Complications with Reconstruction Procedures in Pylorus-preserving Pancreaticoduodenectomy

This study was conducted retrospectively to examine the efficacy of Traverso reconstruction compared with Billroth I reconstruction after pylorus-preserving pancreaticoduodenectomy, in the prevention of several complications. Pylorus-preserving pancreaticoduodenectomy is an aggressive surgery, and insufficiency of the pancreaticoenterostomy plays an important role in the postoperative progression. However, reports examining the correlation between pancreatic fistula and the type of reconstruction after pylorus-preserving pancreaticoduodenectomy have been limited. Sixty-four patients who underwent pylorus-preserving pancreaticoduodenectomy (33 reconstructed by the Traverso technique and 31 reconstructed by the Billroth I technique) were entered into this study to investigate whether the complications were related to the type of reconstruction procedure employed. Insufficiency of the pancreaticojejunostomy, including major leakage and pancreatic fistula, occurred in 18.2% of the reconstructions by Billroth I and 0% of the reconstructions by Traverso (p < 0.05). In addition, jejunal obstruction by recurrent tumor in the remnant pancreas was observed in 3 patients reconstructed by Billroth I, and required palliative bypass surgery. Reconstruction by the Traverso procedure after pylorus-preserving pancreaticoduodenectomy is a safe surgical method and has an advantage for advanced pancreatic cancer, which has high risk of jejunal obstruction by recurrent tumor in the remnant pancreas.     

Binding pancreaticojejunostomy is a new technique to minimize leakage

Pancreaticoduodenectomy (Whipple procedure) has been the standard treatment for periampullary and pancreatic carcinoma. A leak or fistula from the pancreatic anastomosis is the leading cause of morbidity and mortality after pancreaticoduodenectomy. In order to effectively prevent the development of pancreatic fistulae, we designed a special technique called binding pancreaticojejunostomy, by which 3 cm of the serosa-muscular sheath of the jejunum was bound to the pancreatic remnant. We have performed this procedure in 105 consecutive patients; none of the cases developed pancreatic fistula. It is a safe, simple, and efficient technique.     

Thoracoscopic splanchnicectomy for pain control in irresectable pancreatic cancer

AIM: Disabling pain for many patients with irresectable pancreatic cancer is poorly managed and can remain a significant problem until death. The aim of this study was to evaluate the safety and efficacy of thoracoscopic splanchnicectomy for pain control in patients with irresectable pancreatic cancer. PATIENTS AND METHODS: Thirteen patients suffering from intractable pain due to irresectable pancreatic cancer underwent 15 attempted thoracoscopic splanchnicectomy procedures. All patients were opiate dependent. Right-sided splanchnicectomy was performed for a dominantly right-sided pain, whereas a centralized, bilateral, or left-sided pain was managed by left splanchnicectomy. If pain recurred, patients were offered to have the procedure repeated on the contralateral side. RESULTS: Thoracoscopic splanchnicectomy procedure was a technical failure because of pleural adhesions in 1 patient. Fourteen (10 left- and 4 right-sided) thoracoscopic splanchnicectomies were successfully completed in 12 patients. Immediate pain relief was achieved in all 12 patients after unilateral thoracoscopic splanchnicectomy. Pain relief persisted until death in 8 patients and until the latest postoperative follow-up visit at 5 months in 1 patient. Two patients required a contralateral procedure for pain recurrence. A 3rd patient had a recurrent pain but refused contralateral intervention. Except for the latter, none of the patients required opioids. CONCLUSION: Thoracoscopic splanchnicectomy is a safe, simple, and effective minimally invasive procedure. It offers a substantial relief of pain in patients with unresectable pancreatic cancer.     

