Surgical outcomes of pancreaticoduodenectomy in young patients: A case series

Combined robotic/open pancreaticoduodenectomy in the young aged < 50 years

Impact of age on surgical and survival outcomes after combined robotic/open pancreaticoduodenectomy (CR/OPD) has not been extensively studied. This study aimed to evaluate the surgical and survival outcomes of patients aged < 50 years who underwent CR/OPD. A comparative study was conducted on patients who underwent CR/OPD divided into two groups: the young (age < 50 years) and the old (age ≥ 50 years). A total of 555 patients were included in this study, with 53 (9.5%) in the young group and 502 (90.5%) in the old group. Periampullary adenocarcinomas were less common in the young group (32.1% vs. 76.5%), whereas solid and pseudopapillary tumors (9.4% vs. 1.0%) and neuroendocrine tumors (15.1% vs. 3.6%) were more common. Soft pancreatic parenchyma (77.4% vs. 76.5%) and non-dilated (≤ 3 mm) pancreatic ducts (77.4% vs. 62.5%) were more prevalent in the young group. The young group had a shorter length of stay (median, 16 vs. 20 days). No significant differences were observed in the other surgical outcomes and risks, including postoperative pancreatic fistula (POPF) (7.5% vs. 8.0%). Survival outcomes for overall periampullary adenocarcinoma favored the young group, with a 5-year survival rate of 76.4% vs. 46.7% in the old group. In conclusion, RPD in the young patients (< 50 years) is associated with comparable surgical outcomes and favorable survival outcomes for periampullary adenocarcinoma compared with the older patients (≥ 50 years). These findings highlight the feasibility and safety of RPD in the young population, although the prevalence of soft pancreatic parenchyma and non-dilated pancreatic ducts was higher in the young group.

Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy: The Role of the Roux-en-Y Configuration

Background

Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients' outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients' outcome.

Methods

The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed.

Results

Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C).

Conclusion

Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.

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.

Pregnancy after Whipple procedure: a new case and review of the literature

Background: Whipple procedure is a complex operation usually performed to treat periampullary neoplasms. There are only four case reports of five pregnancies after Whipple procedure, with limited evidence about how to manage pregnancy after this surgery.Case: A 28-year-old gravida 5 Para 2022 presented to our hospital at 20 weeks with worsening depression. She had a history of Whipple for a solid pseudopapillary neoplasm of the pancreas followed by two pregnancies. In the first, she underwent successful induction of labor at 38 weeks for pregestational diabetes. In her second pregnancy, she had multiple admissions for diabetic ketoacidosis. She was scheduled for induction of labor at 35 weeks but given unstable lie, underwent cesarean delivery.Conclusion: Women with a history of Whipple procedure generally have successful pregnancies with the most common antenatal complications including diabetes mellitus, abdominal pain and pancreatitis/cholangitis.