Improved hospital morbidity, mortality, and survival after the Whipple procedure.

Between 1969 and 1986, 88 patients had a Whipple resection for adenocarcinoma of the pancreas (N = 50), ampulla (N = 19), distal bile duct (N = 10), and duodenum (N = 9). Forty-nine patients were men, 39 were women, and the mean age was 58 years (range: 34-84 years). The patients were divided into two groups on the basis of two different time periods: those operated on from 1969 to 1980 (N = 41) and those operated on from 1981 to 1986 (N = 47). There were no significant differences between the two groups in terms of mean age, sex distribution, duration of symptoms before presentation, or mean weight loss. Likewise, preoperative laboratory data were similar for both groups of patients. In addition, mean tumor size for patients with pancreatic cancer (3.5 cm vs. 3.2 cm) and patients with nonpancreatic periampullary cancer (1.9 cm vs. 2.2 cm) was similar in both groups, as was the incidence of positive lymph nodes. Among the 41 patients operated on during the first period, hospital morbidity and mortality rates were 59% and 24%, respectively. In contrast, hospital morbidity and mortality rates were 36% and 2%, respectively, among the 47 patients operated on during the recent period. During the recent period, more Whipple procedures were performed each year (7.8 vs. 3.4) and by fewer surgeons (3.4 operations/surgeon vs. 1.9 operations/surgeon). In addition, between 1981 and 1986, there were fewer total pancreatectomies (9% vs. 39%), fewer vagotomies (26% vs. 76%), and more pyloric-preserving procedures (30% vs. 0) performed compared with the earlier period. During the recent period, mean operative time (7.8 vs. 9.0 hours), mean estimated blood loss (1694 vs. 3271 mL), and mean intraoperative blood replacement (3.6 vs. 6.3 units) were all significantly less than in the earlier period. These findings suggest that the recent decline in operative morbidity and mortality may be due to fewer surgeons performing more Whipple resections in less time and with less blood loss. The actuarial 5-year survival rate for the 38 patients with nonpancreatic periampullary cancer was 34%. Surprisingly, the actuarial 5-year survival rate among the 50 patients with pancreatic cancer was 18%. Moreover, in the absence of positive lymph node involvement, the 5-year actuarial survival rate among patients with pancreatic cancer was 48%. No explanation is obvious for the improvement in survival among patients with pancreatic cancer.     

Whipple术后胆囊癌

Whipple手术已成为胰头癌、胆总管中下段癌、壶腹癌和十二指肠癌的常规治疗方法.近期笔者收治了1例Whipple术后胆囊癌病人,报告如下.     

Pyloric preservation with the Whipple procedure

The pylorus-preserving pancreatoduodenectomy simplifies resection, allows a satisfactory postoperative weight gain, prevents postgastrectomy symptoms, is followed by a low rate of jejunal ulceration, and can be performed with an extremely low postoperative mortality rate, providing that the pancreatic and biliary anastomoses are constructed so that no leakage occurs. Preliminary data indicate a satisfactory survival rate when this procedure is used for periampullary cancer, and reasonable relief of pain is achieved when the procedure is used in chronic pancreatitis.     

Late pancreaticojejunostomy stent migration and hepatic abscess after Whipple procedure

A previously unreported late complication of a transanastomotic stent across a pancreaticotojejunostomy is described. The stent migrated distally into the jejunal lumen, through the biliary anastomis into the bile duct and proximally into the liver where it served as a nidus for infection with abscess formation. A percutaneous transhepatic interventional radiologic approach both drained the abscess and pushed the stent out of the liver and biliary tree and into the bowel, with complete recovery. The decision by the surgeon to use a stent in these patients is discussed, and the complications associated with stenting a pancreaticojejunostomy are reviewed.     

Whipple手术死亡原因分析

目的分析Whipple手术死亡原因,探讨降低手术病死率的方法和手段.方法回顾1980年初至1999年底20年间425例Whipple手术,对其中28例手术死亡病例的术前高危因素、术中情况、术后处理等因素进行分析探讨,提出防治严重并发症发生的方法.结果425例手术中共死亡28例,手术病死率6.6%.死亡的28例中,男性16例,女性12例;年龄30～81岁;良性病变4例,恶性病变24例;术前24例患者合并有高危因素,其中合并二种以上高危因素的20例(71%);专业手术组手术病死率4.8%(16/331),非专业手术组手术病死率12.8%(12/94);手术时间4.5～17.0 h,平均(7.8+2.6)h;术中出血量800～12 000 ml(2 330±2 220)m1;术后严重并发症中,手术并发症包括消化道瘘、消化道出血、腹腔出血、腹腔严重感染等;非手术并发症包括心、肺、肝、肾等重要脏器功能衰竭以及严重代谢障碍等.19例患者因手术并发症而直接导致死亡,其中消化道瘘9例、腹腔出血4例、消化道出血3例、腹腔严重感染3例;9例患者由于非手术并发症死亡.结论Whipple手术死亡率受多方面因素影响;手术的专业化、规范化,术前重要脏器功能的合理评估,减少手术并发症的发生,提高严重并发症的处理水平,对降低手术病死率至关重要.     

