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%.

Post-endoscopic retrograde cholangiopancreatography pancreatitis: Risk factors and predictors of severity

AIM

To detect risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and investigate the predictors of its severity.

METHODS

This is a prospective cohort study of all patients who underwent ERCP. Pre-ERCP data, intraoperative data, and post-ERCP data were collected.

RESULTS

The study population consisted of 996 patients. Their mean age at presentation was 58.42 (± 14.72) years, and there were 454 male and 442 female patients. Overall, PEP occurred in 102 (10.2%) patients of the study population; eighty (78.4%) cases were of mild to moderate degree, while severe pancreatitis occurred in 22 (21.6%) patients. No hospital mortality was reported for any of PEP patients during the study duration. Age less than 35 years (P = 0.001, OR = 0.035), narrower common bile duct (CBD) diameter (P = 0.0001) and increased number of pancreatic cannulations (P = 0.0001) were independent risk factors for the occurrence of PEP.

CONCLUSION

PEP is the most frequent and devastating complication after ERCP. Age less than 35 years, narrower median CBD diameter and increased number of pancreatic cannulations are independent risk factors for the occurrence of PEP. Patients with these risk factors are candidates for prophylactic and preventive measures against PEP.

Intraoperative endoscopic retrograde cholangio-pancreatography: A useful tool in the hands of the hepatobiliary surgeon

AIM: To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) for patients with gall bladder stones (GS) and common bile duct stones (CBDS).

METHODS: Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram (TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS.

RESULTS: Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases (84.2%) where removal of stones were successful; passed stones in 6 cases (7.9%); short lower end stricture with small stones present in two cases (2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case (1.3%) which was treated by open hepaticojejunostomy; and one case (1.3%) was proved to be ampullary carcinoma and whipple’s operation was scheduled.

CONCLUSION: The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.

Partial posterior wrap (toupet)in patients with defective esophageal body motility

BACKGROUND

The effectiveness of partial posterior wrap (Toupet procedure) in patients with defective esophageal body motility is controversial.

AIM OF THE STUDY

To evaluate the effect of Toupet procedure upon the outcome of laparoscopic (LF) and open (OF) fundoplications in gastroesophageal reflux disease (GERD) patients with defective esophageal body motility.

PATIENTS AND METHODS

This study included 32 patients with severe GERD who underwent Toupet procedure; 18 (56.25%) OF 'and 14 (43.75%) LF. Outcome measures included assessment of relief of the symptoms, results of repeated endoscopy, barium study, manometry and pH metry; both early (within six months) and late (two years at least).

RESULTS

Relief of heartburn was achieved in 26 patients (81.3%). These include 14 (77.7%) and 12 (85.7%) patients who underwent OF and LF respectively. Occasional dysphagia developed in six patients (18.7%) early, and three (9.4%) late; all were managed conservatively. Endoscopic esophagitis healed in 26 patients (81.3%); 14 (77.7%) OF and 12 (85.7%) LF. Mean LES and body pressures improved (10.5 to 17.7 and 29.0 to 41.0 mmHg respectively). Persistent acid reflux was detected in six patients (18.7%); two (22.3%) OF and two (14.3%) LF.

CONCLUSION

Toupet fundoplication is an effective procedure for reflux control except in patients with severe GERD.