROUND

In 2016, the International Study Group of Pancreatic Fistula (ISGPS) proposed an updated definition for postoperative pancreatic fistula (POPF). Pancreas texture (PT) is an established risk factor of POPF. The definition of soft vs. hard texture, however, remains elusive.

METHODS

A systematic search was performed to identify PT definitions and a meta-analysis linking POPF to PT using the updated ISGPS definition.

RESULTS

122 studies including 22 376 patients were identified. Definition criteria for PT varied among studies and most classified PT in hard and soft based on intraoperative subjective assessment. The total POPF rate (pooled grades B and C) after pancreatoduodenectomy was 14.5% (n = 10 395) and 15.5% (n = 3767) after distal pancreatectomy. In pancreatoduodenectomy, POPF rate was higher in soft compared to hard pancreas (RR, 4.4, 3.3 to 6.1; p < 0.001; n = 6393), where PT grouped as soft and hard. No data were available for intermediate PT.

CONCLUSION

The reported POPF rates may be used in planning future prospective studies. A widely accepted definition of PT is lacking and a correlation with the risk of POPF is based on subjective evaluation, which is still acceptable. Classification of PT into 2-groups is more reasonable than classification into 3-groups.

Selection of pancreaticojejunostomy technique after pancreaticoduodenectomy: duct-to-mucosa anastomosis is not better than invagination anastomosis: A meta-analysis

BACKGROUND

One of the most clinically significant current discussions is the optimal pancreaticojejunostomy (PJ) technique for pancreaticoduodenectomy (PD). We performed a meta-analysis to compare duct-to-mucosa and invagination techniques for pancreatic anastomosis after PD.

METHODS

A systematic search of PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to June 1, 2018 was performed. Randomized controlled trials (RCTs) comparing duct-to-mucosa versus invagination PJ were included. Statistical analysis was performed using RevMan 5.3 software.

RESULTS

Eight RCTs involving 1099 patients were included in the meta-analysis. The rate of postoperative pancreatic fistula (POPF) was not significantly different between the duct-to-mucosa PJ (110/547, 20.10%) and invagination PJ (98/552, 17.75%) groups in all 8 studies (risk ratio, 1.13; 95% CI, 0.89-1.44; P = .31). The subgroup analysis using the International Study Group on Pancreatic Fistula criteria showed no significant difference in POPF between duct-to-mucosa PJ (97/372, 26.08%) and invagination PJ (78/377, 20.68%). No significant difference in clinically relevant POPF (CR-POPF) was found between the 2 groups (55/372 vs 40/377, P = .38). Additionally, no significant differences in delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, operation time, or length of stay were found between the 2 groups. The overall morbidity and mortality rates were not significantly different between the 2 groups.

CONCLUSION

The duct-to-mucosa technique seems no better than the invagination technique for pancreatic anastomosis after PD in terms of POPF, CR-POPF, and other main complications. Further studies on this topic are therefore recommended.

The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: A network meta-analysis of randomized control trials

BACKGROUND

A number of pancreatic anastomosis methods for pancreaticoduodenectomy including pancreaticogastrostomy(PG), duct-to-mucosa pancreaticojejunostomy(duct-to-mucosa PJ), invagination pancreaticojejunostomy(invagination PJ) and binding pancreaticojejunostomy(BPJ), but the optimal choice remains unclear. We performed a network meta-analysis to synthesize direct and indirect evidence to identify the optimal choice for pancreatic anastomosis after pancreaticoduodenectomy METHODS: We searched the Embase, PubMed and Cochrane library databases for randomized control trials. The relative risk (RR) and its 95% confidence interval (CI) were calculated. The primary outcome is postoperative pancreatic fistula (POPF).

RESULT

In total, 16 RCT studies, including a total of 2396 patients, met our criteria. The results showed that PG is not superior to invagination PJ (RR 0.70 95%CI: 0.35-1.39) and duct-to-mucosa PJ (RR 0.58 95%CI: 0.30-1.10) according to the ISGPS definition. Furthermore PG cannot reduce the POPF rates than invagination PJ (RR 0.51 95%CI: 0.2-1.21) and duct-to-mucosa PJ (RR 0.46 95%CI: 0.16-1.14) according to the soft pancreatic texture. BPJ might reduce the incidence of POPF than duct-to-mucosa PJ (RR 0.00 95%CI: 0.00-0.04), invagination PJ (RR 0.00 95%CI: 0.00-0.03), PG (RR 0.00 95%CI: 0.00-0.03), but the results have major limitations with only one RCT reported BPJ and different definition of POPF.

CONCLUSION

There are no significant differences among BPJ, duct-to-mucosa PJ, invagination PJ and PG in the prevention of POPF, overall morbidity, mortality and DGE. However, further randomized controlled trials should be undertaken to ascertain these findings, especially for BPJ.

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.

Leakage of an Invagination Pancreaticojejunostomy May Have an Influence on Mortality

Purpose: No consensus exists regarding the most effective form of pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).

