Ductal adenocarcinoma of the pancreatic head: a focus on current diagnostic and surgical concepts

Complete surgical resection still remains the only possibility of curing pancreatic cancer, however, only 10% of patients undergo curative surgery. Pancreatic resection currently remains the only method of curing patients, and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer. Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques. Nevertheless, even in experienced hands, perioperative morbidity rates (delayed gastric emptying, pancreatic fistula etc.) are as high as 50%. Different strategies to reduce postoperative morbidity, such as different techniques of gastroenteric reconstruction (pancreatico-jejunostomy vs pancreatico-gastrostomy), intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome. The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct (< 3 mm). The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying, respectively. Currently, the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity, but without any positive impact on overall survival. However, there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.     

Sepsis delays gastric emptying following pylorus-preserving pancreaticoduodenectomy

BACKGROUND/AIMS: The mechanism of delayed gastric emptying following pylorus-preserving pancreaticoduodenectomy is not completely understood. METHODOLOGY: The records of 25 patients who underwent pylorus-preserving pancreaticoduodenectomy were reviewed. Correlations of postoperative delayed gastric emptying defined as the need for postoperative nasogastric decompression for > 10 days, with perioperative parameters and clinical outcome were analyzed. RESULTS: Delayed gastric emptying occurred in 13 patients. Age, gender, presence of pancreatic carcinoma, operating time, estimated blood loss, and preservation of right gastric artery did not affect the incidence of delayed gastric emptying. Patients with pancreatic fibrosis (n = 13) had a significantly lower incidence of delayed gastric emptying than in those without fibrosis (n = 12) (23% vs. 83%, P = 0.0048). Ten patients developed postoperative septic complications, including anastomotic leakage (n = 7), pneumonia (n = 2), and severe wound infection (n = 1). The incidence of postoperative delayed gastric emptying was significantly higher in patients with septic complications than in those without septic complications (100% vs. 20%, P = 0.0001). Also, patients with intraabdominal sepsis had a significantly higher incidence of delayed gastric emptying (P = 0.0052). CONCLUSIONS: Delayed gastric emptying following pylorus-preserving pancreaticoduodenectomy is related to the presence of non-fibrotic pancreas and postoperative septic complications.     

Omental flaps reduces complications after pancreaticoduodenectomy

BACKGROUND:Major complications after pancreaticoduodenectomy are usually caused by a leaking pancreaticojejunal anastomosis.Omental flaps around various anastomoses were used to prevent the formation of fistula.METHODS:We reviewed 147 patients who had undergone pancreaticoduodenectomy between March 2006 and March2012.The patients were divided into 2 groups according to the application of omental flaps around various anastomoses:group A(101 patients)who underwent omental wrapping procedure;group B(46 patients)who did not undergo the omental wrapping procedure.Perioperative data of the two groups were reviewed to assess the effectiveness of omental flap procedure in the prevention of pancreatic fistula and other complications.RESULTS:No differences were observed in the clinical characteristics between the 2 groups.The incidences of pancreatic fistula(4.0%vs 17.4%),post-pancreatectomy hemorrhage(0vs 6.5%),biliary fistula(1.0%vs 13.0%),and delayed gastric emptying(4.0%vs 17.4%)were significantly less frequent in group A.The overall morbidity(18.8%vs 47.8%)and hospital stay(8.3 vs 9.6 days)were also significantly lower in group A than in group B.CONCLUSIONS:Omental flaps around various anastomoses after pancreaticoduodenectomy can reduce the incidences of pancreatic fistula,biliary fistula,post-pancreatectomy hemorrhage and delayed gastric emptying.This procedure is simple and effective to reduce the overall morbidity after pancreaticoduodenectomy.     

Prophylactic irrigation around a pancreaticojejunostomy for the treatment of a pancreatic fistula after a pancreaticoduodenectomy in patients with a risky pancreatic remnant