机器人辅助胰腺手术：附33例报告

目的探讨机器人外科手术系统辅助胰腺手术的安全性、可行性。方法 2010年3月～2011年9月完成机器人辅助胰腺手术33例,其中胰十二指肠切除术11例,胰体尾切除术10例（其中5例保留脾脏）,胰腺中段切除术7例,Beger术4例,胰腺肿瘤切除术1例。结果 33例均在机器人辅助手术系统下完成手术,无中转开腹。11例胰十二指肠切除术手术时间（457.7±39.1）min,术中出血（667.3±271.6）ml,6例术中输血;7例胰腺中段切除术手术时间（215.7±55.9）min,术中出血（192.9±109.7）ml,无术中输血;10例胰体尾切除术手术时间（159.0±81.0）min,术中出血量中位数500 ml（50～1200 ml）,2例术中输血;4例Beger术手术时间（298.8±33.8）min,术中出血（425.0±236.3）ml,无术中输血;1例胰腺肿瘤切除术手术时间190 min,术中出血50 ml,无术中输血。33例术后住院（21.6±8.0）d。术后胰漏14例,吻合口出血3例,吻合口漏1例,除1例术后吻合口漏、1例吻合口出血者行二次手术治疗外,其余患者经保守治疗后顺利康复。术后病理：8例为恶性肿瘤,且切缘全部阴性;22例为良性肿瘤;3例为慢性胰腺炎。33例随访1～19个月,（13.5±5.7）月,1例导管腺癌术后6个月肿瘤复发,进行化疗,余7例恶性肿瘤未发现肿瘤复发转移,其余患者均恢复良好,随访至2012年1月无病人死亡。结论机器人辅助手术系统应用于胰腺外科是安全、可行的。     

Interventional pancreaticojejunostomy after pancreatoduodenectomy

Background Leakage from the pancreaticoenteric anastomosis after pancreatoduodenectomy (PD) is closely associated with intra-abdominal hemorrhage with ensuing high mortality. Methods Interventional pancreaticojejunostomy was performed in 10 patients with external drainage of pancreatic juice after two-staged PD or leakage from pancreaticojejunostomy after PD. The jejunum was punctured using a 22-gauge needle into the pancreatic fistula during endoscopic observation of the jejunal lumen, followed by the insertion of two 0.35-inch guide-wires into the jejunum and pancreatic fistula. Finally, a stenting tube was placed between the jejunum and pancreatic fistula. Results No severe complications developed. Oral intake was instituted the following day in 8 of 10 patients, and on the 7th day in the remaining two patients. Conclusion This interventional procedure is considered to be safe and easy to perform, and in the future, it may permit a reduction in the number of second laparotomies in pancreatic fistula.     

Urological complications after simultaneous renal and pancreatic transplantation.

OBJECTIVE: To report the urological complications after simultaneous renal and pancreatic transplantation. DESIGN: Retrospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 143 consecutive patients having simultaneous renal and pancreatic transplantation by one of three techniques. 33 segmental pancreas with duct occlusion, 77 whole pancreas with bladder diversion, and 33 enteric diversion with systemic (n = 26) or portal venous drainage (n = 7). Urological complications were related to the pancreatic transplant, to the renal transplant, or unrelated to the transplant. MAIN OUTCOME MEASURES: Morbidity. RESULTS: After occlusion of the duct and enteric diversion, there were no urological complications related to the pancreatic transplant. On the other hand, among the 77 patients with pancreatic drainage into the bladder, urological complications were common (56/77; 73%). Complications related to the renal transplant were recorded in 6/33 (18%), 26/77 (34%) and 12/33 (36%), respectively. Complications unrelated to the transplant occurred in 6/77 patients (8%) in the bladder drainage group. Five patients after bladder drainage required cystoenteric conversion. CONCLUSIONS: Enteric diversion is a safe alternative to bladder diversion and results in significantly fewer urological complications.     

Hand-Assisted Staging Laparoscopy for Suspected Malignancies of the Pancreas

Fewer than 20% of patients with pancreatic cancer have resectable tumours at the time of diagnosis. In two patients with a pancreas neoplasm a laparoscopic staging work-up was performed. Because of the described limitations of laparoscopy, we propose to switch to a hand-assisted procedure. In our opinion the benefits of hand-assisted laparo-scopic surgery, such as safe blunt digital dissection, restoration of tactile feedback and restored proprioception, account for greater accuracy in TNM staging and in the assessment of resectability of pancreatic cancer.     