Methods: Data were gathered through the American College of Surgeons-National Surgical Quality Improvement Program, Pancreatectomy Demonstration Project. A total of 1781 patients underwent a PD at 43 institutions. After appropriate exclusions, 890 patients were analyzed. Patients were divided into duct-to-mucosa (n = 734, 82%) and invagination (n = 156, 18%) groups and were compared by unadjusted analysis. Type of PJ was included in eight separate morbidity and mortality multivariable analyses.

Results: Invagination patients had higher serum albumin (p < 0.01) and lower body mass index (p < 0.01), were less likely to have a preoperative biliary stent (p < 0.01), and were more likely to have a soft gland (p < 0.01). PJ anastomosis type was not associated with morbidity but was associated with mortality (duct-to-mucosa vs. invagination, odds ratio = 0.22, p < 0.01). Among patients who developed a clinically relevant pancreatic fistula, none of the 119 duct-to-mucosa, compared with 5 of 21 invagination, patients died (p < 0.01).

Conclusion: Patients who undergo a PJ by duct-to-mucosa or invagination differ with respect to preoperative and intraoperative variables. When an invagination PJ leaks, there may be a greater influence on mortality than when a duct-to-mucosa PJ leaks.

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.

A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients

BACKGROUND

Double-loop (DL) reconstruction after pancreaticoduodenectomy (PD), diverting pancreatic from biliary secretions, has been reported to reduce rates and severity of postoperative pancreatic fistula (POPF) compared to single loop (SL) reconstruction at the price of prolonged operative duration. This study investigated the feasibility of a new reconstruction method combining the advantages of DL with the simplicity of SL in patients with high-risk pancreas.

METHODS

A modified single-loop (mSL) reconstruction was used in patients undergoing PD with a soft pancreatic remnant and a pancreatic duct smaller than 3 mm (n = 50). The loop between the pancreatic and the biliary anastomoses was left longer and a side-to-side jejunojejunal anastomosis was performed between them at the lowest point to promote isolated flow of pancreatic and biliary secretions. Rate and severity of POPF, mortality, duration of surgery, and POPF-associated morbidity were compared to those of 50 matched patients with SL and 25 patients with DL reconstruction.

RESULTS

Duration of surgery was 57 min longer for DL, but equal for mSL and SL. The POPF rate did not differ between the three groups. The severity of POPF was more pronounced in the SL group (62% grade C: p = 0.011). Mortality and major morbidity were lower and hospital stay shorter in the mSL and DL groups compared to the SL group.

CONCLUSIONS

The new mSL reconstruction was safer than conventional SL and faster to perform than DL reconstruction in patients with a high-risk pancreas. It did not influence the rate of POPF, but reduced its severity, leading to less major morbidity and mortality.

Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis

Objective

We aimed to compare the two most commonly used pancreatico-jejunostomy reconstruction techniques—duct-to-mucosa and invagination.

Methods

Databases, including MEDLINE, EMBASE, Cochrane Library, and several clinical trial registration centers were searched. Randomized controlled trials that compared duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were included and analyzed.

Results

In total, seven RCTs were included, involving 850 patients. The difference in postoperative pancreatic fistula rate between the duct-to-mucosa and invagination pancreaticojejunostomy was not significant (RR = 1.03, 95% CI = 0.76-1.39, P = 0.86). There was no significant difference in clinically relevant postoperative pancreatic fistula between the two groups (RR = 0.78, 95% CI = 0.15-3.96, P = 0.77). The overall morbidity, overall mortality, delayed gastric emptying, intra-abdominal collection, reoperation rate, and length of hospital stay between the two groups were not significantly different. Sensitivity analysis showed that the meta-analysis was stable. Further, no significant publication bias was seen.

Conclusions

Duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were comparable in terms of postoperative pancreatic fistula incidence and other parameters.

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.

Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy

BACKGROUND

The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy.

METHODS

Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay.

RESULTS

Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028).

CONCLUSION

This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).

Technical Details and Results of a Modified End-to-Side Technique of Pancreatojejunostomy: a Personal Series of 100 Patients

BACKGROUND

The treatment of pancreatic stump is a critical step of pancreatoduodenectomy (PD) because leaks from this anastomosis incur major morbidity and mortality. We describe the technical details of a modified end-to-side pancreatojejunostomy (mPJ), and report on the outcome of the first 100 patients.

METHODS

From October 2008 to June 2017, 424 pancreatic resections were performed, of which 203 were PD. The mPJ was introduced in November 2010 and used in 100 consecutive patients, by a single surgeon. Data were retrieved from a prospectively collected Institutional database, and used for the present retrospective evaluation. Post-operative pancreatic fistulas (POPF) were stratified with the Fistula Risk Score (FRS), based on the 2005-International Study Group of Pancreatic Fistula classification (ISGPFc) and on the subsequent 2016-revised version (ISGPSc).

