An easier method for performing a pancreaticojejunostomy for the soft pancreas using a fast-absorbable suture

AIM： To clarify the usefulness of a new method for performing a pancreaticojejunostomy by using a fast-absorbable suture material irradiated polyglactin 910, and a temporary stent tube for a narrow pancreatic duct with a soft pancreatic texture.METHODS： Among 63 consecutive patients with soft pancreas undergoing a pancreaticoduodenectomy from 2003 to 2006, 35 patients were treated with a new reconstructive method. Briefly, after the pancreatic transaction, a stent tube was inserted into the lumen of the pancreatic duct and ligated with it by a fast-absorbable suture. Another tip of the stent tube was introduced into the intestinal lumen at the jejunal limb, where a purse-string suture was made by another fast-absorbable suture to roughly fix the tube. The pancreaticojejunostomy was completed by ligating two fast-absorbable sutures to approximate the ductal end and the jejunal mucosa, and by adding a rough anastomosis between the pancreatic parenchyma and the seromuscular layer of the jejunum. The initial surgical results with this method were retrospectively compared with those of the 28 patients treated with conventional duct-to-mucosa anastomosis.RESULTS： The incidences of postoperative morbidity including pancreatic fistula were comparable between the two groups （new; 3%-17% vs conventional; 7%-14% according to the definitions）. There was no mortality and re-admission. Late complications were also rarely seen.CONCLUSION： A pancreaticojejunostomy using an irradiated polyglactin 910 suture material and a temporary stent is easy to perform and is feasible even in cases with a narrow pancreatic duct and a normal soft pancreas.     

Conservative resection for benign tumors of the proximal pancreas

AIM： To evaluate the safety and long-term prognosis of conservative resection （CR） for benign or borderline tumor of the proximal pancreas.
METHODS： We retrospectively analyzed 20 patients who underwent CR at the Second Affiliated Hospital of Zhejiang University School of Medicine between April 2000 and October 2008. For pancreaticojejunostomy, a modified invagination method, continuous circular invaginated pancreaticojejunostomy （CCI-PJ） was used. Modified continuous closed lavage （MCCL） was performed for patients with pancreatic fistula.
RESULTS： The indications were： serous cystadenomas in eight patients, insulinomas in six, non-functional islet cell tumors in three and solid pseudopapillary tumors in three. Perioperative mortality was zero and morbidity was 25%. Overall, pancreatic fistula was present in 25% of patients. At a mean follow up of 42.7 mo, all patients were alive with no recurrence and no new-onset diabetes mellitus or exocrine dysfunction.
CONCLUSION： CR is a safe and effective procedure for patients with benign tumors in the proximal pancreas, with careful CCI-PJ and postoperative MCCL.     

Strategies for pancreatic anastomosis after pancreaticoduodenectomy:What really matters?

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 Pub Med 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.     

A new pancreaticojejunostomy technique: A battle against postoperative pancreatic fistula

AIM:To present a new technique of end-to-side, ductto-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and insertion of a silicone stent. METHODS:We present an end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and the insertion of a silicone stent. This technique was performed in thirty-two consecutive patients who underwent a pancreaticoduodenectomy procedure by the same surgical team, from January 2005 to March 2011. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity. RESULTS:There were 32 patients who underwent end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation. Thirteen of them were women and 19 were men. These data correspond to 40.6% and 59.4%, respectively. The mean age was 64.2 years, ranging from 55 to 82 years. The mean operative time was 310.2 ± 40.0 min, and was defined as the time period from the intubation up to the extubation of the patient. Also, the mean time needed to perform the pancreaticojejunostomy was 22.7 min, ranging from 18 to 25 min. Postoperatively, one patient developed a low output pancreatic fistula, three patients developed surgical site infection, and one patient developed pneumonia. The rate of overall morbidity was 15.6%. There was no 30-d postoperative mortality. CONCLUSION:This modification appears to be a significantly safe approach to the pancreaticojejunostomy without adversely affecting operative time.     

