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Olakowski M, Jabłońska B, Mrowiec S. A chronicle of the pancreatoduodenectomy technique development - from the surgeon's hand to the robotic arm. Acta Chir Belg 2023; 123:94-101. [PMID: 36250406 DOI: 10.1080/00015458.2022.2135251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) remains one of the most challenging abdominal surgical procedures. METHODS A review of the literature regarding the history of PD, starting from the pioneers, Walter Kausch and Alan Whipple, through the great surgeons of the last century, up to the present day. RESULTS The greatest development of the PD technique took place at the end of the twentieth century. Over the last 40 years, there have been huge technological advances in medicine, which have resulted in the introduction of laparoscopic and robotic techniques for abdominal surgery. However, it turns out that PD is still performed as it used to be "by the surgeon's hand" via laparotomy rather than using the most modern robot or laparoscope and is currently recommended by experts for treatment of pancreatic head cancer (PHC). This is mainly caused by not many data comparing these three PD methods. Moreover, increasingly the results achieved by surgeons advanced in minimally invasive pancreatic resections are comparable to or even better than those achieved by the open method in reference centres. Robot-assisted PD appears to be gaining an advantage over laparoscopic technique in the efficacy of PHC treatment. The obstacles most inhibiting the use of surgical robotics are the high cost of the device and procedure, and the long learning curve. A bright future lies ahead for both methods, with the robotic technique in the forefront. CONCLUSIONS Despite significant advances in access and surgical technique, PD remains a challenging surgical procedure requiring a big surgeon's experience.
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Affiliation(s)
- Marek Olakowski
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice, Poland
| | - Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice, Poland
| | - Sławomir Mrowiec
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice, Poland
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Hai H, Li Z, Zhang Z, Cheng Y, Liu Z, Gong J, Deng Y. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2022; 3:CD013462. [PMID: 35289922 PMCID: PMC8923262 DOI: 10.1002/14651858.cd013462.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Hua Hai
- Department of Operating Room, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuyin Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziwei Zhang
- Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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OUP accepted manuscript. Br J Surg 2022; 109:812-821. [DOI: 10.1093/bjs/znac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/07/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022]
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Okubo S, Hashimoto M, Kojima K, Makuuchi M, Kobayashi Y, Shindoh J. Clinical impact of the new "twin U-stitch method" of pancreaticogastrostomy in pancreaticoduodenectomy. Langenbecks Arch Surg 2021; 407:1263-1269. [PMID: 34846600 DOI: 10.1007/s00423-021-02384-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The optimal pancreaticogastrostomy (PG) method for reducing pancreatic fistula (PF) incidence remains unclear. This retrospective review aimed to evaluate the clinical impact of the "twin U-stitch method" and compared it with the conventional invagination method. METHODS Data of 183 consecutive patients who underwent PG after pancreaticoduodenectomy (PD) between January 2015 and November 2020 were evaluated. PF incidence was compared between patients who experienced twin U-stitch PG (twin U-stitch group) and those who experienced conventional invagination PG (conventional PG group). RESULTS The twin U-stitch and conventional PG methods were performed in 97 and 86 patients, respectively. The time required for twin U-stitch PG was shorter than conventional PG (9.3 min vs 20.0 min, P < 0.001). The twin U-stitch group showed a lower incidence of PF than the conventional PG group (8% vs. 19%, P = 0.038). Multivariate analysis confirmed that twin U-stitch PG was significantly correlated with a decreased risk of PF (odds ratio, 0.23; P = 0.006), independent of the texture of the pancreas. Subgroup analysis of patients with soft-textured pancreas showed that the median drain amylase levels in the twin U-stitch group on postoperative days (POD) 1 and 3 were significantly lower than those in the conventional PG group (POD 1: 1,335 vs. 5,991 U/L, P < 0.001; POD 3: 212 vs. 518, P = 0.001). CONCLUSION The twin U-stitch method was simple and preferable to the conventional method for preventing PF in patients with PD.