BACKGROUND/AIMS: Postoperative morbidity after a pancreaticoduodenectomy remains high mainly due to pancreatic fistula, but effective methods to prevent the development of pancreatic fistula have yet to be established. The present study prospectively investigated whether postoperative prophylactic irrigation around the pancreaticojejunostomy might be able to prevent eventual pancreatic fistula and infectious complications after a pancreaticoduodenectomy. METHOD: Among 75 patients undergoing a pancreaticoduodenectomy between 2003 and 2005, 50 patients in whom the drain amylase level on postoperative day 1 were 1,500 IU/L or more were selected for the present study. Twenty-six of the 50 patients underwent postoperative prophylactic 72-hour continuous irrigation around the pancreaticojejunostomy starting from postoperative day 1 (Irrigation group). On the other hand, 24 of them did not undergo such irrigation (Non-irrigation group). The incidence of pancreatic fistula, infectious complications, delayed gastric emptying, and the length of hospital stay were then compared between the 2 groups. RESULTS: The incidences of pancreatic fistula, wound infection, drain infection, sepsis, delayed gastric emptying, overall morbidity, and length of hospital stay were found to be significantly less in the irrigation group than in the non-irrigation group. CONCLUSIONS: Prophylactic irrigation may possibly be able to prevent the occurrence of pancreatic fistula and infectious complications after a pancreaticoduodenectomy in patients with a risky pancreatic remnant.     

Continuous suture of the pancreatic stump and Braun enteroenterostomy in pancreaticoduodenectomy

AIM:To investigate a new modification of pancreaticoduodenectomy(PD)-a mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy.METHODS:Two hundred and three patients underwent PD from 2009 to 2014 and were classified into two groups:Group A(98 patients),who received PD with a mesh-like running suturing for the pancreatic remnant,and Braun’s enteroenterostomy; and Group B(105 patients),who received standard PD.Demographic data,intraoperative findings,postoperative morbidity and perioperative mortality between the two groups were compared by univariate and multivariate analysis.RESULTS:Demographic characteristics between Group A and Group B were comparable.There were no significant differences between the two groups concerning perioperative mortality,and operative blood loss,as well as the incidence of the postoperative morbidity,including reoperation,bile leakage,intraabdominal fluid collection or infection,and postoperative bleeding.Clinically relevant postoperative pancreatic fistula(POPF) and delayed gastric emptying(DGE) were identified more frequently in Group B than in Group A.Technique A(PD with a mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy) was independently associated with decreased clinicallyrelevant POPF and DGE,with an odds ratio of 0.266(95%CI:0.109-0.654,P =0.004) for clinically relevant POPF and 0.073(95%CI:0.010-0.578,P =0.013) for clinically relevant DGE.CONCLUSION:An additional mesh-like running suturing of the pancreatic remnant and Braun’s enteroenterostomy during PD decreases the incidence of postoperative complications and is beneficial for patients.     

Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes

BackgroundBlumgart's pancreaticojejunostomy (PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes.MethodsWe performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula (CR-POPF) and analysis of its risk factors.ResultsThe CR-POPF rate was 12.3%. Fistula risk score (FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay.ConclusionBlumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.     

A systematic review and network meta-analysis of different surgical approaches for pancreaticoduodenectomy

BackgroundMinimally invasive pancreaticoduodenectomy (MIPD) is a demanding surgical procedure, thus explaining its slow expansion and limited popularity amongst Hepato-Pancreatico-Biliary (HPB) surgeons. However, three main advantages of robotic assisted pancreaticoduodenectomy (PD) including improved dexterity, 3D vision less surgical fatigue, may overcome some of the hurdles and ultimately lead to a wider adoption. This systematic review and network meta-analysis aims to evaluate the current literature on open and MIPD.MethodsA systematic literature search was conducted for studies reporting robotic, laparoscopic and open surgery for PD. Network meta-analysis of intraoperative (operating time, blood loss, transfusion rate), postoperative (overall and major complications, pancreatic fistula, delayed gastric emptying, length of hospital stay) and oncological outcomes (R0 resection, lymphadenectomy) were performed.ResultsSixty-one studies including 62,529 patients were included in the network meta-analysis, of which 3% (n = 2131) were totally robotic (TR) and 10% (n = 6514) were totally laparoscopic (TL). There were no significant differences between surgical techniques for major complications, overall and grade B/C fistula, biliary leak, mortality and R0 resections. Transfusion rates were significantly lower in TR compared to TL and open. Operative time for TR was longer compared with open and TL. Both TL and TR were associated with significantly lower rates of wound infections, pulmonary complications, shorter length of stay and higher lymph nodes examined when compared to open. TR was associated with significantly lower conversion rates than TL.ConclusionIn summary, this network meta-analysis highlights the variability in techniques within MIPD and compares other variations to the conventional open PD. Current evidence appears to demonstrate MIPD, both laparoscopic and robotic techniques are associated with improved rates of surgical site infections, pulmonary complications, and a shorter hospital stay, with no compromise in oncological outcomes for cancer resections.     

