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Wu JM, Lin YJ, Wu CH, Kuo TC, Tien YW. Novel Non-duct-to-Mucosa Pancreaticojejunostomy Reconstruction After Pancreaticoduodenectomy: Focus on the Occurrence of Post-pancreatectomy Hemorrhage and Intra-abdominal Abscess. Ann Surg Oncol 2023; 30:5063-5070. [PMID: 36808588 DOI: 10.1245/s10434-023-13114-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/02/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND Postoperative pancreatic fistulas (POPFs) are considered inevitable in some patients after pancreaticoduodenectomy (PD), and measures to minimize their clinical impact are needed. Postpancreatectomy hemorrhage (PPH) and intra-abdominal abscess (IAA) are the most severe POPF-related complications, and concomitant leakage of contaminated intestinal content is considered the main cause. An innovative method, modified non-duct-to-mucosa pancreaticojejunostomy (TPJ), was created to prevent concomitant leakage of intestinal content, and its effectiveness was compared between two periods. METHODS All PD patients undergoing pancreaticojejunostomy from 2012 to 2021 were included. The TPJ group consisted of 529 patients recruited from January 2018 to December 2021. A total of 535 patients receiving the conventional method (CPJ) from January 2012 to June 2017 were used as a control group. PPH and POPF were defined according to the International Study Group of Pancreatic Surgery definition, but only PPH grade C was included for analysis. An IAA was defined as a collection of postoperative fluid managed by CT-guided drainage with documental culture. RESULTS There were no significant differences in the rate of POPF between the two groups (46.0% vs. 44.8%; p = 0.700). Furthermore, the percentages of bile in the drainage fluid in the TPJ and CPJ groups were 2.3% and 9.2%, respectively (p < 0.001). Lower proportions of PPH (0.9% vs. 6.5%; p < 0.001) and IAA (5.7% vs. 10.8%; p < 0.001) were observed for TPJ than for CPJ. On adjusted models, TPJ was significantly associated with a lower rate of PPH (odds ratio [OR] 0.132, 95% confidence interval [CI] 0.051-0.343; p < 0.001) and IAA (OR 0.514, 95% CI 0.349-0.758; p = 0.001) than CPJ. CONCLUSIONS TPJ is feasible to be performed and is associated with a similar rate of POPF but a lower percentage of concomitant bile in the drainage fluid and subsequent rates of PPH and IAA than CPJ.
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Affiliation(s)
- Jin-Ming Wu
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu County, Taiwan, ROC
| | - Young-Jen Lin
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Chien-Hui Wu
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Ting-Chun Kuo
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan, ROC.
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Zhang L, Zhu X, Zhu Y, Huang J, Tao L, Chen Y. Chen's penetrating-suture technique for pancreaticojejunostomy following pancreaticoduodenectomy. BMC Surg 2023; 23:146. [PMID: 37248522 DOI: 10.1186/s12893-023-02054-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 05/23/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the most serious complication and the main reason for morbidity and mortality after pancreaticoduodenectomy (PD). Currently, there exists no flawless pancreaticojejunal anastomosis approach. We presents a new approach called Chen's penetrating-suture technique for pancreaticojejunostomy (PPJ), which involves end-to-side pancreaticojejunostomy by suture penetrating the full-thickness of the pancreas and jejunum, and evaluates its safety and efficacy. METHODS To assess this new approach, between May 2006 and July 2018, 193 consecutive patients who accepted the new Chen's Penetrating-Suture technique after a PD were enrolled in this study. Postoperative morbidity and mortality were evaluated. RESULTS All cases recovered well after PD. The median operative time was 256 (range 208-352) min, with a median time of 12 (range 8-25) min for performing pancreaticojejunostomy. Postoperative morbidity was 19.7% (38/193) and mortality was zero. The POPF rate was 4.7% (9/193) for Grade A, 1.0% (2/193) for Grade B, and no Grade C cases and one urinary tract infection. CONCLUSION PPJ is a simple, safe, and reliable technique with ideal postoperative clinical results.
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Affiliation(s)
- Lihong Zhang
- Department of Hepatobiliary Surgery, Affiliated Hospital of Yangzhou University, 368 Hanjiang Road, Yangzhou, 225012, Jiangsu Province, China
| | - Xuefeng Zhu
- Department of Hepatobiliary Surgery, Taixing People's Hospital of Yangzhou University, 1 Changzheng Road, Taixing, 225400, Jiangsu Province, China
| | - Yongsheng Zhu
- Department of Hepatobiliary Surgery, Taixing People's Hospital of Yangzhou University, 1 Changzheng Road, Taixing, 225400, Jiangsu Province, China
| | - Jianjun Huang
- Department of Hepatobiliary Surgery, Taixing People's Hospital of Yangzhou University, 1 Changzheng Road, Taixing, 225400, Jiangsu Province, China
| | - Lide Tao
- Department of Hepatobiliary Surgery, Affiliated Hospital of Yangzhou University, 368 Hanjiang Road, Yangzhou, 225012, Jiangsu Province, China
| | - Yijun Chen
- Department of Hepatobiliary Surgery, Taixing People's Hospital of Yangzhou University, 1 Changzheng Road, Taixing, 225400, Jiangsu Province, China.
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Hwang TL, Kao HW, Hsu CP, Hsu JT, Yeh CN, Yeh TS. Secure reconstruction after pancreaticoduodenectomy: Review and improved our continuous duct-to-mucosa anastomosis. FORMOSAN JOURNAL OF SURGERY 2023; 56:1-8. [DOI: 10.1097/fs9.0000000000000001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Abstract
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.
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El Asmar A, Ghabi E, Akl B, Abou Malhab C, Saber T, Eid S, Mahfouz E, Rahban H, El Rassi Z. Preoperative NLR and PLR are predictive of clinically relevant postoperative pancreatic fistula. SURGERY IN PRACTICE AND SCIENCE 2022; 10:100122. [PMID: 39845613 PMCID: PMC11749980 DOI: 10.1016/j.sipas.2022.100122] [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: 06/22/2022] [Revised: 08/20/2022] [Accepted: 08/21/2022] [Indexed: 11/21/2022] Open
Abstract
Background Clinically relevant postoperative pancreatic fistula (CR-POPF) is a dreaded complication following pancreatic surgery. Several scores attempt to predict CR-POPF occurrence to better manage outcomes in patients undergoing pancreaticoduodenectomy (PD). In our study, we investigate the prognostic role of several demographic and clinico-pathological variables. We focus on clinical biomarkers, the Neutrophil-to-Lymphocytes Ratio (NLR) and Platelet-to-Lymphocyte ratio (PLR), which can be easily used in predicting CR-POPF occurrence. Methods Patients who underwent a PD with curative intent at our institution, between 2008 and 2018 were reviewed. Statistical analysis was conducted to determine the association between various demographic and clinico-pathological variables, with the occurrence of clinically significant POPF. Results 117 patients underwent a PD at our institution. Statistically significant associations on multivariate analysis were observed for the absence of preoperative diabetes mellitus, a pathological stage ≥III, an elevated NLR (> 4) and an elevated PLR (> 158). Conclusion The NLR and PLR are predictive of CR-POPF occurrence following PD. These readily available biomarkers can add value to risk stratification tools to assess CR-POPF occurrence and individualize patient care plans.