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Affiliation(s)
- Satoshi Okubo
- Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Tokyo, Minato-ku, 105-8470, Japan.,Okinaka Memorial Institute for Medical Disease, Tokyo, Japan
| | - Masaji Hashimoto
- Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Tokyo, Minato-ku, 105-8470, Japan. .,Okinaka Memorial Institute for Medical Disease, Tokyo, Japan.
| | - Kazutaka Kojima
- Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Tokyo, Minato-ku, 105-8470, Japan
| | - Mikio Makuuchi
- Department of Gastroenterological Surgery, Sannoudai Hospital, 4-1-38 Higashiishioka, Ishioka-city, Ibaraki, 315-0037, Japan
| | - Yuta Kobayashi
- Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Tokyo, Minato-ku, 105-8470, Japan.,Okinaka Memorial Institute for Medical Disease, Tokyo, Japan
| | - Junichi Shindoh
- Department of Gastroenterological Surgery, Toranomon Hospital, 2-2-2 Toranomon, Tokyo, Minato-ku, 105-8470, Japan.,Okinaka Memorial Institute for Medical Disease, Tokyo, Japan
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Rate of Post-Operative Pancreatic Fistula after Robotic-Assisted Pancreaticoduodenectomy with Pancreato-Jejunostomy versus Pancreato-Gastrostomy: A Retrospective Case Matched Comparative Study. J Clin Med 2021; 10:jcm10102181. [PMID: 34070025 DOI: 10.3390/jcm10102181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/08/2021] [Accepted: 05/14/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Different techniques of pancreatic anastomosis have been described, with inconclusive results in terms of pancreatic fistula reduction. Studies comparing robotic pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are scarcely reported. METHODS The present study analyzes the outcomes of two case-matched groups of patients who underwent PG (n = 20) or PJ (n = 40) after pancreaticoduodenectomy. The primary aim was to compare the rate of post-operative pancreatic fistula. RESULTS Operative time (375 vs. 315 min, p = 0.34), estimated blood loss (270 vs. 295 mL, p = 0.44), and rate of clinically relevant post-operative pancreatic fistula (12.5% vs. 10%, p = 0.82) were similar between the two groups. PJ was associated with a higher rate of intra-abdominal collections (7.5% vs. 0%, p = 0.002), but lower post-pancreatectomy hemorrhage (2.5% vs. 10%, p = 0.003). PG was associated with a lower rate of post-operative pancreatic fistula (POPF) (33.3% vs. 50%, p = 0.003) in the high-risk group of patients. CONCLUSIONS The outcomes of post-operative pancreatic fistula are comparable between the two reconstruction techniques. PG may have a lower incidence of POPF in patients with high-risk of pancreatic fistula.
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Prete FP, Di Meo G, Liguori P, Gurrado A, De Luca GM, De Leo V, Testini M, Prete F. Modified "Blumgart-Type" Suture for Wirsung-Pancreaticogastrostomy: Technique and Results of a Pilot Study. Eur Surg Res 2021; 62:105-114. [PMID: 33975310 DOI: 10.1159/000515987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/17/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) represents the principal determinant of morbidity and mortality after pancreaticoduodenectomy. Since 1994 we have been performing pancreaticogastrostomy with duct-to-mucosa anastomosis (Wirsung-pancreaticogastric anastomosis [WPGA]), but postoperative morbidity, although limited, was still a concern. An original pancreas-transfixing suture technique, named "Blumgart's anastomosis" (BA), has shown efficacy at reducing fistula rates from pancreaticojejunostomy. Few cohort studies have shown that WPGA with pancreas-transfixing stitches may help reduce the rate of POPF. We designed a novel "Blumgart-type" modification of WPGA (B-WPGA) aiming at harnessing the full potential of the Blumgart design. METHODS A prospective development study was designed around the application of B-WPGA after pancreaticoduodenectomy for primary periampullary tumors. It focused on describing the early iterations of this technique and on assessing the rate of POPF and delayed post-pancreatectomy hemorrhage (DPH) (primary outcomes), along with other perioperative outcomes. Technically, after mobilizing the pancreatic remnant for a few centimeters, the Wirsung duct is cannulated. A lozenge of seromuscular layer is excised from the posterior gastric wall, matching the shape and size of the pancreas's cut surface. Two to four transparenchymal pancreatic-to-gastric submucosa U stitches with 4/0 Gore-Tex are positioned cranially and caudally to the Wirsung duct, respectively, mounted on soft clamps, and tied onto the gastric serosa only after duct-to-mucosa anastomosis. Postoperative follow-up was standardized by protocol and included a pancreatic enzyme check on the drain output. RESULTS From February 2018 to June 2019, in 15 continuous cases, B-WPGA was performed after pancreaticoduodenectomy. Indications for pancreaticoduodenectomy were mainly ampulla of Vater and pancreatic head adenocarcinomas. There was no operative mortality and no pancreatic anastomosis-related morbidity. Two events (13%) of transiently elevated amylase in the drain fluid, not matching the definition of POPF, were identified in patients with a soft pancreas on postoperative day 2. No DPHs were recorded after a minimum follow-up of 18.6 months. DISCUSSION/CONCLUSION The principles of BA may be safely applied to the WPGA model. B-WPGA allows (1) gentle compression and closure of the small secondary ducts in the pancreatic remnant; (2) partial invagination of the pancreatic body in the gastric wall, with the pancreatic cut surface protected by the gastric submucosa; and (3) prevention of parenchymal fractures, as the pancreaticogastric stitches are tied onto the gastric serosa. Despite the limited number of cases in this study, the absence of mortality and anastomosis-related complications supports further reproduction of this technical variant. Larger studies are necessary to determine its efficacy.
