MODIFIED HEIDELBERG TECHNIQUE FOR PANCREATIC ANASTOMOSIS

A new method of pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy: A retrospective analysis of 93 cases

INTRODUCTION

Pancreaticojejunostomy have been studied and modified for more than a hundred years. We investigated a new method of pancreaticojejunostomy to explore its value in laparoscopic pancreaticoduodenectomy.

PATIENTS AND METHODS

A retrospective analysis was conducted on the clinical data of 93 patients who underwent laparoscopic pancreaticoduodenectomy with 'Shunt-block combined' pancreaticojejunostomy at Ningbo Medical Center Lihuili Hospital from April 2017 to February 2023.

RESULTS

All patients successfully completed the surgery, with two cases requiring conversion to open surgery. The average operation time was 328.5 (180-532) min, the average intraoperative blood loss was 182.9 (50-1000) mL and the average laparoscopic pancreaticojejunostomy time was 29.6 (20-39) min. There were no cases of grade C pancreatic fistula postoperatively, 10 cases of grade B pancreatic fistula, 43 cases of biochemical fistula and 40 cases without detected pancreatic fistula.

CONCLUSION

'Shunt-block combined' pancreaticojejunostomy was a safe and effective method for pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.

PANCREATODUODENECTOMY AS TREATMENT FOR RECURRENT ACUTE PANCREATITIS DUE TO PANCREAS DIVISUM

BACKGROUND

Pancreas divisum is an anatomical abnormality where the junction of the main and accessory pancreatic duct fails to occur and the smaller-caliber duct acts as dominant, resulting in overload during the drainage of the organ's secretion through the minor duodenal papilla.

AIMS

To report a case of recurrent acute pancreatitis due to symptomatic pancreas divisum who underwent pancreatoduodenectomy.

CASE REPORT

A 21-year-old male patient presented with intermittent painful crises, located in the upper abdomen, with radiation to the back, associated with nausea and vomiting, for the past three years. Magnetic resonance imaging and endoscopic retrograde cholangiopancreatography revealed pancreas divisum, subsequently confirmed by endoscopic ultrasound. An attempt was made through endoscopic intervention but failed to catheterize the minor papilla; therefore, a pancreaticoduodenectomy was indicated. The organ was identified as hard and atrophied, with moderate peripancreatic inflammation. The histopathological findings also identified a focal well-differentiated G1-type neuroendocrine tumor measuring 0.4 cm.

CONCLUSIONS

In patients with pancreas divisum, rare cases may progress to recurrent acute pancreatitis. Pancreaticoduodenectomy is an option in symptomatic patients who had no success with endoscopic treatment.

Development and validation of a novel pancreaticojejunostomy strategy based on the anatomical location of the main pancreatic duct that can reduce the risk of postoperative pancreatic fistula after pancreatoduodenectomy

Background

Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD). The effect of the location of the main pancreatic duct on POPF development is not completely elucidated. This study aimed to investigate the association between the location of the main pancreatic duct and POPF, and the effect of pancreaticojejunostomy based on the location of the main pancreatic duct on the risk of POPF.

Methods

This retrospective study enrolled 871 patients who underwent PD between January 2018 and December 2021. Logistic regression analysis was performed to identify the independent risk factors associated with POPF. Predictive performance was evaluated using the receiver operating characteristic curves. In addition, a novel pancreaticojejunostomy strategy that could reduce the risk of POPF was adopted.

Results

Based on the multivariate analysis, the pancreatic texture and the location of the main pancreatic duct were the independent risk factors of POPF. A threshold ratio of 0.397 was used to distinguish the central from the eccentric pancreatic ducts. Notably, patients with the central pancreatic duct had a significantly lower incidence rate of POPF than those with the eccentric pancreatic ducts (10.6% vs. 44.8%, P<0.001). The novel group exhibited a significantly lower incidence rate of POPF than the conventional group (13.7% vs. 23.0%, P=0.02), and the incidence rate of other complications was not high.

Conclusions

The location of the main pancreatic duct is associated with POPF development. However, implementing the novel pancreaticojejunostomy approach can effectively reduce the risk of POPF while ensuring safety.

PANCREATODUODENECTOMY DUE TO LIPOMATOUS PSEUDOHYPERTROPHY OF THE PANCREAS

BACKGROUND

Lipomatous pseudohypertrophy of the pancreas, pancreatic lipomatosis, pancreatic steatosis, non-alcoholic fatty pancreatic disease, or fatty pancreas is an extremely rare disease, characterized by the organ enlargement and a localized or diffuse replacement of pancreatic acinar cells by mature adipose tissue, preserving the pancreatic ductal system and islets of Langerhans.

AIMS

To report a rare case of lipomatous pseudohypertrophy of the pancreas in a symptomatic patient and the surgical treatment employed.