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Affiliation(s)
- Antoine El Asmar
- Department of Surgical Oncology, Institut Jules Bordet, Université Libre de Bruxelles (ULB)
| | - Elie Ghabi
- Department of Surgery, Division of Hepatopancreatobiliary Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States of America
| | - Bernard Akl
- Department of Urology, Saint George Hospital University Medical Center, Achrafieh, Beirut, Lebanon
| | - Christina Abou Malhab
- Department of General Surgery, Saint George Hospital University Medical Center, Achrafieh, Beirut, Lebanon
| | - Toufic Saber
- Department of General Surgery, Saint George Hospital University Medical Center, Achrafieh, Beirut, Lebanon
| | - Sarah Eid
- Department of Radiology, Saint George Hospital University Medical Center, Achrafieh, Beirut, Lebanon
| | - Elissa Mahfouz
- Department of General Surgery, Saint George Hospital University Medical Center, Achrafieh, Beirut, Lebanon
| | - Hind Rahban
- Department of Clinical Laboratory, Saint George Hospital University Medical Center, Achrafieh, Beirut, Lebanon
| | - Ziad El Rassi
- Department of General Surgery, Chief of Department, Professor of Surgery, Saint George Hospital University Medical Center, Achrafieh, Beirut, Lebanon
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Hong D, Li H, Liu X, Jiang P, Yu G, Liu X, Liu J, Liu Y, Liu J, Lau WY. Incidence of postoperative pancreatic fistula after using a defined pancreaticojejunostomy technique for laparoscopic pancreaticoduodenectomy: A prospective multicenter study on 1033 patients. Int J Surg 2022; 101:106620. [PMID: 35447363 DOI: 10.1016/j.ijsu.2022.106620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/23/2022] [Accepted: 04/08/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE This prospective multicenter study aimed to study the incidence of postoperative pancreatice fistula using a defined technique of pancreaticojejunostomy (PJ) in laparoscopic pancreaticoduodenectomy (LPD). BACKGROUND PJ is a technically challenging and time-consuming procedure in LPD. Up to now, only a few small sample size studies have been reported on various PJ techniques in LPD, none of which has widely been accepted by surgeons. METHODS This prospective study enrolled consecutive patients who underwent LPD using a defined technique of PJ at four institutions in China between January 2017 and December 2020. RESULTS Of 1045 patients, after excluding 12 patients (1.2%) due to conversion to open surgery, 1033 patients were analysed. The males comprised of 57.12% (590/1033), and females 42.88% (443/1033), with a mean age of 59.00 years. The mean ± s.d. operation time was (270.2 ± 101.8) min. The median time for PJ was 24min (IQR = 20.0-30.0). The overall incidence of postoperative pancreatic fistula was 12.6%, including 67 patients (6.5%) with Grade A biochemical leak, 50 patients (4.8%) with Grade B, and 13 patients (1.3%) with Grade C pancreatic fistulas. The overall incidence of major complications (Clavien-Dindo score ≥3) was 6.3% and the 30-day mortality was 2.8%. CONCLUSION The pancreaticojejunostomy technique for LPD was safe, simple and reproduceable with favorable clinical outcomes. However, further validations using high-quality RCTs are still required to confirm the findings of this study.
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Affiliation(s)
- DeFei Hong
- Department of General Surgery, Sir Run Run Shaw Hospital, The Medicine School of Zhejiang University, Hangzhou, China
| | - HuaGen Li
- Department of General Surgery, Sir Run Run Shaw Hospital, The Medicine School of Zhejiang University, Hangzhou, China
| | - XiaoLong Liu
- Department of General Surgery, Sir Run Run Shaw Hospital, The Medicine School of Zhejiang University, Hangzhou, China
| | - Peiqiang Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Guangsheng Yu
- Department of Hepatobiliary and Pancreatic Surgery, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Xueqing Liu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jianhua Liu
- Department of Hepatobiliary and Pancreatic Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China.
| | - YaHui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China.
| | - Jun Liu
- Department of Hepatobiliary and Pancreatic Surgery, Shandong Provincial Hospital, Jinan, Shandong, China.
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.
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Double purse-string telescoped pancreaticogastrostomy is not superior in preventing pancreatic fistula development in high-risk anastomosis: a 6-year single-center case-control study. Langenbecks Arch Surg 2021; 407:1073-1081. [PMID: 34782930 DOI: 10.1007/s00423-021-02376-6] [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: 05/30/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ). METHODS From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF. RESULTS The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P < 0.001), even after a matching process on ua-FRS. In the multivariate analysis, the type of anastomosis (P = 0.88), body mass index (P = 0.47), or main pancreatic duct diameter (P = 0.7) did not influence CR-POPF occurrence. CONCLUSIONS For patients with high-risk anastomosis, the double purse-string telescoped PG technique was not superior to the PJ technique for preventing CR-POPF.
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Blumgart Anastomosis After Pancreaticoduodenectomy. A Comprehensive Systematic Review, Meta-Analysis, and Meta-Regression. World J Surg 2021; 45:1929-1939. [PMID: 33721074 PMCID: PMC8093149 DOI: 10.1007/s00268-021-06039-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The superiority of Blumgart anastomosis (BA) over non-BA duct to mucosa (non-BA DtoM) still remains under debate. METHODS We performed a systematic search of studies comparing BA to non-BA DtoM. The primary endpoint was CR-POPF. Postoperative morbidity and mortality, post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), reoperation rate, and length of stay (LOS) were evaluated as secondary endpoints. The meta-analysis was carried out using random effect. The results were reported as odds ratio (OR), risk difference (RD), weighted mean difference (WMD), and number needed to treat (NNT). RESULTS Twelve papers involving 2368 patients: 1075 BA and 1193 non-BA DtoM were included. Regarding the primary endpoint, BA was superior to non-BA DtoM (RD = 0.10; 95% CI: -0.16 to -0.04; NNT = 9). The multivariate ORs' meta-analysis confirmed BA's protective role (OR 0.26; 95% CI: 0.09 to 0.79). BA was superior to DtoM regarding overall morbidity (RD = -0.10; 95% CI: -0.18 to -0.02; NNT = 25), PPH (RD = -0.03; 95% CI -0.06 to -0.01; NNT = 33), and LOS (- 4.2 days; -7.1 to -1.2 95% CI). CONCLUSION BA seems to be superior to non-BA DtoM in avoiding CR-POPF.