Vasoplegic syndrome during Whipple procedure

Vasoplegic syndrome is an unusual cause of refractory hypotension under general anesthesia. It is commonly described in the setting of cardiac surgery, but rarely seen in noncardiac setting. We describe successful management of vasoplegic syndrome during Whipple procedure with vasopressin infusion. A high index of suspicion and prompt treatment with vasopressin can be lifesaving in patients with risk factors for vasoplegic syndrome who present with severe refractory hypotension and who respond poorly to fluid administration and routine vasopressor infusion.     

Pancreatic anastomotic leak after the Whipple procedure is reduced using the surgical microscope

BACKGROUND: Pancreatic anastomotic leakage (Leak) is the most common major complication after pancreaticoduodenectomy (PD). In this study we tested the hypothesis that better vision would improve the technical performance of this anastomosis and result in a lower Leak rate. METHODS: A retrospective review of 266 consecutive patients who underwent PD with pancreaticojejunostomy between 1996 and 2003 was carried out. In the first 196 patients we had used an end-to-side, internally-stented, duct-to-mucosa pancreaticojejunostomy aided by surgical Loupes at 2.5x magnification (Loupes group). In the next 70 patients we substituted the surgical microscope at 12.5x for the surgical Loupes (microscope group). Risk factors associated with Leak were determined for all 266 cases and then the outcomes for each group were compared. RESULTS: Leak was observed in 11.7% of patients (31 of 266). Uni- and multivariate analysis showed 3 independent risk factors for Leak: (1) male gender (odds ratio [OR], 3.10); (2) a pancreatic duct size of less than or equal to 3 mm (OR, 7.75); and (3) not using the microscope (OR, 7.43). The Leak rate in the Loupes group was 15% (29 of 196) and in the microscope group 2.9% (2 of 70, P = .008). The mean hospital length of stay was longer in the Loupes group (11.3 days) as compared to the microscope group (9.0 days, P < .001). In the high-risk subset for Leak with duct size less than or equal to 3 mm (n = 147), the Leak rate was 23% in the Loupes group vs 4.2% in the microscope group (P = .027). CONCLUSION: The enhanced vision provided by the surgical microscope allowed precise construction of the anastomosis resulting in a significant decrease in Leak, particularly when a patient was at risk for Leak, ie, pancreatic duct less than or equal to 3 mm.     

Effect of antecolic reconstruction on delayed gastric emptying after the pylorus-preserving Whipple procedure

HYPOTHESIS: Antecolic duodenojejunostomy prevents delayed gastric emptying (DGE) after a pylorus-preserving Whipple (ppW) procedure better than retrocolic duodenojejunostomy. DESIGN: A single operation team's experience with antecolic and retrocolic duodenojejunostomy in ppW is analyzed on a prospective database using univariate and multivariate models. SETTING: Tertiary referral center that focuses on pancreatic diseases. PATIENTS AND INTERVENTIONS: One hundred consecutive patients undergoing a ppW procedure with retrocolic reconstruction between January 1, 1996, and December 31, 2001, and 100 consecutive patients undergoing a ppW procedure with antecolic reconstruction between January 1, 2002, and December 31, 2003. Characteristics such as median age, median hospital stay, sex, diagnosis, previous operations, blood loss, surgical and medical complications, American Society of Anesthesiologists risk groups, stent implantation, and especially DGE were matched for the comparison groups. MAIN OUTCOME MEASURES: We compared DGE, characteristics, and perioperative variables in patients with antecolic vs retrocolic reconstruction after ppW. RESULTS: The DGE occurred significantly more often in patients with retrocolic reconstruction than in those with antecolic reconstruction (P < .001). The antecolic and retrocolic study groups were comparable in age (P = .25), sex (P = .48), and postoperative surgical (P = .19) and medical (P = .054) complications. The univariate analysis between patients with and without DGE did not show significant differences regarding diagnosis, previous operations, blood loss, surgical and medical complications, American Society of Anesthesiologists classification, or stent implantation. In the multivariate analysis, only the type of reconstruction (P = .006) and sex (P = .04) seemed to affect DGE. CONCLUSION: We recommend antecolic duodenjejunostomy in patients undergoing a ppW procedure regardless of their diagnosis.     