METHODS

A 24-year-old male patient with weight loss (10 kilograms in 8 months), hyperglycemia, severe and recurrent acute abdominal pain, epigastric discomfort associated with nausea, vomiting, and jaundice for 40 days. Magnetic resonance imaging was performed, revealing an irregular lipomatous pseudohypertrophy of the pancreas, measuring 6.0 × 5.6 cm in the head, uncinate process, and part of the body of the pancreas. The pancreatic duct dilation was diffuse and irregular, associated with atrophy of the remnant parenchyma, particularly in the tail of the pancreas. The patient underwent pancreatoduodenectomy without total mesopancreas excision followed by pancreatojejunostomy.

RESULTS

The postoperative course was uneventful, the length of stay in the ICU was two days, and the patient was discharged on the seventh postoperative day.

CONCLUSIONS

The disease treatment depends on the signs and symptoms at presentation and a pancreatoduodenectomy is indicated in patients with severe and recurrent abdominal pain.

Secure reconstruction after pancreaticoduodenectomy: Review and improved our continuous duct-to-mucosa anastomosis

Pancreatic anastomotic leakage is the most common major complication after pancreaticoduodenectomy (PD). The incidence of pancreatic anastomotic leak or fistula has declined to less than 20%, and mortality from this complication has decreased to less than 10% in recent years. The ideal surgical procedures to achieve the most secure pancreaticojejunostomy were compared and reviewed. A single-institution and personal experience was retrogradely compared with two periods between 1988 and 2017, which involved 121 patients who were designed to compare the outcome of complications with or without pancreatic stump by four to six sutures before continuous duct-to-mucosa PD. The surgical reconstruction technique was standardized and unique, and the pancreaticojejunal anastomosis was created using the duct-to-mucosa without (group A, n = 62) and with (group B, n = 59) interrupted stump sutures. The rate of grade A pancreatic fistula was 6.9% in group A and 0% in group B (P < 0.05). Postoperative mortality was 0% in group B. No patient underwent reoperative PD due to pancreatic anastomotic leak. The length of stay during admission and after surgery was significant lower in group B, which was due to less complication after surgery. Interrupted suture of pancreatic stump with a continuous duct-to-mucosa end-to-side pancreaticojejunostomy plus external drainage is the best secure method for pancreaticojejunostomy after PD.

Surgical Management of Postoperative Grade C Pancreatic Fistula following Pancreatoduodenectomy

Background

The incidence of Grade C postoperative pancreatic fistula ranges from 2 to 11% depending on the type of pancreatic resection. This complication may frequently require early relaparotomy and the surgical approach remains technically challenging and is still associated with a high mortality. Infectious complications and post-operative hemorrhage are the two most common causes of reoperation.

Summary

The best management of grade C pancreatic fistulas remains controversial and ranges from conservative approaches up to completion pancreatectomy. The choice of the technique depends on the patient's conditions, intraoperative findings, and surgeon's discretion. A pancreas-preserving strategy appears to be attractive, including from simple to more complex procedures such as debridement and drainage, and external wirsungostomy. Completion pancreatectomy should be reserved for selected cases, including stable patients with severe infection complication or hemorrhage after pancreatic fistula who do not respond to pancreas-preserving procedures.

Key Messages

This review describes the current options for management of grade C pancreatic fistula after pancreatoduodenectomy with regard to indication, choice of procedure and outcomes of the different approaches.

Pancreaticojejunostomy Conducive to Biological Healing in Minimally Invasive Pancreaticoduodenectomy

BACKGROUND

Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in minimally invasive surgery is difficult to perform, more simplified methods are needed to guarantee a safe pancreatic anastomosis. The concept of "biological healing" proposed in recent years has changed the conventional understanding of the anastomosis, which recommends rich blood supply, low tension, and loose sutures in the reconstruction of the pancreatic outflow tract.

METHODS

A literature search was conducted in PubMed for articles on pancreaticojejunostomy published between January 2014 and December 2021. After following a due selection process, several techniques developed in accordance with the concept of biological healing that were found suitable for minimally invasive surgery and their related clinical outcomes were described in this review.

RESULTS

The incidence of clinically relevant pancreatic fistula associated with the presented techniques did not exceed 15.9%, indicating superior results compared to Cattell-Warren double-layer duct-to-mucosa anastomosis (incidence: approximately 20%). The features and drawbacks of these approaches have been enumerated from the viewpoint of biological healing.

CONCLUSIONS

This review described several modified pancreaticojejunostomy techniques with the advantages of a simplified procedure and a lower incidence of pancreatic fistula. Surgeons can choose to apply them in clinical practice to improve patient prognosis.