RESULTS

ISGPFc POPF occurred in 17/100 (17%): grade A in 10/100 (10%), grade B in 6/100 (6%) and grade C in 1/100 (1%). On the ISGPSc, POPF rate averaged 7%: grade B in 6/100 (6%) and grade C in 1/100 (1%). POPF rate associated with high FRS was 18.8%/6.3% (ISGPFc/ISGPSc). With low and intermediate FRS, POPFs were 5.3%/0% (ISGPFc/ISGPSc) and 21.3%/9.8% (ISGPFc/ISGPSc) respectively. Re-operation rate was 3%. In-hospital mortality rate was 2% and specific mortality rate for POPF was 1%.

CONCLUSIONS

The mPJ technique is associated with a POPF rate which was less than expected, especially for "difficult" pancreas with high FRS (soft gland texture and small duct). A larger prospective series is needed in addition to comparative studies with other techniques for robust assessment.

Pancreaticojejunostomy: Does the technique matter? A randomized trial

BACKGROUND

Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a randomized trial.

METHODS

This open-label randomized trial was done at a tertiary care center from January 2009 to October 2015. Patients with resectable periampullary tumours with a pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the two techniques using computer generated random numbers. The primary outcome was postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency of other postoperative complications.

RESULTS

A total of 193 patients were randomized and analyzed (intention-to-treat analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable for baseline demographic and clinical profiles. The incidence of POPF in the entire study group was 23.8%. There was no statistically significant difference between the two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C (clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups were comparable with respect to the secondary outcomes.

DISCUSSION

The duct-to-mucosa technique of PJ after PD is not superior to the dunking technique with respect to POPF rate. (CTRI/2010/091/000531).

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.

Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases

AIM

To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors.

METHODS

This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017).

RESULTS

The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods.

CONCLUSION

Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

An intuitive method of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: use of one-step circumferential interrupted sutures

Pancreaticoenteric anastomosis is the origin of postoperative pancreatic fistula (POPF). Although a variety of methods have been proposed to decrease the POPF rate, randomized controlled trials performed so far have failed to demonstrate superiority of any particular method to the others. Cattell-Warren duct-to-mucosa pancreaticojejunostomy (PJ) is a widely practiced procedure. Their method is challenging, especially when the pancreatic duct is small. We assumed that the difficulty resides in the pancreatic duct becoming difficult to access when the posterior row is tied before suturing the anterior row. We have modified the duct-to-mucosa PJ so that the entire circumference of the inner layer can be sutured and tied in one-step by anchoring and retracting the anterior row. The jejunal roux-limb and pancreatic stump are positioned spatially apart, allowing enough space for free needle work. During a 13-year period, 151 patients underwent pancreaticoduodenectomy with this method, and the cumulative POPF and mortality rates were 37.1% and 4.6%, respectively. These rates were stable throughout the study period, implicating a relative independence from surgeons' experience. We believe that our method is intuitive, easy to grasp, and can be readily adopted even by surgeons not accustomed to pancreaticoduodenectomy.

Normal Postoperative Computed Tomography Findings after a Variety of Pancreatic Surgeries

Pancreatic surgery remains the only curative treatment for pancreatic neoplasms, and plays an important role in the management of medically intractable diseases. Since the original Whipple operation in the 20th century, surgical techniques have advanced, resulting in decreased postoperative complications and better clinical outcomes. Normal postoperative imaging findings vary greatly depending on the surgical technique used. Radiologists are required to be familiar with the normal postoperative imaging findings, in order to distinguish from postoperative complications or tumor recurrence. In this study, we briefly review a variety of surgical techniques for the pancreas, and present the normal postoperative computed tomography findings.

Meta-analysis of invagination and duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: An update

OBJECTIVE

Duct-to-mucosa and invagination are two commonly used techniques of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy. Previously, we conducted a systematic review comparing the safety and efficacy of the two PJ techniques. Here, we added new evidence and updated our previous conclusion.

METHODS

We systematically searched multiple databases and included randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination techniques of PJ. The quality of evidence was assessed using Jadad score, and reporting bias was evaluated using funnel plots. Meta-analysis was performed using a random-effects model. Risk ratio (RR) and 95% confidence interval (CI) were calculated. The primary outcome was pancreatic fistula, and the secondary outcomes included mortality, reoperation, morbidity and postoperative hospital stay. Trial sequential analysis was performed to calculate the required information size.

RESULTS

Seven RCTs with 850 participants were included. No significant difference was detected in the rates of pancreatic fistula (RR 0.98, 95% CI 0.63 to 1.53), mortality (RR 0.94, 95% CI 0.40 to 2.18), reoperation (RR 1.23, 95% CI 0.69 to 2.20) and morbidity (RR 0.98, 95% CI 0.82 to 1.16) between the two groups. However, patients who underwent duct-to-mucosa PJ had a significantly shorter postoperative hospital stay (mean difference -2.80, 95% CI -5.08 to -0.52). Trial sequential analysis showed that another 279 participants were needed for conclusive results.

CONCLUSIONS

Given the current evidence, duct-to-mucosa PJ did not decrease the rates of pancreatic fistula and other adverse events as compared to invagination PJ; however, it did reduce postoperative hospital stay. Further RCTs are needed.