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Affiliation(s)
- Francesco Paolo Prete
- Academic General Surgery Unit, Department of Biomedical Sciences and Human Oncology, Policlinico di Bari, Bari, Italy
| | - Giovanna Di Meo
- Academic General Surgery Unit, Department of Biomedical Sciences and Human Oncology, Policlinico di Bari, Bari, Italy.,Surgical Oncology Unit, Department of Surgery, Ospedale Generale Regionale "F. Miulli", Acquaviva delle Fonti, Italy
| | - Patrizia Liguori
- Surgical Oncology Unit, Department of Surgery, Ospedale Generale Regionale "F. Miulli", Acquaviva delle Fonti, Italy
| | - Angela Gurrado
- Academic General Surgery Unit, Department of Biomedical Sciences and Human Oncology, Policlinico di Bari, Bari, Italy.,University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Giuseppe Massimiliano De Luca
- Academic General Surgery Unit, Department of Biomedical Sciences and Human Oncology, Policlinico di Bari, Bari, Italy
| | - Vincenzo De Leo
- Surgical Oncology Unit, Department of Surgery, Ospedale Generale Regionale "F. Miulli", Acquaviva delle Fonti, Italy
| | - Mario Testini
- Academic General Surgery Unit, Department of Biomedical Sciences and Human Oncology, Policlinico di Bari, Bari, Italy.,University of Bari "Aldo Moro" Medical School, Bari, Italy
| | - Fernando Prete
- University of Bari "Aldo Moro" Medical School, Bari, Italy.,Surgical Oncology Unit, Department of Surgery, Ospedale Generale Regionale "F. Miulli", Acquaviva delle Fonti, Italy
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7
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Preoperative Predictors for 90-Day Mortality after Pancreaticoduodenectomy in Patients with Adenocarcinoma of the Ampulla of Vater: A Single-Centre Retrospective Cohort Study. Surg Res Pract 2021; 2021:6682935. [PMID: 33728373 PMCID: PMC7937469 DOI: 10.1155/2021/6682935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/08/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023] Open
Abstract
Background The standard treatment for ampullary adenocarcinoma is pancreaticoduodenectomy. Identification of preoperative risk factors might help the clinician to select patients fit for resection and potentially decrease morbidity and mortality after PD. We conducted a cohort study to determine the preoperative factors related to 90-day severe morbidity and mortality after PD. Methods We conducted a retrospective cohort study in patients with a diagnosis of ampullary adenocarcinoma who underwent an open PD between January 2010 and December 2019 at our tertiary centre. Results Independent preoperative predictors of mortality were the albumin-bilirubin (ALBI) grade 3 (OR: 21.7; CI 95: 2.1–226.9; p=0.01) and the estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m2 (OR: 17.7; CI 95: 1.8–172.6; p=0.013). The eGFR <90 mL/min/1.73 m2 (OR = 6.6; CI 95: 1.9–23.4; p=0.003) and prothrombin time (OR = 1.5; CI 95; 1.1–2.1; p=0.005) were independent predictors for severe morbidity. Conclusion These findings suggest that baseline renal function measured by the eGFR and liver function categorized with the ALBI grading are predictors of severe morbidity and mortality. Thus, they should be considered when selecting patients for PD or the use of neoadjuvant treatments. Further research is warranted.