Scintisplenoportography in assessing patency of distal splenorenal shunts

Scintisplenoportography was performed on 33 occasions in 28 cirrhotic patients who had bled from esophagogastric varices. In 17 cases scintisplenoportography was carried out after a retroperitoneal distal splenorenal shunt procedure and in the remaining 16 instances in patients without any surgical shunt. In four patients scintisplenoportography was performed before and after a surgical shunt procedure, and in one case, before and after the shunt thrombosed. Gammagraphic patterns and spleen-heart times helped determine which patients did not have a surgical shunt, which had a patent shunt, and which patients had a thrombosed shunt. A patent shunt pattern and a thrombosed shunt pattern have been defined. It is concluded that scintisplenoportography is a useful, reproducible, and safe method to assess the patency of distal splenorenal shunts.     

Pancreatic head resection with segmental duodenectomy for intraductal papillary mucinous tumors of the pancreas

Various modifications of organ-preserving pancreatic resections have been performed for intraductal papillary mucinous tumor (IPMT) of the pancreas. The aim of this study was to evaluate usefulness of pancreatic head resection with duodenal segmentectomy (PHRSD), which is one of the organpreserving pancreatic resections for IPMT. Pancreatic head resection with duodenal segmentectomy was indicated for the branch duct type of IPMT. Eight patients underwent PHRSD. The mean operative time was 390 minutes, and the mean blood loss was 1270 ml. Duodenal ischemia was prevented by preserving the duodenal branches of the gastroduodenal artery and the anterior inferior pancreaticoduodenal artery. Complications occurred in four patients: one with pancreatic leak, one with choledochoduodenal anastomotic stenosis, and two with delayed gastric emptying. However, no deaths occurred. The final pathologic diagnosis was adenoma in seven patients and carcinoma in situ in one patient. Six of eight patients had an adenoma with papillary growth in the main pancreatic duct. Postoperative pancreatic endocrine and exocrine functions were satisfactory. All patients were alive without recurrent disease at a median follow-up of 30 months. Pancreatic head resection with duodenal segmentectomy appears to be a useful procedure as an organ-preserving pancreatic resection for the branch duct type of IPMT, because this procedure allows a safe and complete resection of the pancreatic head without ischemia of the common bile duct and the duodenum.     

Hand-assisted staging laparoscopy for suspected malignancies of the pancreas

Fewer than 20% of patients with pancreatic cancer have resectable tumours at the time of diagnosis. In two patients with a pancreas neoplasm a laparoscopic staging work-up was performed. Because of the described limitations of laparoscopy, we propose to switch to a hand-assisted procedure. In our opinion the benefits of hand-assisted laparoscopic surgery, such as safe blunt digital dissection, restoration of tactile feedback and restored proprioception, account for greater accuracy in TNM staging and in the assessment of resectability of pancreatic cancer.     

Short-term clinical outcomes for 100 consecutive cases of laparoscopic pylorus-preserving pancreatoduodenectomy: improvement with surgical experience

Background

Few reports describe the use of laparoscopic pylorus-preserving pancreaticoduodenectomy (LPPPD) in centers with experience using this technique. In addition, the clinical outcomes of this procedure remain undetermined.

Methods

In the current study, 100 patients with benign or malignant lesions in the pancreatic head underwent LPPPD between May 2007 and December 2011. The overall clinical outcomes and changes in these outcomes during the surgeon learning period were analyzed to assess the feasibility and safety of this procedure.

Results

Pathologic examination of the pancreas confirmed intraductal papillary mucinous neoplasms in 37 patients, solid pseudopapillary tumors in 17 patients, neuroendocrine tumors in 15 patients, serous cystic neoplasms in seven patients, pancreatic ductal adenocarcinomas in seven patients, ampulla of Vater tumors and duodenal gastrointestinal stromal tumors in five patients, and other disease in seven patients. The median operative time was 7.9 h, which decreased with accumulating experience of the surgeon using this procedure, from 9.8 h for the first 33 cases to 6.6 h for the last 34 cases. Complications developed in 25 % of the patients, including six cases (6 %) with significant pancreatic fistula [International Study Group on Pancreatic Fistula (ISGPF) grade B]. The complication rate decreased from 33.3 % for the first 33 cases to 17.6 % for the last 34 cases. The mean hospital stay was 14 days, which also decreased from 20.4 days for the first 33 cases to 11.5 days for the last 34 cases. For the 12 patients in the study cohort with invasive malignant disease, the median tumor size was 2.8 cm, and the median number of lymph nodes harvested was 13. All the patients had margin-negative R0 resections.