Pancreatic carcinoma coexisting with chronic pancreatitis versus tumor-forming pancreatitis： Diagnostic utility of the time-signal intensity curve from dynamic contrast-enhanced MR imaging

AIM： To evaluate the ability of the time-signal intensity curve （TIC） of the pancreas obtained from dynamic contrast-enhanced magnetic resonance imaging （MRI） for differentiation of focal pancreatic masses, especially pancreatic carcinoma coexisting with chronic pancreatitis and tumor-forming pancreatitis.
METHODS： Forty-eight consecutive patients who underwent surgery for a focal pancreatic mass, including pancreatic ductal carcinoma （n = 33）, tumor-forming pancreatitis （n = 8）, and islet cell tumor （n = 7）, were reviewed. Five pancreatic carcinomas coexisted with longstanding chronic pancreatitis. The pancreatic TICs were obtained from the pancreatic mass and the pancreatic parenchyma both proximal and distal to the mass lesion in each patient, prior to surgery, and were classified into 4 types according to the time to a peak： 25 s and 1, 2, and 3 min after the bolus injection of contrast material, namely, type-Ⅰ, Ⅱ, Ⅲ, and Ⅳ, respectively, and were then compared to the corresponding histological pancreatic conditions.
RESULTS： Pancreatic carcinomas demonstrated type-Ⅲ （n = 13） or Ⅳ （n = 20） TIC. Tumor-forming pancreatitis showed type-Ⅱ （n = 5） or Ⅲ （n = 3） TIC. All islet cell tumors revealed type-Ⅰ. The type-Ⅳ TIC was only recognized in pancreatic carcinoma, and the TIC of carcinoma always depicted the slowest rise to a peak among the 3 pancreatic TICs measured in each patient, even in patients with chronic pancreatitis.CONCLUSION： Pancreatic TIC from dynamic MRI provides reliable information for distinguishing pancreatic carcinoma from other pancreatic masses, and may enable us to avoid unnecessary pancreatic surgery and delays in making a correct diagnosis of pancreatic carcinoma, especially, in patients with longstanding chronic pancreatitis.     

Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy

BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence. AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula. METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and longterm follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031;and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration. CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.     

An end-to-side suspender pancreaticojejunostomy: A new invagination pancreaticojejunostomy

Background: Postoperative pancreatic fistula(POPF) is a severe complication of the pancreaticoduodenectomy(PD). Recently, we introduced a method of suspender pancreaticojejunostomy(PJ) to the PD. In this study, we retrospectively analyzed various risk factors for complications after PD. We also introduced and assessed the suspender PJ to demonstrate its advantages.Methods: Data from 335 patients with various periampullary lesions, who underwent the Whipple procedure(classic Whipple procedure or pylorus-preserving) PD by either traditional end-to-side invagination PJ or suspender PJ, were analyzed. The correlation between either perioperative or postoperative complications and corresponding PD approaches was evaluated by univariate analysis.Results: A total of 147 patients received the traditional end-to-side invagination PJ, and 188 patients were given the suspender PJ. Overall, 51.9% patients had various complications after PD. The mortality rate was 2.4%. The POPF incidence in patients who received the suspender PJ was 5.3%, which was significantly lower than those who received the traditional end-to-side invagination PJ(18.4%)(P 0.001).Univariate analysis showed that PJ approach and the pancreas texture were significantly associated with the POPF incidence rate(P 0.01). POPF was a risk factor for both postoperative abdominal cavity infection(OR = 8.34, 95% CI: 3.99–17.42, P 0.001) and abdominal cavity hemorrhage(OR = 4.86, 95% CI:1.92–12.33, P = 0.001).Conclusions: Our study showed that the impact of the pancreas texture was a major risk factor for pancreatic leakage after a PD. The suspender PJ can be easily accomplished and widely applied and can effectively decrease the impact of the pancreas texture on pancreatic fistula after a PD and leads to a lower POPF incidence rate.     