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Sun PJ, Yu YH, Li JW, Cui XJ. A Novel Anastomosis Technique for Laparoscopic Pancreaticoduodenectomy: Case Series of Our Center's Experience. Front Surg 2021; 8:583671. [PMID: 33777996 PMCID: PMC7994857 DOI: 10.3389/fsurg.2021.583671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/22/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Laparoscopic pancreaticoduodenectomy has developed rapidly in recent years. Postoperative pancreatic fistula is still the most dangerous complication of laparoscopic pancreaticoduodenectomy. Baumgart pancreaticojejunostomy is considered one of the safest anastomosis procedures, with low rates of pancreatic fistula. We modified Blumgart pancreaticojejunostomy and applied the modified procedure during laparoscopic pancreaticoduodenectomy. The modified procedure entailed a longitudinal U-shaped suture through the pancreas for anastomosis of the pancreatic duct and the jejunal mucosa. Methods: We prospectively collected and retrospectively analyzed the data of 120 patients who underwent laparoscopic pancreaticoduodenectomy from January 2016. The total operative time, time for complete pancreaticojejunostomy, postoperative pancreatic fistula rate, postoperative delayed gastric emptying, postoperative bleeding, postoperative length of hospital stays, and mortality within 90 days after surgery were analyzed. An analysis of laparoscopic pancreaticojejunostomy compared with open pancreaticojejunostomy is also reported. Results: In the laparoscopic pancreaticojejunostomy group, the average total operative time, the average time for complete pancreaticojejunostomy, and the average intraoperative blood loss were 271 min, 35.3 min, and 184 ml, respectively. The total postoperative clinically relevant pancreatic fistula rate was 9.2% (Grade B and C fistulas). The incidence rates of postoperative delayed gastric emptying and postoperative biliary fistula were ~2.5 and 1.7%, respectively. The postoperative bleeding rate was 0.83%, and the average postoperative indwelling time of the abdominal drainage tube was 7.3 days. The postoperative length of hospital stay was 10.8 days, and the mortality rate within 90 days after surgery was 0.83%. The rates of clinically relevant postoperative clinically relevant pancreatic fistula are comparable between laparoscopic and open surgery, there were no other severe postoperative complications in either group. The mean postoperative length of hospital stay was significantly shorter in the laparoscopic pancreaticojejunostomy group. Conclusion: The modified laparoscopic-adapted Blumgart anastomosis simplifies and facilitates the creation of the pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy. The rates of clinically relevant postoperative pancreatic fistula are comparable with those obtained by open surgery, and length of stay are shoter.
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Affiliation(s)
- Pi-Jiang Sun
- Department of Hepatobiliary Surgery, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
| | - Yan-Hua Yu
- Department of Dermatology, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
| | - Jian-Wei Li
- Institute of Hepatopancreatobiliary Surgery, First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xi-Jun Cui
- Department of Hepatobiliary Surgery, Weihai Central Hospital Affiliated to Qingdao University, Weihai, China
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Gupta S, Attri AK, Sharma R, Gureh M, Nasir MI. Binding Pancreaticojejunostomy: Is It Safe? Niger J Surg 2020; 26:48-52. [PMID: 32165836 PMCID: PMC7041346 DOI: 10.4103/njs.njs_17_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/20/2019] [Accepted: 09/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background: Postoperative pancreatic fistula (POPF) or leak from pancreaticojejunostomy (PJ) is one of the most common complications after pancreaticoduodenectomy (PD), with an incidence of 5%–30%. Various techniques have been advocated to bring down the incidence of POPF, but there is still none that can be called the “gold standard”. Peng's binding PJ (BPJ) was proposed as a good method of performing PJ with low fistula rates; we present our results with BPJ. Methods: The data of all patients who underwent PD with BPJ between January 2016 and March 2018 were retrospectively analyzed for demographics, clinical features, type of procedure performed, complications (especially POPF), hospital stay, morbidity, and mortality. Results: A total of 24 patients (18 males and 6 females) were identified. The mean age at the diagnosis was 65.5 ± 6.4 years. Majority of the patients had ampullary carcinoma (62.5%). The most common postoperative complication was delayed gastric emptying seen in 10 patients, whereas only 2 (8.33%) had POPF and there was one mortality. Conclusion: BPJ is safe and is associated with a low incidence of POPF.
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Affiliation(s)
- Sanjay Gupta
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Ashok K Attri
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Rajeev Sharma
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Monika Gureh
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
| | - Md Imran Nasir
- Department of Surgery, Government Medical College and Hospital, Chandigarh, India
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Olakowski M, Grudzińska E, Mrowiec S. Pancreaticojejunostomy-a review of modern techniques. Langenbecks Arch Surg 2020; 405:13-22. [PMID: 31975148 PMCID: PMC7036071 DOI: 10.1007/s00423-020-01855-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/09/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Marek Olakowski
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
| | - Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland.
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
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Jin Y, Feng YY, Qi XG, Hao G, Yu YQ, Li JT, Peng SY. Pancreatogastrostomy vs pancreatojejunostomy after pancreaticoduodenectomy: An updated meta-analysis of RCTs and our experience. World J Gastrointest Surg 2019; 11:322-332. [PMID: 31602291 PMCID: PMC6783689 DOI: 10.4240/wjgs.v11.i7.322] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/11/2019] [Accepted: 06/20/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is one of the most important operations in hepatobiliary and pancreatic surgery. AIM To evaluate the advantages and disadvantages of pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG). METHODS This meta-analysis was performed using Review Manager 5.3. All clinical randomized controlled trials, in which patients underwent PD with pancreatico-digestive tract reconstruction via PJ or PG, were included. RESULTS The search of PubMed, Wanfang Data, EMBASE, and the Cochrane Library provided 125 citations. After further analysis, 11 trials were included from nine counties. In all, 909 patients underwent PG and 856 underwent PJ. Meta-analysis showed that pancreatic fistula (PF) was a significantly lower morbidity in the PG group than in the PJ group (odds ratio [OR] = 0.67, 95% confidence interval [CI]: 0.53-0.86, P = 0.002); however, grades B and C PF was not significantly different between the two groups (OR = 0.61, 95%CI: 0.34-1.09, P = 0.09). Postoperative hemorrhage showed a significantly lower morbidity in the PJ group than in the PG group (OR = 1.47, 95%CI: 1.05-2.06, P = 0.03). Delayed gastric emptying was not significantly different between the two groups (OR = 1.09, 95%CI: 0.83-1.41, P = 0.54). CONCLUSION There is no difference in the incidence of grades B and C PF between the two groups. However, postoperative bleeding is significantly higher in PG than in PJ. Binding PJ or binding PG is a safe and secure technique according to our decades of experience.
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Affiliation(s)
- Yun Jin
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Yang-Yang Feng
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Xiao-Gang Qi
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Geng Hao
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Yuan-Quan Yu
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Jiang-Tao Li
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Shu-You Peng
- Department of General Surgery, the Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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Jin Y, Feng YY, Qi XG, Hao G, Yu YQ, Li JT, Peng SY. Pancreatogastrostomy vs pancreatojejunostomy after pancreaticoduodenectomy: An updated meta-analysis of RCTs and our experience. World J Gastrointest Surg 2019. [DOI: 10.4240/wjgs.v11.i7.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Wang W, Zhang Z, Gu C, Liu Q, Liang Z, He W, Chen J, Lai J. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: A network meta-analysis of randomized control trials. Int J Surg 2018; 57:111-116. [PMID: 29777880 DOI: 10.1016/j.ijsu.2018.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 03/03/2018] [Accepted: 04/02/2018] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Weidong Wang
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Zhaohui Zhang
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China
| | - Chichang Gu
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Qingbo Liu
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China
| | - Zhiqiang Liang
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Wei He
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Jianping Chen
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Jiaming Lai
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China.
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14
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Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a review of traditional and emerging concepts. Clin Exp Gastroenterol 2018; 11:105-118. [PMID: 29588609 PMCID: PMC5858541 DOI: 10.2147/ceg.s120217] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF.