Total closure of pancreatic section for end-to-side pancreaticojejunostomy decreases incidence of pancreatic fistula in pancreaticoduodenectomy

BACKGROUND: Postoperative pancreatic fistula (POPF) is a serious complication and results in prolonged hospitalization and high mortality. The present study aimed to evaluate the safety and effectiveness of total closure of pancreatic section for end-to-side pancreaticojejunostomy in pancreaticoduode-nectomy (PD).METHODS: This was a prospective randomized clinical trial comparing the outcomes of PD between patients who un-derwent total closure of pancreatic section for end-to-side pancreaticojejunostomy (Group A) vs those who underwent conventional pancreaticojejunostomy (Group B). The primary endpoint was the incidence of pancreatic fistula. Secondary endpoints were morbidity and mortality rates.RESULTS: One hundred twenty-three patients were included in this study. The POPF rate was significantly lower in Group A than that in Group B (4.8% vs 16.7%, P<0.05). About 38.3%patients in Group B developed one or more complications;this rate was 14.3% in Group A (P<0.01). The wound/abdomi-nal infection rate was also much higher in Group B than that in Group A (20.0% vs 6.3%, P<0.05). Furthermore, the average hospital stays of the two groups were 18 days in Group A, and 24 days in Group B, respectively (P<0.001). However, there was no difference in the probability of mortality, biliary leakage,delayed gastric emptying, and pulmonary infection between the two groups.CONCLUSION: Total closure of pancreatic section for end-to-side pancreaticojejunostomy is a safe and effective method for pancreaticojejunostomy in PD.     

Symptoms associated with impaired gastric emptying of solids and liquids in functional dyspepsia

OBJECTIVE: The relationship between functional dyspepsia and delayed gastric emptying of solids or liquids is still unclear. The aim of the present study was to investigate in dyspeptic patients the prevalence of delayed gastric emptying for solids or for liquids and to investigate the relationship to the dyspepsia symptom pattern. METHODS: In 392 and 330 patients with functional dyspepsia, the solid and liquid gastric emptying, respectively, was measured using breath tests, and the severity of eight dyspeptic symptoms was scored. RESULTS: Gastric emptying of solids and liquids were delayed in 23% and 35% of the patients. Multivariate analysis showed that the presence of vomiting and postprandial fullness was associated with delayed solid emptying (OR 2.65, 95% CI = 1.62-4.35 and OR 3.08, 95% CI = 1.28-9.16, respectively). Postprandial fullness was also associated with the risk of delayed liquid emptying when symptom was present (OR 3.5, 95% CI = 1.57-8.68), relevant or severe (OR 2.504, 95% CI = 1.41-4.65), and severe (OR 2.214, 95% CI = 1.34-3.67). Severe early satiety was associated with the risk of delayed liquid emptying (OR 1.902, 95% CI = 1.90-3.30). CONCLUSIONS: A subset of dyspeptic patients has delayed gastric emptying of solids or of liquids. Delayed gastric emptying of solids was constantly associated with postprandial fullness and with vomiting. Delayed emptying for liquids was also associated with postprandial fullness and with severe early satiety.     

Gastric marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy due to delayed gastric emptying and Helicobacter pylori infection

Background/Aims: Marginal ulceration and delayed gastric emptying are considerable problems after pancreaticoduodenectomy. Helicobacter pylori (HP) are well known to be associated with gastritis, gastric ulcer and gastric cancer. Thus, we studied the relationship between marginal ulceration and delayed gastric emptying in the early postoperative period after pancreaticoduodenectomy with pancreaticogastrostomy. Methodology: We retrospectively studied 58 patients who underwent pancreaticoduodenectomy with pancreaticogastrostomy. On the basis of the grade of delayed gastric emptying, these patients were divided into 2 groups-WS group; without/with slight delayed gastric emptying and MS group; moderate/severe delayed gastric emptying. Results: Two patients (3.4%) developed postoperative marginal ulcer, these 2 patients had no HP infection; moreover, they belonged to the MS group. Five patients in the WS group were infected with HP; although, postoperative marginal ulceration did not develop in these 5 patients. Conclusions: Delayed gastric emptying might be a stronger promoting factor of postoperative marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy rather than HP infection and prevention of delayed gastric emptying is important to reduce the occurrence rate of postoperative marginal ulcer. Our modified subtotal stomach-preserving pancreaticoduodenectomy is a useful procedure for preventing delayed gastric emptying and postoperative marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy.     