Pancreatic fistula after pancreatectomy： Evolving definitions, preventive strategies and modern management

Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a demanding procedure and whereas mortality after a pancreaticoduodenectomy is currently 〈 3%-5% in experienced high-volume centers, post-operative morbidity is considerable, about 30%-50%. At present, the single most significant cause of morbidity and mortality after pancreatectomy is the development of pancreatic leakage and fistula （PF）. The occurrence of a PF increases the length of hospital stay and the cost of treatment, requires additional investigations and procedures, and can result in life-threatening complications. There is no universally accepted definition of PF that would allow standardized reporting and proper comparison of outcomes between different centers. However, early recognition of a PF and prompt institution of appropriate treatment is critical to the prevention of potentially devastating consequences. The present article, reviews the evolution of post resection pancreatic fistula as a concept, and discusses evolving definitions, the current preventive strategies and the management of this problem.     

Pancreatic guidewire placement for achieving selective biliary cannulation during endoscopic retrograde cholangio-pancreatography

AIM： To investigate the frequency and risk factors for acute pancreatitis after pancreatic guidewire placement （P-GW） in achieving cannulation of the bile duct during endoscopic retrograde cholangio-pancreatography （ERCP）.
METHODS： P-GW was performed in 113 patients in whom cannulation of the bile duct was difficult. The success rate of biliary cannulation, the frequency and risk factors of post-ERCP pancreatitis, and the frequency of spontaneous migration of the pancreatic duct stent were investigated.
RESULTS： Selective biliary cannulation with P-GW was achieved in 73% of the patients. Post-ERCP pancreatitis occurred in 12% （14 patients： mild, 13; moderate, 1）. Prophylactic pancreatic stenting was attempted in 59% of the patients. Of the 64 patients who successfully underwent stent placement, three developed mild pancreatitis （4.7%）. Of the 49 patients without stent placement, 11 developed pancreatitis （22%： mild, 10; moderate, 1）. Of the five patients in whom stent placement was unsuccessful, two developed mild pancreatitis. Univariate and multivariate analyses revealed no pancreatic stenting to be the only significant risk factor for pancreatitis. Spontaneous migration of the stent was observed within two weeks in 92% of the patients who had undergone pancreatic duct stenting.
CONCLUSION： P-GW is useful for achieving selective biliary cannulation, Pancreatic duct stenting after P-GW can reduce the incidence of post-ERCP pancreatitis, which requires evaluation by means of prospective randomized controlled trials,     

Helicobacter species ribosomal DNA in the pancreas, stomach and duodenum of pancreatic cancer patients

AIM: To determine whether gastric and enteric Helicobacter species are associated with pancreatic cancer. METHODS: Patients with exocrine pancreatic cancer (n = 40), neuroendocrine cancer (n=14), multiple endocrine neoplasia type 1 {n = 8), and chronic pancreatitis (n = 5) were studied. Other benign pancreatic diseases (n = 10) and specimens of normal pancreas (n=7) were included as controls. Pancreatic tissue specimens were analyzed by He/icobacter-specific PCR-assay and products were characterized by denaturing gradient electrophoresis and DNA-sequencing. From a subset of the pancreatic cancer patients, gastric and/or duodenal tissue as well as gallbladder and ductus choledochus tissue were analyzed. Gallbladder and choledochus samples were included as controls. Stomach and duodenum samples were investigated to analyze whether a gastric helicobacter might disseminate to the pancreas in pancreatic cancer patients. Pancreatic specimens were analyzed by Bacteroides-specific PCR for detecting the translocation of indigenous gut microbes to the diseased pancreas. RESULTS: Helicobacter DNA was detected in pancreas (tumor and/or surrounding tissue) of 75% of patients with exocrine cancer, 57% of patients with neuroendocrine cancer, 38% of patients with multiple endocrine neoplasia, and 60% of patients with chronic pancreatitis. All samples from other benign pancreatic diseases and normal pancreas were negative. Thirty-three percent of the patients were helicobacter-positive in gastroduodenal specimens. Surprisingly, H. bilis was identified in 60% of the positive gastro-duodenal samples. All gallbladder and ductus cho-ledochus specimens were negative for helicobacter. Bacteroides PCR-assay was negative for all pancreatic samples. CONCLUSION: Helicobacter DNA commonly detected in pancreatic cancer suggests a possible role of the emerging pathogens in the development of chronic pancreatitis and pancreatic cancer.     