Conclusion

The LPPPD procedure is technically safe and feasible, with an acceptable rate of morbidity and other clinical outcomes for benign and malignant diseases. Clinical outcomes can be improved once a learning curve has been overcome.     

Sequential Pancreaticoduodenectomy after Living Donor Liver Transplantation for Cholagiocacinoma

Liver transplantation (LT) for patients with primary sclerosing cholangitis (PSC) is often contraindicated due to concomitant occurrence of cholangiocarcinoma (CC). Cases of simultaneous pancreaticoduodenectomy (PD) with LT have been sporadically reported; however, the applicability of such an invasive procedure to patients with CC has not been validated. We report here a case of sequential PD performed 44 days after a successful living donor liver transplantation (LDLT) using a left lobe graft. Although a clear pancreatic juice leakage through the drain persisted for days after surgery, the patient recovered from the complication and was discharged 32 days after the procedure. Currently, 1 year after LDLT, the patient is doing well with no evidence of recurrence. In conclusion, a sequential PD following LDLT is a safe and feasible option to treat CC complicating PSC. Long‐term follow‐up and accumulation of cases are necessary to evaluate the effectiveness of this procedure for this complicated disease.     

Are major laparoscopic pancreatic resections worthwhile? A prospective study of 32 patients in a single institution

BACKGROUND: Laparoscopic surgery has been used increasingly as a less invasive alternative to conventional open surgery. Recently, laparoscopic therapy for pancreatic diseases has made significant strides. The current investigation studied pancreatic resection by laparoscopy. The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic pancreatic major resection for benign and malignant lesions of the pancreas. METHODS: A prospective study of laparoscopic pancreatic resections was undertaken in patients with benign and malignant lesions of the pancreas. Over an 8-year period, 32 patients underwent laparoscopic pancreatic major resection: 21 left pancreatectomies (1 performed using a retroperitoneal approach), and 11 pancreatoduodenectomies (10 Whipple procedures and 1 total pancreatectomy). All the operations were performed in a single institution. RESULTS: The operations were performed without serious complications. Only one left pancreatectomy was converted to laparotomy because of massive splenic bleeding, and one Whipple procedure was converted because of adhesion to the portal vein. In four of the Whipple operations, the resection was performed completely laparoscopically, and the reconstruction was done via a small midline incision. There was no operative mortality. In 16 patients of the left pancreatectomy group, the spleen was preserved. The mean blood loss was 150 and 162 ml; and the mean operating time was 154 and 284 min, respectively, for the left pancreatectomy and the Whipple procedure. Postoperative complications occurred for five patients after left pancreatectomy and for three patients after the Whipple procedure. Two patients needed surgical reexploration after left pancreatectomy because of intraperitoneal haemorrhage and eventration of the extraction site. Two patients underwent reoperation after the Whipple procedure: one because of intraabdominal bleeding and the other because of small bowel obstruction.The mean hospital stay was 10.8 days after left the pancreatectomy and 13.6 days after the whipple procedure. CONCLUSION: Laparoscopic left pancreatectomy for benign and malignant lesions is feasible, safe, and beneficial. We believe that pancreatoduodenectomy should be performed only in selected cases and by a highly skilled laparoscopic surgeon. If there is any doubt, an open resection should be performed.     