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Affiliation(s)
- Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, Australia
| | - Saxon J Connor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Australian Pancreatic Centre, Sydney, Australia
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15
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Yang F, Jin C, Di Y, He H, Hao S, Yao L, Li J, Fu D. Central pancreatectomy with external drainage of monolayer pancreaticojejunostomy for prevention of postoperative pancreatic fistula: A retrospective cohort study. Int J Surg 2018; 51:104-108. [PMID: 29367037 DOI: 10.1016/j.ijsu.2018.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Postoperative pancreatic fistula (POPF) remains a common problem and leading cause of morbidity and mortality after central pancreatectomy (CP). The aim of this study was to present a technique of external drainage of monolayer pancreaticojejunostomy for prevention of POPF. METHODS Patients received elective CP with external drainage of monolayer pancreaticojejunostomy between January 2010 and December 2016 were retrospectively analyzed. The occurrence and severity of POPF, overall complications, reoperation rate, in-hospital mortality, and length of postoperative hospital stay were measured. The 2016 updated definition and classification system of the International Study Group of Pancreatic Surgery (ISGPS) was used for POPF. In addition, a matched-pairs comparison with internal drainage of pancreaticojejunostomy was made. RESULTS 33 consecutive patients underwent CP with external drainage of monolayer pancreaticojejunostomy during this period. 4 (12.1%) cases developed grade B POPF, among which one patient was classified as having Clavien-Dindo classification IIIa complication. None of the patients developed grade C POPF, delayed gastric emptying, or postpancreatectomy hemorrhage. There was no reoperation or in-hospital mortality occurred. Matched-pairs comparison revealed that patients with external drainage of pancreaticojejunostomy had significantly lower incidence of POPF. CONCLUSION External drainage of monolayer pancreaticojejunostomy seems effective in prevention of POPF after CP.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yang Di
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Hang He
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Sijie Hao
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Lie Yao
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China.
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16
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Xu J, Ji SR, Zhang B, Ni QX, Yu XJ. Strategies for pancreatic anastomosis after pancreaticoduodenectomy: What really matters? Hepatobiliary Pancreat Dis Int 2018; 17:22-26. [PMID: 29428099 DOI: 10.1016/j.hbpd.2018.01.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/28/2017] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Jin Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Shun-Rong Ji
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Bo Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Quan-Xing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China
| | - Xian-Jun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan Univeristy, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan Univeristy, Shanghai 200032, China.
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17
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Routh D, Pathak N, Naidu C, Singh A, Rao P, Ranjan P. A study on outcome of binding pancreaticogastrostomy following pancreaticoduodenectomy: A prospective observational study. Int J Surg 2018; 50:104-109. [DOI: 10.1016/j.ijsu.2017.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 11/29/2017] [Accepted: 12/16/2017] [Indexed: 12/16/2022]
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18
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Egorov VI, Petrov RV. [Simple and reliable pancreatoenteroanastomosis]. Khirurgiia (Mosk) 2017:60-68. [PMID: 29186099 DOI: 10.17116/hirurgia20171160-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- V I Egorov
- Brothers Bakhrushiny City Clinical Hospital, Moscow Department of Healthcare, Moscow, Russia
| | - R V Petrov
- Brothers Bakhrushiny City Clinical Hospital, Moscow Department of Healthcare, Moscow, Russia
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19
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Kang P, Wang Z, Leng K, Zhong X, Wang H, Wan M, Tai S, Cui Y. Binding pancreaticogastrostomy anastomosis in central pancreatectomy: A single center experience. Medicine (Baltimore) 2017; 96:e8354. [PMID: 29137016 PMCID: PMC5690709 DOI: 10.1097/md.0000000000008354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A growing number of central pancreatectomies are performed. However, reconstruction of pancreaticoenteral digestive continuity after central pancreatectomy remains debated. This study evaluates the short-term outcomes of binding pancreaticogastrostomy anastomosis in central pancreatectomy.We have reviewed our experience with 52 patients who underwent binding pancreaticogastrostomy following central pancreatectomy from February 2009 to March 2015. Indication includes 6 noninvasive intraductal papillary mucinous neoplasms, 11 neuroendocrine tumors, 12 solid pseudopapillary tumor, 9 serous cystadenoma, 6 mucinous cystadenoma, and 8 focal pancreatic traumas.The mortality rate was nil while the morbidity rate was 34.6%. Eighteen patients experienced complications including 6 pancreatic fistulas, 2 postpancreatectomy hemorrhages, 4 delayed gastric emptying, 1 hypostatic pneumonia, and 5 pancreatitis. The median postoperative length of hospital stay was 12 days (10 days for patients without fistula). None of the 52 patients were found to have pancreatic endocrine or exocrine insufficiency or recurrence of tumors.Central pancreatectomy with binding pancreaticogastrostomy is a useful and practicable surgical procedure for benign or borderline lesions of the pancreatic neck or proximal body.
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20
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Papalampros A, Niehaus K, Moris D, Fard-Aghaie M, Stavrou G, Margonis AG, Angelou A, Oldhafer K. A safe and feasible "clock-face" duct-to-mucosa pancreaticojejunostomy with a very low incidence of anastomotic failure: A single center experience of 248 patients. J Visc Surg 2016; 153:425-431. [PMID: 27256902 DOI: 10.1016/j.jviscsurg.2016.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) is one of the most frequent and serious postoperative complications of pancreatoduodenectomy (PD). We sought to assess the impact of a novel pancreaticojejunostomy (PJ) on the rates of POPF and overall postoperative complications. METHODS Between 01/2010 and 12/2013, a total of 248 consecutive patients who underwent PD with a modified PJ were identified from our database and retrospectively analyzed. POPF cases were divided into three categories (ISGPF-international study group-guidelines): biochemical fistula without clinical sequelae (grade A), fistula requiring any therapeutic intervention (grade B), and fistula with severe clinical sequelae (grade C). Perioperative outcomes were recorded and analyzed. RESULTS The overwhelming majority of patients had no evidence of fistula. Grade A POPF was observed in 9 (3.62%), grade B in 1 (0.40%), and grade C in 0 patients. There were no postoperative deaths. Overall complications occurred in 61 patients (24.59%) of patients after PD. CONCLUSIONS This modified pancreaticojejunostomy is widely applicable and is associated with very low rates of POPF, low postoperative morbidity and mortality. Overall, it is a feasible and safe novel approach with excellent short-term outcomes.
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Affiliation(s)
- A Papalampros
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; 1st Department of Surgery, University of Athens, Laikon General Hospital, Agiou Thoma 17 street, 11527 Athens, Greece
| | - K Niehaus
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | - D Moris
- 1st Department of Surgery, University of Athens, Laikon General Hospital, Agiou Thoma 17 street, 11527 Athens, Greece.
| | - M Fard-Aghaie
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | - G Stavrou
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | - A-G Margonis
- 1st Department of Surgery, University of Athens, Laikon General Hospital, Agiou Thoma 17 street, 11527 Athens, Greece
| | - A Angelou
- 1st Department of Surgery, University of Athens, Laikon General Hospital, Agiou Thoma 17 street, 11527 Athens, Greece
| | - K Oldhafer
- Department of General and Abdominal Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
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21
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Papalampros A, Niehaus K, Moris D, Fard-Aghaie M, Stavrou G, Margonis AG, Angelou A, Oldhafer K. Une technique d’anastomose pancréaticojéjunale en cadran (de montre) faisable et sûre avec un taux de fistules anastomotiques très faible. Expérience monocentrique à propos de 248 patients. JOURNAL DE CHIRURGIE VISCÉRALE 2016; 153:440-446. [DOI: 10.1016/j.jchirv.2016.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2025]
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22
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Ammori JB, Choong K, Hardacre JM. Surgical Therapy for Pancreatic and Periampullary Cancer. Surg Clin North Am 2016; 96:1271-1286. [PMID: 27865277 DOI: 10.1016/j.suc.2016.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Surgery is the key component of treatment for pancreatic and periampullary cancers. Pancreatectomy is complex, and there are numerous perioperative and intraoperative factors that are important for achieving optimal outcomes. This article focuses specifically on key aspects of the surgical management of periampullary and pancreatic cancers.