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Popov AY, Lishchishin VY, Petrovskiy AN, Lishchenko AN, Grigorov SP, Baryshev AG, Porkhanov VA. [Immediate outcomes of pancreatoduodenectomy after different digestive reconstruction procedures]. Khirurgiia (Mosk) 2021:14-19. [PMID: 33570349 DOI: 10.17116/hirurgia202102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the immediate results of pancreatoduodenectomy depending on digestive reconstruction procedure. MATERIAL AND METHODS We analyzed 242 patients who underwent pancreatoduodenectomy for the period from January 2013 to December 2019. There were 32 combined procedures: 28 (11.6%) with portal vein resection and 8 (3.3%) simultaneous operations (right-sided hemicolectomy - 4, right-sided adrenalectomy - 2, gastrectomy with splenectomy - 2). Pancreatic stump was inserted into the jejunum in 156 (64.5%) patients, into the stomach - in 86 (35.5%) cases. RESULTS Postoperative period was uneventful in 180 (74.4%) patients. Eighty postoperative complications were observed in 62 (25.6%) patients; 221 (91.3%) patients were discharged, 21 (8.7%) patients died. Pancreatic necrosis was the most common postoperative event and provoked 65 (82.5%) various complications (38 (72.1%) in patients with pancreaticojejunostomy and 20 (71.5%) in those with pancreaticogastrostomy). Incidence of complications was similar in both groups. However, pancreaticojejunostomy was followed by severe pancreatic fistula type C in 12 (23.1%) patients, type B in 24 (46.1%) cases. In case of pancreaticogastrostomy, pancreatic fistula type C occurred in 4 (14.3%) cases, type B - in 8 (28.6%) patients. CONCLUSION Pancreatic necrosis was the most common postoperative event after pancreatoduodenectomy. Fewer severe pancreatic fistulae (type C) were recorded after pancreaticogastrostomy although these patients had lower density of the pancreas and unclear pancreatic duct. Choice of pancreatic-digestive anastomosis should be determined by features of pancreatic parenchyma, pancreatic duct diameter. Nevertheless, final decision is a prerogative of surgeon. Pancreaticogastrostomy is especially advisable in minimally invasive PDEs that will simplify inclusion of the pancreas into digestive system and reduce the incidence of complications and mortality.
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Affiliation(s)
- A Yu Popov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - V Ya Lishchishin
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - A N Petrovskiy
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - A N Lishchenko
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - S P Grigorov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
| | - A G Baryshev
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia
| | - V A Porkhanov
- Ochapovsky Regional Clinic Hospital No 1, Krasnodar, Russia.,Kuban State Medical University, Krasnodar, Russia
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Bardol T, Delicque J, Hermida M, Herrero A, Guiu B, Fabre JM, Souche R. Neck transection level and postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort study of 195 patients. Int J Surg 2020; 82:43-50. [PMID: 32841726 DOI: 10.1016/j.ijsu.2020.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/28/2020] [Accepted: 08/01/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of the level of neck transection on clinically relevant postoperative pancreatic fistula (CR-POPF) after standard pancreaticoduodenectomy (PD) with pancreaticojejunostomy. METHOD A total of 195 patients with an early postoperative CT scan were retrospectively analyzed and divided into 2 groups (CR-POPF and No CR-POPF) in order to seek potential risk factors for CR-POPF. We focused our analysis on the relationship between CR-POPF and the level of neck transection, defined by measuring the distance between the left side of the portal vein and the remnant pancreatic stump on the postoperative CT scan. RESULT CR-POPF occurred in 58 out of 195 PD (29.7%); grade B (17%) and grade C (12.7%). The Clavien-Dindo ≥ 3 morbidity rate was 33% (65/195) and the mortality rate was 2.5% (5/195). Multivariate analysis indicated that a 'right-sided' level of neck transection (P = 0.007), a firm pancreatic texture (P = 0.001), and a PD for non-pancreatic ductal adenocarcinoma histology (P = 0.032) were independent risk factors for CR-POPF. A full neck resection with systematic transection ≥7 mm at the left side of the portal vein seems to prevent CR-POPF harboring a protective effect (OR 0.056; 95% CI 0.003 to 0.978; P = 0.039). CONCLUSION Here we further consolidate the concept describing the pancreatic neck as a vascular watershed, showing that a long remnant pancreatic neck could be an independent risk factor for CR-POPF after PD (NCT03850236). TRIAL REGISTRATION NUMBER AND AGENCY The present study was approved by our local ethics committee and was declared on ClinicalTrials.gov (ID: NCT03850236).