Laparoscopic cholecystectomy after pancreatic debridement

Background: Pacreatic debridement is a lifesaving operation in patients with severe acute pancreatitis and pancreatic or peripancreatic necrosis. Even in the presence of gallstones, cholecystectomy may be avoided during the procedure, but definitive treatment of the stones is needed at a later stage. Methods: Five patients (median age 58 years) underwent laparoscopic cholecystectomy, at a median time interval of 15 months, after pancreatic debridement via a dome-shaped upper abdominal incision for severe acute pancreatitis. The use of alternative methods for primary access, additional cannulae to enable division of adhesions, the harmonic scalpel, and the fundus first technique made the laparoscopic approach possible and safe. Results: The median operating time was 130 min. Four patients were discharged home the first or second postoperative day. One patient required a ``mini-laparotomy'' for drainage of a periumbilical hematoma and was discharged on the 13th day. Conclusions: Laparoscopic cholecystectomy can be considered an effective and safe approach for the treatment of gallstones in patients who have undergone pancreatic debridement.     

Palliation of pancreatic cancer using electrolytic ablation

Background: Inoperable pancreatic cancer has a dismal prognosis. Palliation involves either stenting or surgical bypass. Stenting does not relieve gastric outlet obstruction, and surgical bypass is a major procedure. A minimally invasive procedure is needed that relieves both gastric outlet and biliary obstruction, with the potential for relieving pain. Methods: In an experimental model, pancreatic electrolysis was investigated. The pancreatic duct was cannulated via a transduodenal approach with an electrode catheter. In 6 animals an electrolytic "lesion" was created using a direct current generator. Six animals were controls. The local and systemic effects of electrolysis were assessed using histological and biochemical parameters. Results: The pancreatic duct was cannulated in all animals and treatment was uneventful. Electrolytic lesions comprised a central area of necrosis with a sharp demarcation between necrotic and viable pancreas. All animals developed transient hyperamylasemia after electrolysis. There was no significant difference between treatment and controls. Importantly, no animal had clinical, biochemical, or histological evidence of pancreatitis. Conclusions: This experimental study suggested that electrolytic palliation of inoperable pancreatic cancer via the gastrointestinal tract is potentially safe. In patients, this treatment could be performed during endoscopic retrograde cholangiopancreatography and may have therapeutic advantages when compared to stenting or biliary bypass.     

Outcome of laparoscopic pancreatic surgery: endocrine and nonendocrine tumors

Laparoscopic pancreatic surgery (LapPS) for management of benign pancreatic tumors has still not been defined. This paper evaluates the feasibility and outcome of LapPS in patients with endocrine pancreatic tumors (EPTs) and cystic neoplasms of the pancreas (CyNP). Eighteen patients with benign pancreatic tumors underwent LapPS between January 1998 and May 2001. The indications were 10 EPTs (6 sporadic insulinomas, 1 multiple insulinoma of multiple endocrine neoplasia type 1, 2 nonfunctioning tumors, 1 VIPoma) and 8 CyNPs (3 serous cystadenomas, 5 mucinous cystic neoplasms). The laparoscopic procedure was performed using four ports with patients in the half-lateral position. Laparoscopic ultrasonography (LapUS) was used in all cases. Laparoscopic enucleation (LapE) was planned in five patients and performed in four (one conversion for tumor not found during laparoscopy). Laparoscopic pancreatic resection (LapPR) with spleen salvage was planned in 13 patients and performed in 12 (one conversion for metastatic VIPoma), with splenic vessel preservation in 11 patients and short gastric vessel preservation in 1. The average operating time was 3.5 hours after enucleation, 4.0 hours after distal pancreatectomy, and 5.0 hours after subtotal pancreatectomy. Pancreatic fistula was observed in two patients after LapE and in three patients after LapPR. Splenectomy for splenic abscess was performed 1 week after surgery in a patient with short gastric vessel splenic preservation. The average hospital stay was 5 days. We concluded that LapPS is a safe method for removing EPTs and CyNPs, although the incidence of pancreatic fistulas remains high. In selected patients LapPS offers significant benefit to patients: reduced trauma to the abdominal wall, short hospital stay, and a quick postoperative recovery.     