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Affiliation(s)
- John B Ammori
- Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Kevin Choong
- Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Jeffrey M Hardacre
- Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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23
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Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol 2016; 51:1147-54. [PMID: 27216233 PMCID: PMC4975078 DOI: 10.3109/00365521.2016.1169317] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers. METHODS A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF. RESULTS A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained. CONCLUSIONS Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital,
Stavanger,
Norway,Department of Clinical Medicine, University of Bergen,
Bergen,
Norway,CONTACT Kjetil Søreide
Department of Gastrointestinal Surgery, Stavanger University Hospital, POB 8100,
N-4068Stavanger,
Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital,
Oslo,
Norway
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24
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Testini M, Piccinni G, Lissidini G, Gurrado A, Tedeschi M, Franco IF, Di Meo G, Pasculli A, De Luca GM, Ribezzi M, Falconi M. Surgical management of the pancreatic stump following pancreato-duodenectomy. J Visc Surg 2016; 153:193-202. [PMID: 27130693 DOI: 10.1016/j.jviscsurg.2016.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.
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Affiliation(s)
- M Testini
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy.
| | - G Piccinni
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G Lissidini
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - A Gurrado
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Tedeschi
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - I F Franco
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G Di Meo
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - A Pasculli
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G M De Luca
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Ribezzi
- Anesthesiology Unit, Department of Emergency Surgery and Organs Transplantation, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Falconi
- Pancreatic Surgery Unit, San Raffaele Hospital IRCCS, University Vita e Salute, Milan, Italy
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25
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Pancreaticojejunostomy versus pancreaticogastrostomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 18:762-8. [PMID: 21912837 DOI: 10.1007/s00534-011-0428-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE In the majority of reports morbidity after pancreaticoduodenectomy remains high and leakage from the pancreatic stump still accounts for the majority of surgical complications. Many technical modifications of the pancreaticoenteric anastomosis to decrease the pancreatic leakage rate have been suggested. METHODS A Medline search for surgical guidelines, prospective randomized controlled trials, systematic meta-analyses, and clinical results was performed with regard to technical aspects of reconstruction, i.e., pancreaticojejunostomy versus pancreaticogastrostomy, after pancreaticoduodenectomy. Here we illustrate the different approaches to reconstruction, with an emphasis on technical aspects and their details. CONCLUSIONS Pancreaticojejunostomy appears to be the most widely performed reconstruction, but pancreaticogastrostomy is a reasonable alternative. However, in the analysis of the clinical results it is important to know which specific pancreaticoenteric anastomosis is considered; for example, end-to-end, dunking, invagination of the pancreatic stump, or duct-to-mucosa. It is hoped that collaborative trials will provide high-level data to allow tailoring of the operative technique, depending on the risk factors for pancreatic leakage in any particular patient.
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26
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Xu J, Zhang B, Shi S, Qin Y, Ji S, Xu W, Liu J, Liu L, Liu C, Long J, Ni Q, Yu X. Papillary-like main pancreatic duct invaginated pancreaticojejunostomy versus duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized trial. Surgery 2015; 158:1211-1218. [PMID: 26036878 DOI: 10.1016/j.surg.2015.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 03/29/2015] [Accepted: 04/09/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Development of a postoperative pancreatic fistula (POPF) is the single most significant complication of pancreatic anastomosis, which is a key procedure in pancreaticoduodenectomy. We previously reported a new papillary-like pancreaticojejunostomy, and a retrospective study showed a benefit in reducing the incidence of grade B/C POPF compared with duct-to-mucosa pancreaticojejunostomy. The aim of this study was to reassess whether the new pancreaticojejunostomy would decrease the POPF rate. METHODS A prospective, randomized, controlled trial (NCT01731821 registered at http://ClinicalTrials.gov) involving 308 patients who underwent pancreaticoduodenectomy was conducted. RESULTS The overall POPF rate was significantly lower in the papillary-like group compared with the duct-to-mucosa group (14/155 [9.0%] vs 31/153 [20.3%]; P = .005), and the grade B/C POPF rate of the papillary-like group was significantly decreased compared with the duct-to-mucosa group. Multivariable analyses identified higher body mass index (odds ratio [OR], 3.520; P = .000), longer operative time (OR, 2.587; P = .041), soft texture and nondilated main pancreatic duct (OR, 0.365; P = .014), and the duct-to-mucosa pancreaticojejunostomy (OR, 0.405; P = .013) as significant risk factors for POPF. Further stratified analyses showed that, for patients with soft texture and nondilated main pancreatic duct, the POPF rate in the papillary-like group (9.6%) was significantly lower than that in the duct-to-mucosa group (27.3%). However, for patients with hard texture or dilated main pancreatic duct, there was no difference between the 2 groups (7.8% vs 8.6%; P > 0.999). CONCLUSION The new papillary-like pancreaticojejunostomy may provide a better option for patients with soft texture and nondilated main pancreatic duct.
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Affiliation(s)
- Jin Xu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Bo Zhang
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Si Shi
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Yi Qin
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Shunrong Ji
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Wenyan Xu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Jiang Liu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Liang Liu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Chen Liu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Jiang Long
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Quanxing Ni
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Xianjun Yu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China.
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Gómez T, Palomares A, Serradilla M, Tejedor L. Reconstruction after pancreatoduodenectomy: Pancreatojejunostomy vs pancreatogastrostomy. World J Gastrointest Oncol 2014; 6:369-376. [PMID: 25232462 PMCID: PMC4163735 DOI: 10.4251/wjgo.v6.i9.369] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 03/18/2014] [Indexed: 02/05/2023] Open
Abstract
Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy (PD) in order to decrease postoperative complications, mainly pancreatic fistulas (PF). In this work, we compare the two most frequent techniques of reconstruction after PD, pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), in order to determine which of the two is better. A systematic review of the literature was performed, including major meta-analysis articles, clinical randomized trials, systematic reviews, and retrospective studies. A total of 64 articles were finally included. PJ and PG are usually responsible for most of the postoperative morbidity, mainly due to the onset of PF, being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia. The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG. PF, delayed gastric emptying and mortality were not different. Although there was heterogeneity between these studies, all were conducted in specialized centers by highly experienced surgeons, and the surgical care was likely to be similar for all the studies. The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa. Exocrine function appears to be worse after PG than after PJ, resulting in severe atrophic changes in the remnant pancreas. Depending on the type of PJ or PG used, the PF rate and other complications can also be different. The best method to deal with the pancreatic stump after PD remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon’s preference and adherence to basic principles such as good exposure and visualization. In conclusion, up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD.
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Lee KF. Management of the pancreatic stump after pancreaticoduodenectomy. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kit-Fai Lee
- Department of Surgery; Prince of Wales Hospital; The Chinese University of Hong Kong; Hong Kong
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Chen YJ, Lai ECH, Lau WY, Chen XP. Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature. Int J Surg 2014; 12:706-11. [PMID: 24851718 DOI: 10.1016/j.ijsu.2014.05.060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/11/2014] [Accepted: 05/14/2014] [Indexed: 01/15/2023]
Abstract
Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.