Contemporary Surgical, Oncological, and Survival Outcomes of Pancreaticoduodenectomy for Periampullary Tumours: a 5-Year Experience from Tertiary Cancer Center

With advances in surgical management of pancreaticoduodenectomy (PD), mortality rate for PD has been reported to be less than 5%. Postoperative pancreatic fistula (POPF) remains a major complication and morbidity after PD with incidence of up to 40%. This is a retrospective analysis of patients who underwent PD in a tertiary cancer referral center in southern India. Data was collected for the patients operated during the period from Jan 2014 to Dec 2018. Surgicopathological, oncological, and survival outcomes were described. Of 76 patients presumed as operable, 16 were excluded and data analyzed for 60 patients. Forty-four percent underwent classical Whipple's PD and 56% pylorus-preserving PD. The most common postoperative complications were wound infection (25%); pneumonia (20%); clinically relevant POPF (13%); and delayed gastric emptying (19%). Thirty-day in-hospital mortality was 5%, 90-day mortality was 8.3%, and fistula-related mortality was 1.6%. Ampullary cancer was the most common histology. Three-year survival rate was 23.3% with a mean overall survival of 33.2 months with significantly better survival in the node negative than positive group (41.3 vs 20.5 months, P = 0.003) and significantly lower survival in pancreatic head cancer than other tumor histologies (16.6 vs 37.3 months, P = 0.002). Multivariate analysis has shown pancreatic head histology (HR = 2.38, 95% CI (1.08-5.26), P = 0.033) and nodal positivity (HR = 2.38, 95% CI (1.27-4.44), P = 0.007) as poor prognostic factors. Pancreaticoduodenectomy is a safe operation in experienced hands. Adhering to a meticulous adaptable reproducible anastomotic technique with standard perioperative management strategies significantly decreases the operative morbidity and mortality.

Combined Bile Duct and Pancreatic Duct Injuries during Distal Gastrectomy for Obstructing Peptic Ulcer Disease

A combination of bile and pancreatic duct injuries is very rare. Anomalous ductal anatomy, distorting duodenal fibrosis, and pancreatic atrophy predispose to this untoward complication during performance of distal gastrectomy for benign peptic stricture. The technical challenges posed by this complication and experience gained by managing it are shared.

Extended liver surgery for gallbladder cancer revisited: Is there a role for hepatopancreatoduodenectomy?

Gallbladder cancer (GBCA) is a rare and fatal disease and the majority of patients presents with advanced stage. Surgical resection associated with lymphadenectomy is the only chance for cure. For patients in stages III and IV, extended resection is the only treatment to achieve R0 margins. For GBCA invading the hepatoduodenal ligament and pancreatoduodenal region, the resection of extrahepatic bile duct and pancreas is necessary. Hepatopancreatoduodenectomy (HPD) represents the most complex and challenging procedure in the hepatopancreatobiliary region. Kuno at the Cancer Institute Hospital Tokyo performed the first HPD in Japan in 1974 and in 1980 Takasaki presented five cases and the 30-day mortality was 60%. After that, other countries started to perform the procedure including United States and Brazil. The main complications are liver failure and pancreatic fistula. Advancements in perioperative care, surgical technique, medical instruments and postoperative at intensive care unit have resulted in reduction in morbidity and mortality. The use of portal vein embolization is indicated to increase the liver volume in patients with insufficient remnant. Preoperative biliary drainage can prevent cholangitis and improve hepatic function. This procedure should be recommended before extended HPD in jaundiced patients. Operative results with mortality rates below 5% at high volume centers suggest that HPD should be performed at centers with expertise in hepatopancreatobiliary surgery.

Pancreaticojejunostomy-a review of modern techniques

Background

Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared to the other methods.

Purpose

The aim of this review was to provide a concise and illustrated description of the most recent methods of pancreaticojejunostomy. Their development was directly related to the still ongoing search by surgeons for such a technique of anastomosis that would eliminate the problem of POPF.

Conclusions

Knowledge of various techniques of anastomosis may help the surgeon to find the most suitable and optimal method of pancreatic-intestinal anastomosis for the patient.

Modified Heidelberg technique of pancreatic anastomosis postpancreaticoduodenectomy - 10 years of experience

Context

Pancreatic fistula has forever been a dreaded complication after pancreatic anastomosis (PA). We present a retrospective analysis of 10 years of experience with the Modified Heidelberg technique (MHT) that has been recently described.

Aim

The aim of the study is to establish postoperative pancreatic fistula (POPF) rates after MHT.

Settings and Design

This is a retrospective observational study carried out at a tertiary cancer center in South India in the Department of Surgical Oncology.

Subjects and Methods

Two hundred and eight consecutive patients who underwent pancreaticoduodenectomy (PD) and PA with MHT for a variety of proximal pancreatic lesions from January 2008 to February 2018 were included in this study. The incidence of POPF was recorded by the International Study Group on Pancreatic Fistula 2005 and 2016 definitions.

Statistical Analysis Used

Epidemiological and clinical data are expressed in ratios and percentage and presented in table format.

Results

Between January 2008 and March 2016, 186 patients underwent PD, and MHT was used for PA. Five (2.7%) patients developed Grade A POPF whereas Grades B and C were seen in three (1.6%) patients each with one death. Between April 2016 and February 2018, 22 patients underwent PD. Two patients (9%) had biochemical leak whereas none of them developed clinically relevant POPF. No deaths were recorded in this period. Overall, Grade B and Grade C POPF rates were 1.4% each, whereas 30-day mortality was 0.4%.

Conclusions

Results of this study indicate that MHT is a safe, reliable, easy to learn, and adopt technique of pancreatic reconstruction after PD.