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Affiliation(s)
- Thomas Bardol
- Department of Digestive Surgery and Transplantation, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France.
| | - Julien Delicque
- Department of Radiology, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Margaux Hermida
- Department of Radiology, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Astrid Herrero
- Department of Digestive Surgery and Transplantation, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Boris Guiu
- Department of Radiology, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Jean-Michel Fabre
- Department of Digestive Surgery and Transplantation, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Regis Souche
- Department of Digestive Surgery and Transplantation, University Hospital Center, Montpellier-Nimes University, 641 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
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10
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Permanent Pancreatic Duct Occlusion With Neoprene-based Glue Injection After Pancreatoduodenectomy at High Risk of Pancreatic Fistula: A Prospective Clinical Study. Ann Surg 2020; 270:791-798. [PMID: 31567180 PMCID: PMC6867669 DOI: 10.1097/sla.0000000000003514] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this study was to assess safety and efficacy of pancreatic duct occlusion (PDO) with neoprene-based glue in selected patients undergoing pancreatoduodenectomy (PD) at high risk of postoperative pancreatic fistula (POPF).
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11
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Cheng Y, He S, Xia J, Ding X, Liu Z, Gong J. Duct-to-mucosa pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Hippokratia 2019. [DOI: 10.1002/14651858.cd013462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Sirong He
- Chongqing Medical University; Department of Immunology, College of Basic Medicine; No. 1 Yixue Road Chongqing China 450000
| | - Jie Xia
- Chongqing Medical University; The Key Laboratory of Molecular Biology on Infectious Diseases; Chongqing China 450000
| | - Xiong Ding
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
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Tonolini M, Ierardi AM, Carrafiello G. Elucidating early CT after pancreatico-duodenectomy: a primer for radiologists. Insights Imaging 2018; 9:425-436. [PMID: 29654405 PMCID: PMC6108971 DOI: 10.1007/s13244-018-0616-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/12/2018] [Accepted: 03/06/2018] [Indexed: 02/07/2023] Open
Abstract
Abstract Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically demanding, high-risk operation burdened with high morbidity (complication rates 40–50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require familiarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayed gastric emptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis. Teaching Points • Pancreatico-duodenectomy (PD) is a technically demanding surgery burdened with high morbidity (40–50%). • Multidetector CT is the mainstay technique to investigate suspected complications following PD. • Interpreting post-PD CT requires knowledge of surgically altered anatomy and expected findings. • CT showing collection at surgical site supports clinico-biological diagnosis of pancreatic fistula. • Other complications include biliary leaks, haemorrhage, abscesses and venous thrombosis.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
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Cheng Y, Briarava M, Lai M, Wang X, Tu B, Cheng N, Gong J, Yuan Y, Pilati P, Mocellin S. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2017; 9:CD012257. [PMID: 28898386 PMCID: PMC6483797 DOI: 10.1002/14651858.cd012257.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatoduodenectomy is a surgical procedure used to treat diseases of the pancreatic head and, less often, the duodenum. The most common disease treated is cancer, but pancreatoduodenectomy is also used for people with traumatic lesions and chronic pancreatitis. Following pancreatoduodenectomy, the pancreatic stump must be connected with the small bowel where pancreatic juice can play its role in food digestion. Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are surgical procedures commonly used to reconstruct the pancreatic stump after pancreatoduodenectomy. Both of these procedures have a non-negligible rate of postoperative complications. Since it is unclear which procedure is better, there are currently no international guidelines on how to reconstruct the pancreatic stump after pancreatoduodenectomy, and the choice is based on the surgeon's personal preference. OBJECTIVES To assess the effects of pancreaticogastrostomy compared to pancreaticojejunostomy on postoperative pancreatic fistula in participants undergoing pancreaticoduodenectomy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9), Ovid MEDLINE (1946 to 30 September 2016), Ovid Embase (1974 to 30 September 2016) and CINAHL (1982 to 30 September 2016). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) and screened references of eligible articles and systematic reviews on this subject. There were no language or publication date restrictions. SELECTION CRITERIA We included all randomized controlled trials (RCTs) assessing the clinical outcomes of PJ compared to PG in people undergoing pancreatoduodenectomy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. We performed descriptive analyses of the included RCTs for the primary (rate of postoperative pancreatic fistula and mortality) and secondary outcomes (length of hospital stay, rate of surgical re-intervention, overall rate of surgical complications, rate of postoperative bleeding, rate of intra-abdominal abscess, quality of life, cost analysis). We used a random-effects model for all analyses. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes (using PG as the reference) with 95% confidence intervals (CI) as a measure of variability. MAIN RESULTS We included 10 RCTs that enrolled a total of 1629 participants. The characteristics of all studies matched the requirements to compare the two types of surgical reconstruction following pancreatoduodenectomy. All studies reported incidence of postoperative pancreatic fistula (the main complication) and postoperative mortality.Overall, the risk of bias in included studies was high; only one included study was assessed at low risk of bias.There was little or no difference between PJ and PG in overall risk of postoperative pancreatic fistula (PJ 24.3%; PG 21.4%; RR 1.19, 95% CI 0.88 to 1.62; 7 studies; low-quality evidence). Inclusion of studies that clearly distinguished clinically significant pancreatic fistula resulted in us being uncertain whether PJ improved the risk of pancreatic fistula when compared with PG (19.3% versus 12.8%; RR 1.51, 95% CI 0.92 to 2.47; very low-quality evidence). PJ probably has little or no difference from PG in risk of postoperative mortality (3.9% versus 4.8%; RR 0.84, 95% CI 0.53 to 1.34; moderate-quality evidence).We found low-quality evidence that PJ may differ little from PG in length of hospital stay (MD 1.04 days, 95% CI -1.18 to 3.27; 4 studies, N = 502) or risk of surgical re-intervention (11.6% versus 10.3%; RR 1.18, 95% CI 0.86 to 1.61; 7 studies, N = 1263). We found moderate-quality evidence suggesting little difference between PJ and PG in terms of risk of any surgical complication (46.5% versus 44.5%; RR 1.03, 95% CI 0.90 to 1.18; 9 studies, N = 1513). PJ may slightly improve the risk of postoperative bleeding (9.3% versus 13.8%; RR 0.69, 95% CI: 0.51 to 0.93; low-quality evidence; 8 studies, N = 1386), but may slightly worsen the risk of developing intra-abdominal abscess (14.7% versus 8.0%; RR 1.77, 95% CI 1.11 to 2.81; 7 studies, N = 1121; low quality evidence). Only one study reported quality of life (N = 320); PG may improve some quality of life parameters over PJ (low-quality evidence). No studies reported cost analysis data. AUTHORS' CONCLUSIONS There is no reliable evidence to support the use of pancreatojejunostomy over pancreatogastrostomy. Future large international studies may shed new light on this field of investigation.
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Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Marta Briarava
- University of PadovaDepartment of Surgery, Oncology and GastroenterologyPadovaItaly
| | - Mingliang Lai
- Jiangjin Central HospitalDepartment of Clinical LaboratoryNo. 65, Jiang Zhou RoadChongqingChina402260
| | - Xiaomei Wang
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Bing Tu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Yuhong Yuan
- McMaster UniversityDepartment of Medicine, Division of Gastroenterology1280 Main Street WestRoom HSC 3N51HamiltonONCanadaL8S 4K1
| | - Pierluigi Pilati
- University of PadovaMeta‐Analysis Unit, Department of Surgery, Oncology and Gastroenterologyvia Giustiniani 2PadovaItaly35128
| | - Simone Mocellin
- University of PadovaDepartment of Surgery, Oncology and GastroenterologyPadovaItaly
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Mocellin S, Briarava M, Yuan Y, Pilati P. Anastomosis to stomach versus anastomosis to jejunum for reconstructing the pancreatic stump after pancreatoduodenectomy. Hippokratia 2016. [DOI: 10.1002/14651858.cd012308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Simone Mocellin
- University of Padova; Department of Surgery, Oncology and Gastroenterology; Via Giustiniani 2 Padova Veneto Italy 35128
- IOV-IRCCS; Istituto Oncologico Veneto; Padova Italy 35100
| | - Marta Briarava
- University of Padova; Department of Surgery, Oncology and Gastroenterology; Via Giustiniani 2 Padova Veneto Italy 35128
| | - Yuhong Yuan
- McMaster University; Department of Medicine, Division of Gastroenterology; 1280 Main Street West Room HSC 3N51 Hamilton ON Canada L8S 4K1
| | - Pierluigi Pilati
- University of Padova; Meta-Analysis Unit, Department of Surgery, Oncology and Gastroenterology; via Giustiniani 2 Padova Italy 35128
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