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Affiliation(s)
- Yong-jun Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
| | - Eric C H Lai
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chaiwan, Hong Kong, China.
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
| | - Xiao-ping Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
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Kim JM, Hong JB, Shin WY, Choe YM, Lee GY, Ahn SI. Preliminary results of binding pancreaticojejunostomy. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2014; 18:21-5. [PMID: 26155242 PMCID: PMC4492331 DOI: 10.14701/kjhbps.2014.18.1.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 10/15/2013] [Accepted: 10/25/2013] [Indexed: 11/17/2022]
Abstract
Backgrounds/Aims The post-operative complications and clinical course of pancreaticoduodenectomy (PD) largely depend on the pancreaticojejunostomy (PJ). Several methods of PJ are in clinical use. We analyzed the early results of binding pancreaticojejunostomy (BPJ), a technique reported by SY Peng. Methods We retrospectively reviewed the clinical results of patients who received BPJ in Inha University Hospital from 2006 to 2011. 21 BPJs were performed with Peng's method. The definition of postoperative pancreatic fistula (PF) was a high amylase content (>3 times the upper normal serum value) of the drain fluid (of any measurable volume), at any time on or after the 3rd post-operative day. The pancreatic fistula was graded according to the International Study Group for Pancreatic Fistula (ISGPF) guidelines. Results Of the 21 patients who received BPJ, 11 were male. The median age was 61.2 years. PD surgery included 4 cases of Whipple's procedures and 17 cases of pylorus-preserving PD. According to the post-operative course, 16 patients recovered well with no evidence of PF. A total of 5 patients (23.8%), including 3 grade A PFs and 2 grade C PFs, suffered from a pancreatic fistula. 3 patients with grade A PF recovered with conservative management. Conclusions The BPJ appears to be a relatively safe procedure based on this preliminary study, but further study is needed to validate its safety.
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Affiliation(s)
- Jin Min Kim
- Department of Surgery, Inha University Hospital, Incheon, Korea
| | - Jung Bum Hong
- Department of Surgery, Inha University Hospital, Incheon, Korea
| | - Woo Young Shin
- Department of Surgery, Inha University Hospital, Incheon, Korea
| | - Yun-Mee Choe
- Department of Surgery, Inha University Hospital, Incheon, Korea
| | - Gun Young Lee
- Department of Surgery, Inha University Hospital, Incheon, Korea
| | - Seung Ik Ahn
- Department of Surgery, Inha University Hospital, Incheon, Korea
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Yu K, Li W, Ji Y, Wu W, Shen D, Zhu J. Wound healing after mesh inner embedding and outer binding pancreaticojejunostomy in piglets. Surg Innov 2013; 21:496-503. [PMID: 24368398 DOI: 10.1177/1553350613513513] [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 The aim of this study was to introduce a novel technique of pancreaticojejunostomy, namely, mesh inner embedding and outer binding pancreaticojejunostomy, and to evaluate wound healing after this operation in piglets. METHODS Thirty-six domestic piglets were randomly divided into 2 groups after pancreaticoduodenectomy: the mesh inner embedding and outer binding pancreaticojejunostomy group (n = 18) and the conventional double-deck invaginated pancreaticojejunostomy group (n = 18). Bursting pressure and breaking strength were assessed on the operative day and on days 7 and 14 postoperatively. The pathologic findings and collagen content of the anastomotic site were evaluated on days 7 and 14 postoperatively. RESULTS Both the bursting pressure and breaking strength were significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 0, 7, and 14 (P < .01). The collagen content of the anastomotic site was significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 7 and 14 postoperatively (P < .01). The anastomotic site was more completely repaired by connective and granulation tissue in the mesh inner embedding and outer binding pancreaticojejunostomy group on day 7 than in the double-deck invaginated pancreaticojejunostomy group. CONCLUSION Mesh inner embedding and outer binding pancreaticojejunostomy significantly enhanced the anastomotic firmness and sped up the wound healing process compared with conventional mesh inner embedding and outer binding pancreaticojejunostomy. Therefore, it may decrease the risk of pancreatic fistulas after pancreaticoduodenectomy.
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Affiliation(s)
- Kai Yu
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Li
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Ji
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wanbo Wu
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Dijian Shen
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jinhui Zhu
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Hashimoto D, Chikamoto A, Ohmuraya M, Hirota M, Baba H. Pancreaticodigestive anastomosis and the postoperative management strategies to prevent postoperative pancreatic fistula formation after pancreaticoduodenectomy. Surg Today 2013; 44:1207-13. [PMID: 23842691 DOI: 10.1007/s00595-013-0662-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 06/04/2013] [Indexed: 12/14/2022]
Abstract
Over the past 100 years, advances in surgical techniques and perioperative management have reduced the morbidity and mortality after pancreaticoduodenectomy (PD). Many techniques have been proposed for the reconstruction of the pancreaticodigestive anastomosis to prevent the development of a postoperative pancreatic fistula (POPF), but which is the best approach is still highly debated. We carried out a systematic review to determine and compare the effectiveness of various methods of anastomosis after PD. A meta-analysis and most randomized controlled trials (RCTs) showed that the mortality, POPF rate and incidence of other postoperative complications were not statistically different between the pancreaticogastrostomy and pancreaticojejunostomy (PJ) groups. One RCT showed that a binding PJ significantly decreased the risk of POPF and other postoperative complications compared with conventional PJ. External duct stenting reduced the risk of clinically relevant POPF in a meta-analysis and RCTs. The prophylactic use of octreotide after PD does not result in a reduced incidence of POPF. In conclusion, our findings suggest that the successful management of pancreatic anastomoses may depend more on the meticulous surgical technique, surgical volume, and other management parameters than on the type of technique used. However, some new approaches, such as binding PJ, and the use of external stents should be considered in further RCTs.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
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Casadei R, Ricci C, Silvestri S, Campra D, Ercolani G, D'Ambra M, Pinna AD, Fronda GR, Minni F. Peng's binding pancreaticojejunostomy after pancreaticoduodenectomy. An Italian, prospective, dual-institution study. Pancreatology 2013; 13:305-9. [PMID: 23719605 DOI: 10.1016/j.pan.2013.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 11/11/2012] [Accepted: 03/04/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate Peng's binding pancreaticojejunostomy as a safe technique which avoids anastomotic leakage after a pancreaticoduodenectomy. METHODS Prospective, observational, dual-institutional study, of patients who underwent a Peng's binding pancreaticojejunostomy was conducted. It was compared with an historical control group of patients who underwent duct to mucosa pancreaticojejunostomy. Overall postoperative mortality, morbidity, postoperative pancreatic fistulas, postpancreatectomy hemorrhage, reoperation, length and costs of hospital stay were collected. Factors related with pancreatic fistula were: sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, type of resection, extension of resection, characteristics of the pancreatic remnant, pathological diagnosis and surgeons. Univariate and multivariate analyzes were carried out. RESULTS Sixty-nine patients who underwent binding pancreaticojejunostomy were reported. The control group consisted of 52 patients. The mean length of hospital stay was significantly shorter in the control group than in binding group (p = 0.003). Multivariate analyzes showed that soft pancreatic remnant was significantly related to an increasing rate of postoperative pancreatic fistula (OR 3.7-CI 1.1-12.8-P = 0.034) while the type of pancreatic anastomosis was not significantly related with the occurrence of postoperative pancreatic fistula. CONCLUSIONS In the European population, the binding pancreaticojejunostomy according to Peng did not preclude or reduce the postoperative pancreatic fistula rate.