Risk factors of pancreatic leakage after pancreaticoduodenectomy

AIM: To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage. METHODS: Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage. RESULTS: Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) developed postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical significance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P = 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy. CONCLUSION: Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.     

Pancreaticojejunostomy without stent (with video)

There is a high risk of anastomotic leakage following pancreaticojejunostomy after pancreaticoduodenectomy or middle pancreatectomy in patients with a normal soft pancreas because of the abundant exocrine function. Therefore, pancreaticojejunostomy is generally performed using a stent tube (stented method). However, pancreaticojejunostomy with a certain duct-to-mucosa anastomosis does not always require a stent tube even in patients with a normal soft pancreas. We have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stent tube (nonstented method) and obtained good results. The objective of this technique is to maintain adequate patency of the anastomosis using a fine atraumatic needle and monofilament suture. The pancreas, including the pancreatic duct, is sharply transected with a scalpel. Any arterial bleeding points on the pancreatic cut end are repaired with fine nonabsorbable sutures. The end-to-side anastomosis between the pancreas and jejunum consists of two layers of sutures. The outer layer is composed of the capsular parenchyma of the pancreas and the jejunal seromuscularis, and the inner layer is composed of the pancreatic duct with an adequate pancreatic parenchyma and the whole jejunal wall. Complete pancreaticojejunostomy using duct-to-mucosa anastomosis does not require a stent tube. This nonstented method can be considered one of the basic procedures for pancreaticojejunostomy because of its safety and reliability.     

Pancreaticogastrostomy: a pancreas-transfixing method with duct-to-mucosa anastomosis (with video)

Pancreatic fistula still remains a persistent problem after pancreaticoduodenectomy. We have devised a pancreas-transfixing suture method of pancreaticogastrostomy with duct-to-mucosa anastomosis. This technique is simple and reduces the risk of pancreatic leakage by decreasing the risk of suture injury of the pancreas and by embedding the transected stump into the wall of the stomach. This novel technique of pancreaticogastrostomy is an effective reconstructive procedure following pancreaticoduodenectomy, especially for patients with a soft and fragile pancreas.     

A new technique for pancreaticogastrostomy for the soft pancreas: the transfixing suture method

Background/Purpose

Pancreatic anastomotic leakage remains a persistent problem after pancreaticoduodenectomy (PD). The presence of soft, nonfibrotic pancreatic tissue is one of the most important risk factors for pancreatic leakage. Accordingly, we devised a pancreas-transfixing suture method for pancreaticogastrostomies in patients with a soft, nonfibrotic pancreatic remnant.

Methods

The pancreas-transfixing method was applied in 103 consecutive patients after either standard PD (49 patients) or pylorus-preserving pancreaticoduodenectomy (PPPD) (54 patients) for malignant or benign disease. Of these 103 patients, 65 had a soft, nonfibrotic pancreatic remnant. For the pancreaticogastrostomy technique, an ultrasonically activated scalpel was used for transecting the pancreas. The inner layer involves a duct-to-mucosa anastomosis with an internal stent and the outer layer involves a single row of pancreas-transfixing sutures between the pancreatic remnant and the posterior gastric wall.

Results

Operative mortality was zero and morbidity was 22%. Only two patients (2%) developed pancreatic leaks; both resolved nonoperatively with the continuation of closed drainage.

Conclusions

This technique is simple and appears to reduce the risk of pancreatic leakage, possibly by decreasing the risk of suture injury of the pancreas and by embedding the transected stump into the wall of the stomach. This novel pancreaticogastrostomy technique is an effective reconstructive procedure, especially for patients with a soft, nonfibrotic pancreas.     