Relationship between gastrointestinal and extra-gastrointestinal symptoms and delayed gastric emptying in functional dyspeptic patients

AIM: Delayed gastric emptying and an enlarged fasting gastric antrum are common findings in functional dyspepsia but their relationship with gastrointestinal (GI), and the frequently associated extra-GI symptoms remains unclear. This study evaluated the relationship between GI and extra-GI symptoms, fasting antral volume and delayed gastric emptying in functional dyspepsia. METHODS: In 108 functional dyspeptic patients antral volume and gastric emptying were assessed with ultraso-nography (US). Symptoms were assessed with standardized questionnaire. The association of symptoms and fasting antral volume with delayed gastric emptying was estimated with logistic regression analysis. RESULTS: Delayed gastric emptying was detected in 39.8% of the patients. Postprandial drowsiness (AOR 11.25; 95%CI 2.75-45.93), nausea (AOR 3.51; 95%CI 1.19-10.32), fasting antral volume (AOR 1.93; 95%CI 1.22-3.05), were significantly associated with delayed gastric emptying. Symptoms, mainly the extra-GI ones as postprandial drowsiness and nausea, combined with fasting antral volume predicted the modality of gastric emptying with a sensitivity and specificity of 78%. CONCLUSION: In functional dyspeptic patients, (1) an analysis of fasting antral volume and of symptoms can offer valuable indication on the modality of gastric emptying, and (2) it seems appropriate to inquire on postprandial drowsiness that showed the best correlation with delayed gastric emptying.     

Effects of metoclopramide and bethanechol on delayed gastric emptying present in gastroesophageal reflux patients

Gastric emptying has been reported to be delayed in a significant percentage of patients with gastroesophageal reflux. The rationale for the use of metoclopramide and bethanechol in gastroesophageal reflux has been based on their ability to stimulate lower esophageal sphincter pressure and enhance acid clearance mechanisms. In this study, we investigated the comparative efficacies of metoclopramide and bethanchol in improving the rate of gastric emptying in gastroesophageal reflux patients in whom delayed emptying was present. Gastric emptying studies used an isotope-labeled mixed solid-liquid meal. Thirteen reflux patients with delayed gastric emptying received metoclopramide, 10 mg intramuscularly, and subcutaneous bethanechol, 0.07 mg/kg, in a randomized single-blind fashion. Eleven additional reflux patients with delayed gastric emptying received oral metoclopramide, 10 mg, in an open-labeled fashion. After parenteral metoclopramide, gastric emptying was significantly (p less than 0.05) faster compared with both the initial basal day and the bethanechol treatment day. Compared with the normal gastric emptying rate established in 26 control subjects, metoclopramide accelerated gastric emptying into the normal range. Bethanechol did not increase gastric emptying. Metoclopramide orally also significantly improved gastric emptying. Our study indicates that metoclopramide, both parenterally and orally, increased the rate of gastric emptying in those reflux esophagitis patients in whom it was delayed, while bethanechol did not improve the degree of gastric retention in the same patients. Our results extend the rationale for the therapeutic efficacy of metoclopramide in gastroesophageal reflux disease.     

Gastroesophageal reflux and gastric emptying,revisited

Total gastric emptying is delayed in 10% to 33% of adult patients with gastroesophageal reflux disease (GERD), but a strong correlation between duration of gastric emptying and severity of acid reflux or esophagitis has never been proved. Previous studies reported that patients with GERD might have exaggerated postprandial fundus relaxation with retention of food and triggering of transient lower esophageal sphincter relaxations (TLESRs). There is a positive correlation between postprandial fundus relaxation and number of TLESRs and also between proximal gastric emptying and esophageal acid exposure. However, new studies suggest that a high number of TLESRs and reflux events may occur even with accelerated gastric emptying, and prolonged gastric retention might be associated with less rather than more esophageal acid exposure. Using simultaneous gastric emptying and esophageal pH impedance we found that the rate of gastric emptying might determine the acidity and proximal extent of reflux: The slower the emptying, the higher the pH and proximal extent of the refluxate.     