Rescue ERCP and insertion of a small-caliber pancreatic stent to prevent the evolution of severe post-ERCP pancreatitis: a case-controlled series

Introduction  Recently prophylactic placement of a trans-sphincteric pancreatic stent has successfully been applied to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Rescue ERCP and emergency application of small-caliber pancreatic stents during the early course of post-ERCP pancreatitis as a possible endoscopic therapy has not been reported yet. Methods  All patients who underwent ERCP were hospitalized for at least 24 h, with routine laboratory testing of amylase levels. Out of 1,225 ERCPs, evolution of severe post-ERCP pancreatitis was anticipated in six consecutive patients, based on severe pancreatic pain attack, more than tenfold elevation of serum amylase levels at 8 and 24 h, and moderate rise of white blood cell (WBC) and C-reactive protein (CRP) levels. Rescue ERCP and emergency application of small-caliber (4-5F, 4-cm, Geenen stent) pancreatic stents were successfully performed in all patients within 8–20 h after the initial ERCP. Results  Moderate to severe papillary oedema was observed in all patients during the rescue ERCP. Pancreatic pain was promptly reduced after the rescue pancreatic drainage procedure and completely diminished within 24 h after pancreatic stenting. Serum amylase levels were exponentially reduced and normalized within 72 h in all patients; no pancreatic necrosis or any other late complications were observed. Pancreatic stents could be safely removed a few days later. Conclusion  Rescue pancreatic stenting with small-caliber prophylactic pancreatic stents seems to be a safe and effective procedure that might be feasible to stop the evolution of severe post-ERCP pancreatitis, but prospective controlled studies are clearly demanded to support this innovative approach.     

Pancreatic head resection with segmental duodenectomy: safety and long-term results

OBJECTIVE: To evaluate the usefulness and long-term results with pancreatic head resection with segmental duodenectomy (PHRSD; Nakao's technique) in patients with branch-duct type intraductal papillary mucinous neoplasms (IPMNs). A prospective study from Nagoya (Japan) and Barcelona (Spain). SUMMARY BACKGROUND DATA: Surgery should be the first choice of treatment of IPMNs. An aggressive surgery (eg, pancreatoduodenectomy) should be questioned in patients with an indolent disease or with noninvasive tumors. Recently, organ-preserving pancreatic resections for benign and noninvasive IPMN located in the head of the pancreas have been described. We have PHRSD in which the pancreatic head can be completely resected and the major portion of the duodenum can be preserved by this procedure. There have been only 4 reports concerning PHRSD with <8 patients (each one) in the English literature. METHODS: Thirty-five patients underwent PHRSD (20 men, 15 women), mean age 65.1 +/- 9.0 (range, 55-75). Mean maximal diameter of the cystic lesion was 26.4 +/- 5.3 mm (range, 20-33 mm) and mean diameter of the main pancreatic duct was 3.3 +/- 0.5 mm (range, 3.0-4.0 mm). Alimentary tract reconstruction was performed in 20 patients by pancreatogastrostomy, duodenoduodenostomy, and choledochoduodenostomy (type A) and 15 patients by pancreaticojejunostomy, duodenoduodenostomy and choledochojejunostomy (Roux-en-Y; type B). Surgical parameters, postoperative complications, endocrine function, exocrine function, and long-term outcomes were evaluated. To compare the perioperative factors, a matched-pairs analysis between PHRSD patients and patients with pylorus preserving pancreaticoduodenectomy (PPPD) was performed. In the latter group were included 32 patients with branch-duct type of IPMN operated during the same time period that patients with PHRSD. The mean follow-up period was 48.8 months. RESULTS: Mean operative time after PHRSD was 365 +/- 50 and mean surgical blood loss was 615 +/- 251 mL. There was no mortality. Pancreatic fistula occurred in 10% and 13% with types (alimentary tract reconstruction) A and B, respectively. Noninvasive IPMN was found in 31 patients and invasive IPMN in 4 patients (11.4%). In the matched-pairs analysis between PHRSD and PPPD, the 2 procedures were comparable in regard to operation time and intraoperative blood loss. The overall incidence of pancreatic fistula was higher after PPPD than after PHRSD; the difference was not statistically significant. When fistulas occurred after PHRSD they were grade A (biochemical). In contrast, pancreatic fistulas after PPPD were grade A in 78% of cases and grade B in 22% (clinically relevant fistula). The incidence of delayed gastric emptying was significantly higher in the PPPD group compared with the PHRSD group (P < 0.01). Endocrine pancreatic function, measured by fasting blood glucose levels and HbA1, levels was unchanged in 94.28% of patients, in the PHRSD group, and in 87.87% in the PPPD group. Body weight was unchanged in 80% after PHRSD and in 59% after PPPD. Postoperative enzyme substitution was needed in 20% of patients after PHRSD and in 40% patients after PPPD. The 5-year survival rate was 100% in patients with benign IPMN and 42% in patients with invasive IPMN. CONCLUSION: PHRSD is a safe and reasonable technique appropriate for selected patients with branch-duct IPMN. The major advantages of PHRSD are promising long-term results in terms of pancreatic function (exocrine and endocrine) with important consequences in elderly patients. Long-term outcome was satisfactory without tumor recurrence in noninvasive carcinoma. PHRSD should therefore be considered as an adequate operation as an organ-preserving pancreatic resection for branch-duct type of IPMN located at the head of the pancreas.     