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Affiliation(s)
- Riccardo Casadei
- Department of Surgery and Organ Transplantation, Sant'Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Via Massarenti no. 9, Bologna, Italy.
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New invagination procedure for pancreaticojejunostomy using only four sutures. World J Surg 2013; 37:1178-9. [PMID: 23385641 DOI: 10.1007/s00268-013-1923-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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[Is Peng's pancreaticojejunal anastomosis more effective than mucosa-mucosa anastomosis in duodenopancreatectomy for pancreatic and peri-ampullary tumours?]. Cir Esp 2012; 91:163-8. [PMID: 23219210 DOI: 10.1016/j.ciresp.2012.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 02/24/2012] [Accepted: 04/30/2012] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The pancreatic fistula is the most feared complication after a duodenopancreatectomy, and is the most common independent factor of post-surgical mortality. Peng et al. recently published a pancreaticojejunal anastomosis technique (binding anastomosis) which showed 0% pancreatic fistulas. The objective of this study is to evaluate and validate this new anastomosis technique compared with the conventional pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis. MATERIAL AND METHOD A prospective, non-randomised study was conducted to evaluate and validate this new anastomosis technique compared with the conventional pancreaticojejunal terminolateral duct to mucosa anastomosis. The study included 63 patients who were subjected to a duodenopancreatectomy due to having a pancreatic or periampullary neoplasm. A binding pancreaticojejunostomy according to the technique described by Peng et al. was performed on 30 patients (Group A), and a pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis (conventional technique) was performed on 33 patients (Group B). RESULTS When the results of the 2 techniques were compared, 2/30 (6%) of patients had a pancreatic fistula with the Peng technique, and 4/33 (12%) with the conventional technique, but this was not statistically significant (P=.674). Nor were there any significant differences between the 2 groups on comparing, morbidity, hospital stay and mortality. CONCLUSION The results of this study show that the anastomosis method described by Peng is safe, but is not associated with a lower frequency of pancreatic fistula, general morbidity, or mortality. This leads to the uncertainty of whether it really has any advantages over other techniques.
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The impact of internal or external transanastomotic pancreatic duct stents following pancreaticojejunostomy. Which one is better? A meta-analysis. J Gastrointest Surg 2012; 16:2322-35. [PMID: 23011201 DOI: 10.1007/s11605-012-1987-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of pancreatic duct stent to improve postoperative outcomes of pancreatic anastomosis remains a matter of debate, and the value of stenting when performing anastomosis for normal pancreas (soft and duct less than 3 mm) needs further study. The aim of the present meta-analysis was to evaluate the perioperative outcomes of patients with stenting during pancreatic anastomosis and compare the effect of external stent with that of internal stent indirectly. METHODS A systematic literature search (EMBASE, MEDLINE, PubMed, The Cochrane Library, and Web of Science) was performed to identify studies evaluating external stent or internal stent. Included literature was assessed and extracted by two independent reviewers. A meta-analysis including comparative studies providing data on patients with and without external stenting or internal stenting during pancreaticojejunostomy anastomosis was performed. RESULTS Thirteen articles including 1,867 patients were identified for inclusion: five randomized controlled trials study and eight observational clinical studies. Meta-analyses revealed that use of external stent was associated with a significantly decreased risk for pancreatic fistula in total (odds ratio (OR) 0.47; 95 % confidence interval (CI) 0.31-0.71; P = 0.0004; I (2) = 3 %), pancreatic fistula in normal pancreas(OR 0.5; 95 % CI 0.30-0.82; P = 0.007; I (2) = 5 %), and overall morbidity(OR 0.64; 95 % CI 0.45-0.90; P = 0.01; I (2) = 0 %); however, the meta-analysis showed that there were no significant differences between internal stenting and non-stenting groups as regards perioperative outcomes and that in fact it may increase pancreatic fistula rate in normal pancreas(OR 1.97; 95 % CI 1.05-3.69; P = 0.03; I (2) = 0 %). CONCLUSIONS The results of this analysis demonstrate a trend toward reduced pancreatic fistula with the use of external pancreatic stents in pancreaticojejunostomy. An internal stent does not impact development of fistula and that in fact it was not useful in a soft pancreas. Our conclusion may be limited to stenting during the duct-to-mucosa pancreaticojejunostomy anastomosis, and the value of stenting during invagination anastomosis needs further study.
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Ansorge C, Strömmer L, Andrén-Sandberg Å, Lundell L, Herrington MK, Segersvärd R. Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy. Br J Surg 2012; 99:1076-1082. [DOI: 10.1002/bjs.8784] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Abstract
Background
The morbidity rate after pancreaticoduodenectomy remains high (20–50 per cent) and postoperative pancreatic fistula (POPF) is a major underlying factor. POPF has been reported to be associated with pancreatic consistency (PC) and pancreatic duct diameter (PDD). The aim was to quantify the risk of pancreaticojejunostomy-associated morbidity (PJAM) by means of a structured intraoperative assessment of both characteristics.
Methods
This single-centre prospective observational study included pancreaticoduodenectomies performed between 2008 and 2010 with a standardized duct-to-mucosa end-to-side pancreaticojejunostomy. PC and PDD were assessed during surgery and classified into four grades each (from very hard to very soft, and from larger than 4 mm to smaller than 2 mm, respectively). PJAM was defined as POPF (grade B or C in International Study Group on Pancreatic Fistula classification) or symptomatic peripancreatic collection of either abscess or fluid. PJAM of at least Clavien grade IIIb was considered severe.
Results
PJAM and POPF were observed in 24 (21·8 per cent) and 17 (15·5 per cent) of 110 patients respectively. Softer PC and smaller PDD were risk factors for POPF (both P < 0·001), symptomatic peripancreatic collections (P = 0·071 and P = 0·015) and PJAM (both P < 0·001). Combining consistency and duct characteristics in a composite classification the PJAM risk was stratified as ‘high’ (both risk factors, PJAM incidence 51 per cent), ‘intermediate’ (softer PC or smaller PDD, PJAM 26 per cent) or ‘low’ (no risk factors, PJAM 2 per cent). Severe PJAM was observed only in patients with smaller PDD.
Conclusion
A high-risk pancreatic gland had a 25-fold higher risk of PJAM after pancreaticoduoden- ectomy than a low-risk gland. This simple classification can contribute to more individualized patient management and allow stratification of study cohorts with homogeneous POPF risk.