Effect of a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis in pancreaticoduodenectomy: a single surgeon's experiences

BACKGROUND/AIMS: The aim of the present study is to ascertain the effect of a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis in pancreaticoduodenectomy through a single surgeon's experiences. METHODOLOGY: From March 1, 2002 to March 31, 2005, among 512 patients who had pancreaticoduodenectomy at Asan Medical Center, 56 patients who had a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis were selected consecutively for prospective study. RESULTS: There were 44 pylorus-preserving pancreaticoduodenectomy, 10 pancreaticoduodenectomy, 2 hepatopancreaticoduodenectomy. No pancreatic leakage was reported. All three wound infections recovered after conservative treatment, and a gastric ulcer bleeding was resolved by suture-ligation through laparotomy. There was no mortality after surgery. CONCLUSIONS: Although it is a report with low surgical volume, a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis in pancreaticoduodenectomy is thought to be a good method to prevent the complications of pancreatic leakage using a tight close attachment of pancreas and jejunum.     

Stented pancreaticojejunostomy (with video)

Background/purpose

Using a standardized technique for pancreaticojejunostomy that we term ??pair-watch suturing technique??, we prospectively analyzed the effects of a pancreatic stent tube for preventing pancreatic fistula and furthermore evaluated which perioperative factors had an influence on the development of pancreatic fistula.

Operative procedure

Before anastomosis, we imagine the faces of a pair of wristwatches on the jejunal hole and pancreatic duct. The first stitch was put between 9?o??clock on the pancreatic side and 3?o??clock on the jejunal side, and a total of 7 stitches were put in the posterior wall, followed by 5 stitches in the anterior wall. Using this technique, twelve stitches can be sutured in the first layer anastomosis regardless of the caliber of the pancreatic duct.

Patients and methods

From March 2007 to April 2009, 55 consecutive patients who underwent the pair-watch suturing technique were divided into two groups: stent (n?=?28) and no-stent (n?=?27). The incidence rate of pancreatic fistula was statistically analyzed. From March 2007 to March 2011, 102 consecutive patients were retrospectively divided into two groups according to the International Study Group on Pancreatic Fistula criteria: postoperative pancreatic fistula (POPF) and non-POPF.

Results

Perioperative factors were almost the same between the stent and no-stent groups, and the incidence of pancreatic fistula was very similar: 10.7% in the stent group and 14.8% in the no-stent group. Additionally, all patients who developed pancreatic fistula belonged to grade A. Among 102 patients, 15 (14.7%) were identified as having pancreatic fistula: 9 (8.8%) in grade A, 5 (4.9%) in grade B, and 1 (0.9%) in grade C. Comparing the POPF and non-POPF groups, we could not detect any significant risk factors for the development of pancreatic fistula.

Conclusion

We consider that the pair-watch suturing technique is less susceptible to any factors, providing reliable anastomosis for any size of pancreatic duct and any texture of remnant pancreas.     

Risk factors for postoperative pancreatic fistula after pancreaticoduodenectomy: the significance of the ratio of the main pancreatic duct to the pancreas body as a predictor of leakage

Objective

Postoperative pancreatic fistula (POPF) is a severe and frequent complication after pancreaticoduodenectomy (PD). The aim of this study was to identify an independent predictor of POPF and to assess the efficacy of preoperative multidetector row computed tomography (MDCT) images as an indicator for POPF.

Methods

A total of 122 patients who underwent PD with an end-to-side, duct-to-mucosa pancreaticojejunostomy between January 2005 and May 2009 were retrospectively reviewed. The diameter of the main pancreatic duct (MPD), the diameter of the short axis of the pancreas body, and the ratio of the MPD to the pancreas body (MPD index) were digitally measured based on the curved reformatted images of preoperative MDCT.