Antrectomy with gastrojejunostomy for unresectable pancreatic cancer-causing duodenal obstruction

The traditional approach to gastric outlet obstruction caused by unresectable pancreatic cancer is gastrojejunostomy performed during or after biliary bypass surgery. Previous work showed that gastrojejunostomy failed in 95% of patients with preoperative outlet obstruction, which was evidenced by nausea and vomiting. This study defines a better bypass procedure, namely, antrectomy with gastrojejunostomy, which was performed in 19 such patients. The cancer was primary pancreatic in 17 patients and metastatic to the pancreas in two patients with a renal and urinary bladder primary. All patients had duodenal extension with impaired alimentation. Fourteen patients underwent simultaneous biliary bypass surgery and antrectomy with gastrojejunostomy; the antrectomy with gastrojejunostomy procedure was performed in five patients 3 weeks to 6 months after biliary bypass surgery when duodenal obstruction supervened. Visible cancer extended to the duodenal stump in five patients, including two patients whose partial closure was buttressed with omentum. All 19 patients tolerated regular diet at the time of discharge 1 to 4 weeks after the antrectomy with gastrojejunostomy procedure. All patients, who died at 4 to 21 months after surgery tolerated solid food until immediately before death. All nine surviving patients have taken solid foods 9 to 29 months since the antrectomy with gastrojejunostomy procedure. We conclude that the antrectomy with gastrojejunostomy procedure, whether performed simultaneously with or subsequently to biliary bypass surgery, is the best palliative procedure for duodenal obstruction in patients with unresectable pancreatic cancer.     

Triple-layer duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy

BACKGROUND: Pancreaticoduodenectomy is associated with a high degree of morbidity; the main cause is failure of the pancreatic anastomosis. It is imperative that this is performed safely and is secure. Pancreatic leaks will lead to serious morbidity and even mortality. Here we describe the use of a new surgical triple-layer pancreaticojejunostomy in a group of patients with minimal morbidity. METHODS: This is a retrospective review from a prospective database. Fifty-one consecutive patients underwent a pancreaticoduodenectomy (either pylorus-preserving (PPPD) or classical Whipple's) from May 1999 to December 2005 and had the pancreaticojejunostomy reconstructed as described below. RESULTS: The mean age of the 51 patients was 56.71 +/- 9.0 years; 32 (62.7%) were female and 19 (37.3%) were males. The mean operating time was 368.55 +/- 57.94 min; the average blood loss was 396 +/- 236 ml with 15 patients (29.4%) requiring postoperative blood transfusions. The mean pancreatic duct size was 4.94 +/- 2.6 mm. In terms of pancreatic texture, there were 33 (64.7%) hard pancreas and 18 (35.3%) soft pancreas. PPPD was performed on 28 (54.9%) and the classical Whipple's procedure on 23 (45.1%). Twelve patients had postoperative complications; only 1 patient had a pancreatic fistula which was treated conservatively. CONCLUSION: This method is safe and reliable. It can be used for a myriad of pancreas remnants with a wide range of pancreatic duct sizes.