Laparoscopic Whipple procedure: review of the literature

Introduction  

Laparoscopic pancreatic surgery represents one of the most advanced applications for laparoscopic surgery currently in use. In the past, minimally invasive techniques were only used for diagnostic laparoscopy, staging of pancreatic cancer, and palliative procedures for unresectable pancreatic cancer. With new advances in technology and instrumentation, some sophisticated procedures are currently available, such as the Whipple procedure, one of the most sophisticated applications of minimally invasive surgery.     

Preoperative risk factors influencing inter-stage mortality after the Norwood procedure

Open in a separate window OBJECTIVESWith improvements in early survival after the stage I palliation (S1P) Norwood procedure for hypoplastic left heart syndrome (HLHS) and its variants, inter-stage death accounts for an increasing proportion of mortality. Our aim was to identify the risk factors for inter-stage mortality.METHODSThe records of 322 neonates with HLHS or a variant who underwent the Norwood procedure at our centre between 2001 and 2019 were retrospectively analysed.RESULTSThe diagnoses included 271 neonates with HLHS (84%) and 51 with variants (16%). Aortic atresia was observed in 138 (43%) patients, mitral atresia in 91 (28%), extracardiac anomalies in 42 (13%) and genetic disorder in 14 (4%). The median age and weight of the patients at the S1P Norwood procedure were 9 (interquartile range: 7–12) days and 3.2 (2.9–3.5) kg, respectively. The median cardiopulmonary bypass time was 137 (107–163) min. Modified Blalock–Taussig shunts were used in 159 (49%) and unvalved right ventricle-to-pulmonary artery shunts in 163 (51%) patients. The number of inter-stage deaths was as follows: between S1P and stage II palliation (S2P), 61 including 38 early (<30 days) and 23 late (>30 days) deaths, and between S2P and stage III palliation, 32 deaths. Low birth weight (<2.5 kg) (odds ratio 4.37, P = 0.020) and restrictive atrial septum (odds ratio 2.97, P = 0.013) were identified as risks for early mortality. Low birth weight [hazard ratio (HR) 0.99/g, P = 0.002] was a risk for inter-stage mortality between S1P and S2P. Extracardiac anomalies (HR 4.75, P = 0.049) and significant pre-S1P atrioventricular valve regurgitation (HR: 7.72, P = 0.016) were risks for inter-stage mortality between S2P and stage III palliation. Other anatomical variables including aortic atresia, anatomical subtypes and the diameter of the ascending aorta nor shunt type were not identified as risk factors for mortality during any inter-stage period.CONCLUSIONSThe risk factors for inter-stage attrition after the Norwood procedure were different between each stage. Preoperative factors, including birth weight, restrictive atrial septum and extracardiac anomalies, adversely affected the inter-stage mortality.     

Superior mesenteric vein thrombosis after the Whipple procedure: an aggressive,combined treatment approach

It is now recognized that occlusion of the mesenteric veins not only may complicate a number of disease processes but may occur as a life-threatening complication after abdominal surgery. A 32-year-old woman had mesenteric venous thrombosis after resection of a duodenal inflammatory pseudotumour by pancreatoduodenectomy. She recovered fully after treatment, which consisted of thrombectomy, flushing with urokinase and intravenous administration of heparin. Papaverine infused for 4 days substantially improved bowel viability. Current concepts in mesenteric vein occlusion and the principles of clinical management are reviewed.     

Somatostatin analogues in the prevention of pancreas-related complications after pancreatic resection

Background/Purpose The Achilles' heel of operative pancreatectomies is the pancreaticoenterostomy for proximal resections and the pancreatic parenchymal closure for distal resections. Inhibition of pancreatic exocrine secretions by somatostatin analogues has been suggested to decrease pancreas-specific complications, but this topic remains controversial. Methods We performed a randomized, prospective, placebo-controlled, multicenter trial of the use of perioperative vapreotide, a potent somatostatin analogue, in pancreatic resections for presumed neoplasms in 381 patients without chronic pancreatitis. We also reviewed the literature on the use of somatostatin and its analogues after pancreatectomy. Results When compared to the placebo, perioperative vapreotide had no effect on overall pancreas-specific complications (30.4% vs 26.4%), mortality (0% vs 1.4%), overall complications (40% vs 42%), and duration of hospitalization; there were no differences in complications per type of resection with use of vapreotide — proximal versus distal resection. Seven other prospective, randomized trials provide differing results. Conclusions Our study with vapreotide failed to show any benefit when administered perioperatively (and for 7 days postoperatively) on pancreas-specific complications after major pancreatectomy in patients without chronic pancreatitis. The use of perioperative analogues that suppress pancreatic exocrine secretion seems not to be warranted as routine treatment.     

Feeding jejunostomy during Whipple is associated with increased morbidity

Background

Placement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD.