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Affiliation(s)
- C Ansorge
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - L Strömmer
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - Å Andrén-Sandberg
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - M K Herrington
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
- Department of Biology, Adams State College, Alamosa, Colorado, USA
| | - R Segersvärd
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
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Lai ECS. Vascular resection and reconstruction at pancreatico-duodenectomy: technical issues. Hepatobiliary Pancreat Dis Int 2012; 11:234-42. [PMID: 22672815 DOI: 10.1016/s1499-3872(12)60154-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND With the improvement of perioperative management over the years, pancreatico-duodenectomy has become a safe operation despite its technical complexity. The presence of concomitant visceral artery occlusion unrelated to the underlying malignancy and concomitant major venous infiltration by tumor poses additional hazards to resection which could compromise the postoperative outcome. DATA SOURCES A MEDLINE database search was performed to identify relevant articles using the key words "median arcuate ligament syndrome", "superior mesenteric artery", "replaced right hepatic artery", and "portal vein resection". Additional papers and book chapters were identified by a manual search of the references from the key articles. RESULTS Computed tomography with 3-dimensional reconstruction of the vascular anatomy provides most key information on the potential vascular problems encountered during surgery. A trial clamping of the gastroduodenal artery provides a simple intraoperative assessment for the presence of any significant visceral arterial occlusion. Depending on the timing of diagnosis, division of the median arcuate ligament, bypass or endovascular stenting should be considered. Portal and superior mesenteric vein resection had been used with increasing frequency and safety. The steps and methods taken to reconstruct the venous continuity vary with individual surgeons, and the anatomical variations encountered. With segmental loss of the portal vein, opinions differs with regard to the preservation of the splenic vein, and when divided, the necessity of restoring its continuity; source of the autologous vein graft when needed and whether the use of synthetic graft is a safe alternative. CONCLUSIONS During a pancreatico-duodenectomy, images of computed tomography must be carefully studied to appreciate the changes and variation of vascular anatomy. Adequate preoperative preparation, acute awareness of the probable arterial and venous anatomical variation and the availability of expertise, especially micro-vascular surgery, for vascular reconstruction would help to make the complex pancreatic resection a safer procedure.
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Fernández-Cruz L, Sabater L, Fabregat J, Boggi U. Complicaciones después de una pancreaticoduodenectomía. Cir Esp 2012; 90:222-32. [DOI: 10.1016/j.ciresp.2011.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 03/23/2011] [Accepted: 04/04/2011] [Indexed: 12/18/2022]
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Rosso E, Lopez P, Roedlisch MN, Narita M, Oussoultzoglou E, Bachellier P. Double Omental Flap Reduced Perianastomotic Collections and Relaparotomy Rates after Pancreaticoduodenectomy with Pancreaticogastrostomy. World J Surg 2012; 36:1672-8. [DOI: 10.1007/s00268-012-1546-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Yang SH, Dou KF, Sharma N, Song WJ. The methods of reconstruction of pancreatic digestive continuity after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. World J Surg 2012; 35:2290-7. [PMID: 21800201 DOI: 10.1007/s00268-011-1159-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic fistula (PF) is an important factor responsible for the considerable morbidity associated with pancreaticoduodenectomy (PD). There have been many techniques proposed for the reconstruction of pancreatic digestive continuity to prevent fistula formation but which is best is still highly debated. We carried out a systematic review and meta-analysis to determine the effectiveness of methods of anastomosis after PD. METHODS A full literature search was conducted in the Cochrane Controlled Trials Register Databases, Medline, and other resources irrespective of language. Randomized controlled trials (RCTs) were considered for inclusion. Analyses were carried out using RevMan software. RESULTS In all, ten RCTs that included a total of 1,408 patients were included. The meta-analysis showed that the PF, postoperative complications, biliary fistula, mortality, reoperation, and length of hospital stay were not statistically different between the pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) groups. The PF, postoperative complications, mortality, and reoperation were not statistically different between the duct-to-mucosa PJ and PJ groups. Binding PJ significantly decreased the PF and postoperative complications compared with conventional PJ. The PF, postoperative complications, and mortality were not statistically different between ligation of the pancreatic duct without anastomosis versus PJ. CONCLUSION No pancreatic reconstruction technique after PD was found to be applicable to all kinds of pancreatic remnants in our systematic review and meta-analysis. Some new approaches such as binding PJ and modified PG will be considered for study in the future.
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Affiliation(s)
- Sun Hu Yang
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, 17 Changle Western Road, Xi'an, 710032 Shanxi Province, China
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Liu C, Long J, Liu L, Xu J, Zhang B, Yu X, Ni Q. Pancreatic stump-closed pancreaticojejunostomy can be performed safely in normal soft pancreas cases. J Surg Res 2012; 172:e11-e17. [PMID: 22079848 DOI: 10.1016/j.jss.2011.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/11/2011] [Accepted: 09/02/2011] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pancreatic anastomotic failure remains the main reason for morbidity and mortality after pancreaticoduodenectomy, and there is no existing flawless pancreaticojejunal reconstruction approach to this date, especially for the normal soft pancreas cases. METHODS We compared a pancreatic stump-closed pancreaticojejunostomy technique (group B; n = 33) with conventional duct-to-mucosa fashion (group A; n = 30) retrospectively in 63 normal soft pancreatic texture cases. Some operative related data including postoperative complications, anastomosis time, hospital stay days, mortality rate, and relaparotomy rate were analyzed. RESULTS There was no difference concerning the incidences of postoperative morbidity, including pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, intra-abdominal abscess, and remnant pancreatitis between two groups. The differences of anastomosis time, hospitalization days, relaparotomy rate, and mortality rate were also not significant. However, group B patients had a shorter duration (d) for healing of postoperative pancreatic fistula than group A (15.3 ± 8.5 versus 33.0 ± 14.1 d, P < 0.05). CONCLUSION For the normal soft pancreas cases, pancreatic stump-closed pancreaticojejunostomy technique is quite safe and convenient according to our experience; ideal clinical results could be achieved with its application in the future.
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Affiliation(s)
- Chen Liu
- Department of Pancreatic and Hepatobiliary Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
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Peng SY, Wang JW, Hong DF, Liu YB, Wang YF. Binding pancreaticoenteric anastomosis: from binding pancreaticojejunostomy to binding pancreaticogastrostomy. Updates Surg 2011; 63:69-74. [PMID: 21442343 DOI: 10.1007/s13304-011-0067-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 03/14/2011] [Indexed: 12/22/2022]
Abstract
Potential mechanisms of occurrence of pancreatic leakage mainly include leakage from the needle hole and from the seam at the adjacent stitch, anastomotic blood supply, tension at the anastomosis, poor anastomotic healing, etc. Binding pancreaticojejunostomy (BPJ) is a safe and effective technique that avoids the primary complication of pancreatic anastomosis leakage. There are two problems with BPJ: a high discrepancy in the size of pancreas stump and the jejunal lumen; sutures on to the pancreas for fixation might cause exudation of pancreatic juice into the abdominal cavity. In order to avoid these two problems, binding pancreaticogastrostomy (BPG) is designed and successfully performed clinically with encouraging results. BPG is good for accommodating a large pancreas stump, and the binding technique is very helpful in minimizing the leak rate of pancreaticogastrostomy.
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Affiliation(s)
- Shu You Peng
- Department of General Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
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Yang SH, Dou KF, Song WJ. Peng's binding pancreaticojejunostomy plus external drainage of the pancreatic duct after pancreaticoduodenectomy: a potential choice. J Gastrointest Surg 2011; 15:1067-8. [PMID: 21347874 DOI: 10.1007/s11605-011-1451-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 01/30/2011] [Indexed: 01/31/2023]
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Ball CG, Howard TJ. Does the type of pancreaticojejunostomy after Whipple alter the leak rate? Adv Surg 2010; 44:131-48. [PMID: 20919519 DOI: 10.1016/j.yasu.2010.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis 46202, USA
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Pancreaticogastrostomy for high-risk gland after pancreaticoduodenectomy: an eligible choice? World J Surg 2010; 35:224-5; author reply 226. [PMID: 20495976 DOI: 10.1007/s00268-010-0632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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