Results

Postoperative pancreatic fistula occurred in 33 patients (27%). The operative mortality rate was 3.3% (4 patients). All four patients had grade C POPF. Three died because of hemorrhage from a pseudoaneurysm of the gastroduodenal artery stump, and one died because of sepsis due to major leakage from the pancreaticojejunostomy. In a multivariate analysis, the intraoperative blood loss (/100 ml) [odds ratio (OR), 1.1; 95% confidence interval (CI), 1.05–1.17] and MPD index (<0.2) (OR 50; 95% CI 6–41) proved to be independent predictors of POPF. In patients with an MPD index of <0.2, the incidence of POPF was 45%, and the mortality rate was 7.5%.

Conclusion

The MPD index obtained from preoperative MDCT can be a reliable predictor of POPF after PD.     

Prospective randomized pilot trial comparing closed suction drainage and gravity drainage of the pancreatic duct in pancreaticojejunostomy

Background

Pancreaticojejunal anastomotic leakage remains a major complication after pancreatoduodenectomy, and various means of preventing pancreatic leakage have been studied over the past few decades. The purpose of this study was to determine whether closed suction drainage provided a better option than gravity drainage in pancreaticojejunostomy.

Methods

Between 2004 and 2006, a total of 110 patients who underwent pancreaticojejunostomy at our institute were enrolled in this prospective randomized pilot study. Fifty-five patients were allocated to the closed suction drainage (CD) group and 55 to the gravity drainage (GD) group. In each patient a polyethylene pediatric feeding tube was inserted into the remnant pancreatic duct across a duct-to-mucosa type pancreaticojejunostomy and totally externalized. The tube was then connected to the aspiration bag of a Jackson–Pratt drain to generate negative pressure or to a bile bag for natural drainage. Pancreatic fistulas were defined and graded as A, B, or C according to the international study group for pancreatic fistulas (ISGPF) criteria.

Results

No differences were found between the GD and CD groups in age, sex distribution, or diagnosis. A pancreatic fistula occurred in 24 patients (43.6%) in the GD group and in 14 (25.5%) in the CD group (P = 0.045). In the GD group, grade B and C fistula occurred in 6 patients (10.9%), whereas in the CD group, this occurred in 5 patients (9.1%).

Conclusion

In this study, temporary external drainage of the pancreatic duct with closed suction drainage significantly reduced the incidence of grade A pancreatic fistula. A follow-up randomized prospective multicenter study has been initiated.     

Pancreaticojejunostomy after pancreaticoduodenectomy: Suture material and incidence of post-operative pancreatic fistula

PurposePancreatic fistula represents the most important complication in terms of clinical management and costs after pancreaticoduodenectomy. A lot of studies have investigated several techniques in order to reduce pancreatic fistula, but data on the effect of sutures material on pancreatic fistula are not available. The analysis investigated the role of suture material in influencing pancreatic fistula rate and severity.MethodsResults from 130 consecutive pancreaticoduodenectomy with pancreaticojejunostomy performed between March 2013 and September 2014 were prospectively collected and analyzed. In 65 cases pancreaticojejunostomy was performed with absorbable sutures, in the other 65 cases using non-absorbable sutures (polyester, silk and polybutester).ResultsPancreaticojejunostomy with non-absorbable sutures had the same incidence of pancreatic fistula, but less severe and with less episodes of post-operative bleeding if compared with absorbable sutures. A sub-analysis was carried out comparing polydioxanone with polyester: the latter was associated with a lower pancreatic fistula rate (11.9% vs. 31.7%; p = 0,01) and less severe pancreatic anastomosis dehiscence (grade C - 0% vs. 30%; p = 0.05). Univariate and multivariate analysis confirmed that hard pancreatic texture, pancreatic ductal adenocarcinoma at final histology and the use of polyester for pancreaticojejunostomy were associated with a lower pancreatic fistula rate (p < 0.05).ConclusionFurther studies are needed to investigate the effects of pancreatic juice and bile on different sutures and pancreatic tissue response to different materials. However, pancreaticojejunostomy performed with polyester sutures is safe and feasible and is associated to a lower incidence of pancreatic fistula with less severe clinical impact.