Materials and methods

This is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients.

Results

Thirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001) were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis.

Conclusion

Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity.     

Pylorus-preserving duodenopancreatectomy: Long-term complications and comparison with the Whipple procedure

We have performed 33 pylorus-preserving duodenopancreatectomies. Twenty patients presented with severe chronic pancreatitis and 13 with periampullary adenocarcinoma. We have no postoperative mortality and a 24% rate of morbidity. Complications include anastomotic leaks (2), surgical bleeding (1), anastomotic ulceration (1), and others (4). We have complete follow-up for all cases. In the tumor group, 8 (62%) patients are alive with a mean survival time of 20 months (range: 2–46). In the pancreatitis series, all patients are alive after a mean of 34 months (range: 4–66). We have observed 5 cases (15%) of anastomotic ulcerations responsible for stenosis (2) and acute perforation with peritonitis (2) occurring after a mean interval of 18 months. Four cases have been confirmed histologically after resection. The short- and long-term beneficial effects of the pylorus-preserving operation on patient well-being and nutritional status were confirmed and compared with the results achieved after a Whipple procedure performed in a series of 18 consecutive patients.

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Resumen Hemos practicado 33 pancreatoduodenectomías con preservaciôn del píloro. Veinte pacientes presentaban pancreatitis crónica, 13 adenocarcinoma periampular. No tuvimos mortalidad postoperatoria y la morbilidad fue de 24%. Las complicaciones incluyeron escapes anastomósicos (2), hemorragía quirúrgica (1), ulceración anastomósica (1), y otras (4). Tenemos seguimiento completo en la totalidad de los casos. En el grupo tumoral, 8 pacientes se hallan vivos (62%) con una sobrevida promedio de 20 meses (rango: 2–46). En la serie de pancreatitis, todos los patientes están vivos después de 34 meses (rango: 4–66). Hemos observado 5 casos (15%) de ulceraciones anastomósicas causantes de estenosis (2) y perforación aguda con peritonitis (2) que se presentaron después de un intervalo promedio de 18 meses. Cuatro casos han sido confirmados histologicamente después de la resección. Se confirman los efectos benéficos a corto y largo plazo de la operación con preservación del píloro sobre el bienestar general del paciente y sobre el estado nutricional, en comparación con el procedimiento de Whipple, en una serie de 18 pacientes consecutivos.

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Résumé Nous avons fait 33 duodénopancréatectomies avec conservation du pylore. Vingt patients avaient une pancréatite chronique sévère, 13 avaient un adénocarcinome péri-ampullaire. Il n'y a eu aucun mort et la morbidité post-opératoire était de 24%. Parmi les 8 complications précoces, on a noté 2 fuites anastomotiques, 2 hémorragies nécessitant un traitement chirurgical, et un ulcère anastomotique. Tous les patients ont été suivis. Dans le groupe avec tumeur, 8 patients (62%) sont toujours en vie avec une survie moyenne de 20 mois (extrêmes: 2–46). Dans le groupe avec pancréatite, tous les patients sont en vie avec une survie moyenne de 34 mois (extrêmes: 4–66). Secondairement, nous avons observé 5 cas (15%) d'ulcère anastomotique responsable de sténose (2 cas) et de péritonite par perforation (2 cas), 18 mois en moyenne après la première opération. L'ulcération a été histologiquement vérifiée après résection chirurgicale dans 4 cas. Les effets bénéfiques à court et à long terme de la duodénopancréatectomie céphalique avec conservation du pylore se confirment et sont comparés à ceux de la duodénopancréatectomie céphalique classique, effectuée dans 18 cas pendant cette même période.

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Presented at the Collegium Internationale Chirurgiae Digestivae in Toronto, Ontario, Canada, September, 1989.     

Baropodometric analysis of the functional donor-site morbidity after gastrocnemius or soleus muscle-flap procedure

The triceps surae muscle is a major donor-site for muscle-flap to cover soft-tissue defects of the leg. There are very limited datas on the functional donor-site morbidity in the literature. From a retrospective study on 14 patients, we realized a baropodometric analysis comparing the operated lower limb with the healthy non operated side and a functional evaluation by a questionary. The modified functional score of Kitatoka was good (87/100). Ninety percent of the patients were able to resume a professional activity and 2/3 to resume the sport. The baropodometric analysis did not show statistically significant difference of propulsion and absorption between the healthy side and the operated side, but a modification of the programming of the step. The absence of important functional donor-site morbidity is probably bound to a compensation of the remaining triceps surae muscles and/or to mechanisms of adaptation. Our study confirms the little functional donor-site morbidity of the partial triceps surae muscle-flap procedure. These flaps remain a good solution for the coverage of the soft-tissue defects of the leg.