Role of autonomic dysfunction in patients with functional dyspepsia

BACKGROUND: The role of autonomic dysfunction in patients with functional dyspepsia is not completely understood. AIMS: 1. to prospectively assess abnormalities of autonomic function in patients with functional dyspepsia, 2. to assess whether autonomic dysfunction in these patients is associated with a. visceral hypersensitivity or b. delayed gastric emptying or c. severity of dyspeptic symptoms. PATIENTS: A series of 28 patients with functional dyspepsia and 14 healthy volunteers without gastrointestinal symptoms were studied. METHODS: All patients and controls were submitted to a battery of five standard cardiovascular autonomic reflex tests, dyspeptic questionnaire, gastric barostat tests and gastric emptying tests. RESULTS: 1. Autonomic function tests showed that both sympathetic and parasympathetic scores of dyspeptic patients were significantly higher than in controls; 2. visceral hypersensitivity was confirmed in dyspeptics in response to proximal gastric distension, demonstrating lower pain threshold; 3. delayed gastric emptying occurred more frequently in patients with functional dyspepsia than in controls; 4. epigastric pain and epigastric burning were significantly more prevalent in patients with definite evidence of autonomic dysfunction; 5. No significant association was found between presence of autonomic dysfunction and presence of visceral hypersensitivity or presence of delayed gastric emptying in patients with functional dyspepsia. CONCLUSIONS: We concluded that a possible role of autonomic dysfunction in eliciting dyspeptic symptoms could not be determined from alterations in visceral hypersensitivity or delayed gastric emptying. Autonomic dysfunction might not be the major explanation for symptoms associated with functional dyspepsia.     

Pancreatic carcinoma is associated with delayed gastric emptying

Fifteen patients with histologically confirmed pancreatic carcinoma, without evidence of gastroduodenal invasion or obstruction, were prospectively studied to determine the frequency of gastric emptying disorders as determined by a solid-phase gastric emptying study. Nine of these (60%) had gastric emptying curves more than two standard deviations below normal mean values. The majority of patients did not have symptoms of gastric stasis. Nausea and/or vomiting was present in 33% of patients with abnormal gastric emptying and in none of those with normal emptying. Abdominal and/or back pain was present in 8/9 with delayed gastric emptying and in 3/6 with normal emptying. Disordered gastric emptying did not correlate with tumor stage, histology, location, or hyperbilirubinemia. Delayed solid-food gastric emptying may be responsible for the nonspecific abdominal complaints that occur during the course of pancreatic carcinoma, although more frequently, gastroparesis exists on a subclinical level.     

Tips and tricks of the surgical technique for borderline resectable pancreatic cancer: mesenteric approach and modified distal pancreatectomy with en‐bloc celiac axis resection

Borderline resectable (BR) pancreatic cancer involves the portal vein and/or superior mesenteric vein (PV/SMV), major arteries including the superior mesenteric artery (SMA) or common hepatic artery (CHA), and sometimes includes the involvement of the celiac axis. We herein describe tips and tricks for a surgical technique with video assistance, which may increase the R0 rates and decrease the mortality and morbidity for BR pancreatic cancer patients. First, we describe the techniques used for the “artery‐first” approach for BR pancreatic cancer with involvement of the PV/SMV and/or SMA. Next, we describe the techniques used for distal pancreatectomy with en‐bloc celiac axis resection (DP‐CAR) and tips for decreasing the delayed gastric emptying (DGE) rates for advanced pancreatic body cancer. The mesenteric approach, followed by the dissection of posterior tissues of the SMV and SMA, is a feasible procedure to obtain R0 rates and decrease the mortality and morbidity, and the combination of this aggressive procedure and adjuvant chemo(radiation) therapy may improve the survival of BR pancreatic cancer patients. The DP‐CAR procedure may increase the R0 rates for pancreatic cancer patients with involvement within 10 mm from the root of the splenic artery, as well as the CHA or celiac axis, and preserving the left gastric artery may lead to a decrease in the DGE rates in cases where there is more than 10 mm between the tumor edge and the root of the left gastric artery. The development of safer surgical procedures is necessary to improve the survival of BR pancreatic cancer patients.     

Impact of expanding indications on surgical and oncological outcome in 1434 consecutive pancreatoduodenectomies

BackgroundOver the years, high-volume pancreatic centers expanded their indications for pancreatoduodenectomy (PD) but with unknown impact on surgical and oncological outcome.MethodsAll consecutive PDs performed between 1992–2017 in a single pancreatic center were identified from a prospectively maintained database and analyzed according to three time periods.ResultsIn total, 1434 patients underwent PD. Over time, more elderly patients underwent PD (P < 0.001) with increased use of vascular resection (10.4 to 16.0%, P < 0.001). In patients with cancer (n = 1049, 74.8%), the proportion pT3/T4 tumors increased from 54.3% to 70.6% over time (P < 0.001). The postoperative pancreatic fistula (16.0%), postpancreatectomy hemorrhage (8.0%) and delayed gastric emptying (31.0%) rate did not reduce over time, whereas median length of stay decreased from 16 to 12 days (P < 0.001). The overall failure-to-rescue rate (6.9%) and in-hospital mortality (2.2%) remained stable (P = 0.89 and P = 0.45). In 523 patients with pancreatic cancer (36.5%), the use of both adjuvant and neoadjuvant chemotherapy increased over time (both p<0.001), and the five-year overall survival improved from 11.0% to 17.4% (P < 0.001).ConclusionsIn a period where indications for PD expanded, with more elderly patients, more advanced cancers and increased use of vascular resections, surgical outcome remained favorable and five-year survival for pancreatic cancer improved.     

Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications

Pancreatic fistula after pancreaticoduodenectomy represents a critical trigger of potentially life-threatening complications and is also associated with markedly prolonged hospitalization. Many arguments have been proposed for the method to anastomosis the pancreatic stump with the gastrointestinal tract, such as invagination vs. duct-to-mucosa, Billroth I (Imanaga) vs. Billroth II (Whipple and/or Child) or pancreaticogastrostomy vs. pancreaticojejunostomy. Although the best method for dealing with the pancreatic stump after pancreaticoduodenectomy remains in question, recent reports described the invagination method to decrease the rate of pancreatic fistula significantly compared to the duct-to-mucosa anastomosis. In Billroth I reconstruction, more frequent anastomotic failure has been reported, and disadvantages of pancreaticogastrostomy have been identified, including an increased incidence of delayed gastric emptying and of pancreatic duct obstruction due to overgrowth by the gastric mucosa. We review recent several safety trials and methods of treating the pancreatic stump after pancreaticoduodenectomy, and demonstrate an operative procedure with its advantage of the novel reconstruction method due to our experiences.     

Abnormal gastric myoelectrical activity and delayed gastric emptying in patients with symptoms suggestive of gastroparesis

Gastric myoelectrical activity modulates gastric motor activity. Abnormalities in gastric myoelectrical activity may be associated with gastric motility disorders. The aim of this study was to investigate the correlation of gastric myoelectrical activity with gastric emptying in symptomatic patients with and without gastroparesis. Ninety-seven patients with symptoms suggestive of gastroparesis participated in the study. Gastric myoelectrical activity was recorded using surface electrogastrography. The electrogastrogram (EGG) was recorded for 30 min in the fasting state and for 120 min after a solid test meal. Gastric emptying of the solid meal was simultaneously monitored for 120 min. Patients with delayed gastric emptying showed a significantly lower percentage of normal gastric slow waves (P<0.03) and a significantly reduced increase of the dominant power in the postprandial EGG (P<0.02). Postprandial EGG parameters were found to be able to predict delayed emptying of the stomach. Postprandial gastric dysrhythmia predicts delayed gastric emptying with an accuracy of 78%, while the abnormality in postprandial EGG power predicts delayed gastric emptying with an accuracy of 75%. All patients with abnormalities in both the rhythmicity and the power had delayed gastric emptying. Patients with delayed gastric emptying have a lower percentage of normal gastric slow waves in the EGG and a lower postprandial increase in the dominant power. Abnormalities in the postprandial EGG seem to be able to predict delayed emptying of the stomach. However, a normal EGG does not seem to guarantee normal emptying of the stomach.     

Prophylactic intra-peritoneal drain placement following pancreaticoduodenectomy:A systematic review and metaanalysis

AIM:To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy(PD)with or without prophylactic drainage.METHODS:Relevant comparative randomized and nonrandomized studies were systemically searched based on specific inclusion and exclusion criteria.Postoperative outcomes were compared between patients with and those without routine drainage.Pooled odds ratios(OR)with 95%CI were calculated using either fixed effects or random effects models.RESULTS:One randomized controlled trial and four non-randomized comparative studies recruiting 1728patients were analyzed.Patients without prophylactic drainage after PD had significantly higher mortality(OR=2.32,95%CI:1.11-4.85;P=0.02),despite the fact that they were associated with fewer overall complications(OR=0.62,95%CI:0.48-0.82;P=0.00),major complications(OR=0.75,95%CI:0.60-0.93;P=0.01)and readmissions(OR=0.77,95%CI:0.60-0.98;P=0.04).There were no significant differences in the rates of pancreatic fistula,intraabdominal abscesses,postpancreatectomy hemorrhage,biliary fistula,delayed gastric emptying,reoperation or radiologic-guided drains between the two groups.CONCLUSION:Indiscriminate abandonment of intraabdominal drainage following PD is associated with greater mortality,but lower complication rates.Future randomized trials should compare routine vs selective drainage.