New Pancreatic Duct-Invagination Anastomosis Using UltrasonicDissection for Nonfibrotic Pancreas with a Nondilated Duct

Nonfibrotic pancreases with a nondilated duct are susceptible to pancreatic fistula or leakage following pancreaticoduodenectomy. We developed a novel pancreatic duct-invagination anastomosis using an ultrasonic dissector and applied this technique to 14 consecutive pancreaticoduodenectomies and 1 segmental pancreatectomy for otherwise normal pancreases. With the aid of an ultrasonic dissector, even branch pancreatic ducts were skeletonized, ligated securely, and divided during pancreatic transection. Moreover, the main duct was exposed (> 1 cm) easily by ultrasonic dissection and a small-caliber pancreatic tube was inserted into the duct on the stump. Subsequently, pancreatic duct invagination could be easily done through a 10 G intravenous catheter passed through the gastrointestinal tract. The main duct was anchored to the adjacent serosa, but any pancreatic parenchymal sutures, possibly leading to internal laceration and/or parenchymal ischemia particularly in soft nonfibrotic pancreases, were avoidable during the procedures. All the anastomoses were done within 10 minutes. Only 1 patient (6.7%)developed pancreatic fistula, which resolved spontaneously in 21 days postoperatively. Neither anastomotic leakage nor remnant pancreatitis was seen in this series. Although a prospective, randomized study is needed, this technique may contribute to reduced morbidity after pancreaticoduodenectomy for a nonfibrotic pancreas with a nondilated main duct.     

Randomized clinical trial of ultrasonic dissector or conventional division in distal pancreatectomy for non-fibrotic pancreas.

BACKGROUND: Resection of the non-fibrotic pancreas is prone to postoperative pancreatic fistula because of well preserved exocrine secretions and easily crushed soft parenchyma. The purpose of this study was to evaluate ultrasonic dissection for division of the non-fibrotic pancreas in distal pancreatectomy. METHODS: All pancreata included in this study were soft on direct palpation and their main ducts had no dilatation, at least proximally from the transection line. Fifty-eight patients with gastric cancer or pancreatic disease were randomly assigned to the two groups. In the ultrasonic dissection (UD) group (n = 27), all pancreatic ducts were identified and ligated securely. The stump was left open without parenchymal suturing. In the conventional (CV) group (n = 31), the pancreas was cut with a knife and the stump was oversewn in mattress fashion. The main pancreatic duct was ligated in all patients in both groups. Pancreatic fistula was defined as a pancreatic fluid discharge for more than 7 days after operation diagnosed according to amylase concentration in the drainage fluid. RESULTS: In the UD group, approximately 20-30 tubes including a mean(s.d.) 5.2(0.8) (range 4-6) pancreatic ducts were skeletonized and ligated per patient. There were nine pancreatic fistulas (16 per cent); one in the UD group and eight in the CV group (P = 0.020). CONCLUSION: In distal pancreatectomy for the non-fibrotic pancreas, ultrasonic dissection without suture closure of the stump reduced the incidence of pancreatic fistula compared with conventional division and suture, in this randomized trial.     

Magnetic resonance cholangiopancreatography for postoperative follow-up of intraductal papillary-mucinous tumors of the pancreas

BACKGROUND: After resection of an intraductal papillary-mucinous tumor (IPMT), benign tumors or portions of the resected tumor are sometimes left in place to avoid total pancreatectomy. We evaluated the role of magnetic resonance cholangiopancreatography (MRCP) in postoperative follow-up. METHODS: Twenty-two patients underwent MRCP 0.5 to 6.5 years after pancreatic resection for IPMT. RESULTS: Two patients with surgical margin involvement of the main pancreatic duct showed mildly enhanced ductal dilatation due to anastomotic stenosis. In 4 patients with residual IPMT of the branch ducts, postoperative MRCP demonstrated no changes. MRCP revealed new IPMT 1 year after surgery in 1 patient. No patients showed intraductal or intracystic mural nodules postoperatively. In 3 patients with postoperative pancreatitis or recurrent abdominal discomfort, MRCP demonstrated ductal dilatation and poor secretin-stimulated pancreatic secretion into the gastrointestinal tract, which suggested pancreatoenterostomic stenosis. CONCLUSIONS: MRCP is useful for postoperative follow-up of IPMT, in terms of investigating residual or recurrent IPMT and evaluating postpancreatectomy long-term complications.     

Local pancreatic resection with preoperative endoscopic transpapillary stenting

BACKGROUND: Pancreatic fistula, although not common, can cause serious complications after pancreatectomy. During local pancreatectomy, injury to the main pancreatic duct (in addition to the accessory and side branch ducts) increases the risk of pancreatic fistula formation. Nonetheless, local pancreatic resection maintains the advantage of preserving pancreatic parenchyma. METHODS: In this study, we reviewed the cases of 5 patients who underwent preoperative endoscopic transpapillary pancreatic stenting to help prevent refractory fistula development after local pancreatic resection. RESULTS: Stenting was successful in all 5 patients, and none developed a refractory grade C postoperative pancreatic fistula. CONCLUSIONS: These results suggest that in selected patients, preoperative endoscopic pancreatic stenting may be an effective prophylactic measure to lower the risk of refractory grade C fistula formation after local pancreatic resection.     

Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy.

OBJECTIVE: The authors used prolamine (Ethibloc, Ethicon GmBH, Norderstedt, Germany) for segmental obstruction of the pancreatic duct to prevent pancreatic fistula development after distal pancreatectomy combined with total gastrectomy for gastric malignancies. SUMMARY BACKGROUND DATA: Although the initial clinical application of prolamine was pancreatic duct obstruction for patients with pancreatitis and undergoing pancreatic transplantation and pancreaticoduodenectomy for pancreatic cancer, there are no reports on prevention of pancreatic fistula formation after distal pancreatectomy. METHODS: Prolamine (0.2 mL) was injected into the distal segment of the main duct in the remaining pancreata of 51 patients. Small pancreatic ducts on the cut surface, from which prolamine extravasates, were closed by ligation, the main duct was ligated doubly, and the transected pancreatic margin was closed 15 minutes after phenylpropanolamine hydrochloride injection. RESULTS: No patient developed a pancreatic fistula or the complication of arterial bleeding due to prolonged infection. CONCLUSION: Segmental obstruction of the pancreatic duct with prolamine is useful for preventing pancreatic fistula development after distal pancreatectomy.     

扩大胰十二指肠切除术

1.沿着自然的解剖间隙进行分离。2.所有大血管直接套线结扎,避免钳夹,以免形成假性动脉瘤,导致术后迟发性的大出血。3.横断胆总管后立即引流胆管,可避免胆汁进入手术野,让手术野清爽干净。4.切断胰颈前在胰腺上下缘各缝1针,将胰头端结扎,可减少切断胰颈时的出血。5.清扫范围:上至肝门,下至肠系膜下动脉起始部,右至右肾门,左至腹主动脉左侧缘。肠系膜上动脉要360°骨骼化。6.胰管空肠粘膜对粘膜吻合是最接近生理状态的吻合方式,容易操作,胰漏发生率也不高。     

The VIO soft-coagulation system can prevent pancreatic fistula following pancreatectomy

BACKGROUND/PURPOSE: The VIO soft-coagulation system (SC) is a new device for tissue coagulation. We hypothesized that this device would be an effective tool for sealing small pancreatic ducts, thus reducing pancreatic fistula following pancreatectomy. METHODS: To confirm whether the SC could be used to seal small pancreatic ducts, we measured the burst pressure in sealed ducts in mongrel dogs. Eight dogs underwent distal pancreatectomy, with the remnant stump coagulated by using the SC. The animals were necropsied on postoperative day 10. In a clinical trial, 11 patients who underwent pancreatoduodenectomy with SC treatment (SC group), and 24 patients who underwent pancreatoduodenectomy without SC treatment (non-SC group) were compared. RESULTS: In the experimental study, the burst-pressure test revealed that the SC had efficiently sealed the small pancreatic ducts. Histological examination revealed completely obstructed pancreatic ductal structures, ranging from large pancreatic ducts (diameter, 500 mum) to microscopic ducts. No pancreatic leakage was observed following distal pancreatectomy without main pancreatic duct (MPD) suturing in dogs that had an MPD diameter of less than 500 mum. In the clinical trial, pancreatic fistula developed in only one patient (9.1%) in the SC group, but a pancreatic fistula developed in five patients (20.8%) in the non-SC group. CONCLUSIONS: This novel technique using the SC is an effective procedure for preventing the development of pancreatic fistula following pancreatectomy.     

Ductal branch-oriented minimal pancreatectomy: Two cases of successful treatment

Two patients with intraductal papillary-mucinous adenoma of the pancreas were successfully treated by ductal branch-oriented minimal pancreatectomy. We propose this novel less invasive ductal branch-oriented pancreatectomy, as indicated for benign ductal ectasia of the pancreas. The cystically dilated branch duct is identified by intraoperative ultrasonography, intraoperative balloon pancreatography, and injection of indigocarmine into the cyst. The cystically dilated branch is resected from the surrounding pancreas together with minimal removal of the pancreatic parenchyma. The communicating duct and cutting margins are tightly ligated to prevent pancreatic juice leakage and fistula. A drainage tube is placed in the main pancreatic duct whenever possible. Histopathologic examination of the transected branch duct is necessary to check for mucosal extension of dysplastic epithelium. This ductal branch-oriented minimal pancreatectomy is the least invasive pancreatectomy and a suitable operation for branch-type ductal ectasia of the pancreas, which is usually benign. Received for publication on Jan. 5, 1998; accepted on April 3, 1998     

Pancreatic duct holder for facilitating duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy

Duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy may be technically difficult, particularly in cases in which the remnant pancreas is soft with a small main pancreatic duct. We devised a pancreatic duct holder for duct-to-mucosa pancreatojejunostomy. The holder has a cone-shaped tip. A one-third circle of the tip is cut away, which makes a slit. As the tip is inserted gently into the pancreatic duct, the duct can be adequately expanded. The holder provides a good surgical field for anastomosis. A slit of the tip allows needle insertion. The holder facilitates stitches of the jejunum also. Twelve patients underwent pancreatoduodenectomy, followed by duct-to-mucosa pancreatojejunostomy using the holder. The holder allowed 8 or more stitches in duct-to-mucosa anastomosis, even in patients with a small pancreatic duct. No patients developed prolonged pancreatic leakage or pancreatic fistula postoperatively. In conclusion, the pancreatic duct holder is a simple and useful tool for facilitating duct-to-mucosa pancreatojejunostomy.     

胆胰液分流预防胰十二指肠切除术后胰瘘的价值

目的：探讨胆胰液分流预防胰十二指肠切除术后胰瘘的价值。方法；对91例胰十二指肠切除术患胰、胆、胃消化直重建时分别采用改良Roux-en—Y吻合术、总胆管放置T型引流管和胰管内放置引流管3种胆胰液分流术治疗，同时用未行胆胰液分流术45例作对照。结果：胰十二指肠切除术后行胆胰液分流术91例的胰瘘发生率为2．2％(2／91)，未行胆胰液分流术45例的胰瘘发生率为15．5％(7／45)（P＝0.00065)。应用改Roux－en—Y吻合术6例，胰管内放置引流管26例，无1例出现胰瘘；总胆管放置T型引流管59例，2例出现胰瘘。结论：胆胰液分流是预防胰十二指肠切除术后胰瘘发生的重要环节。     

Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy: a prospective study.

OBJECTIVE: To compare morbidity and mortality rates of stented versus nonstented pancreaticojejunostomy after partial pancreatoduodenectomy. BACKGROUND DATA: Despite a marked reduction in the mortality rate after partial pancreatoduodenectomy in recent years, leakage of the pancreaticojejunostomy still occurs in 5% to 25% of patients and remains the major source of complications. METHODS: The authors compared the morbidity and mortality rates of 85 consecutive patients who had a partial pancreatoduodenectomy with (n = 44) or without (n = 41) temporary stented external drainage of the pancreatic duct between 1994 and 1997. RESULTS: A pancreatic fistula was diagnosed in 3 of the 44 patients (6.8%) with stents versus 12 of the 41 patients (29.3%) without stents. Surgical reintervention was necessary in 1 of the 3 patients with a pancreatic fistula in the stented group and 3 of the 12 patients with a pancreatic fistula in the nonstented group. There were two deaths after surgery, both in the nonstented group. The median hospital stay after surgery was 13 days in patients with stents and 29 days in patients without stents. CONCLUSION: In this nonrandomized prospective observational study, temporary external drainage of the pancreatic duct with a PVC tube significantly reduced the leakage rate of the pancreaticojejunostomy as well as the duration of hospital stay after partial pancreatoduodenectomy. Although promising, these observations require confirmation by further studies.     

保留脾和幽门的腹腔镜全胰十二指肠切除术1例报告

目的：探讨完全腹腔镜下保留脾和幽门的全胰十二指肠切除术的安全性与可行性。方法2013年1月,对1例胰腺多发囊腺瘤合并右肾细胞癌患者行腹腔镜下保留脾和幽门的全胰十二指肠切除联合右肾切除术。腹腔镜器械四孔入路,打开胃结肠韧带、游离胰腺下缘并显露肠系膜上静脉,应用超声刀、组织剪及吸引器锐性和钝性解剖相结合分离胰腺钩突与肠系膜上静脉,沿脾动静脉向左侧胰尾部游离并结扎其分支,解剖肝十二指肠韧带,切断胆总管,应用腔镜切割吻合器距幽门约5 cm处及胰头下缘2 cm处切割闭合十二指肠,将整个胰腺及部分十二指肠切除,消化道胆道重建采用Roux-en-Y吻合。游离右肾,闭合右肾动静脉及输尿管,切除后右肾与胰腺标本从脐下扩大切口取出。结果手术顺利完成,手术时间7．5 h,术中出血约1100 ml,术后无胆肠吻合口漏等并发症,术后15天出院,随访6个月,血糖控制在4～14 mmol/L,无肾肿瘤复发转移。结论腹腔镜下保留脾和幽门的全胰十二指肠切除术可行、安全,手术方法有待更多经验积累及随机临床论证。     

十字型胰胆引流管的应用研究

胰瘘和胆瘘是胰十二指肠切除术后最常见和最严重的并发症，为预防其发生，除吻合方法的不断改进外，胰液及胆汁的引流是预防胰、胆瘘的关键。为了合理引流胰液及胆汁，作者研制了一种十字型胰胆引流管，经临床应用１６例，效果满意，术后未发生胰瘘和胆瘘。作者认为，该管集胰液内、外引流管和胆总管Ｔ型引流管于一体，能起到合理引流胰液和胆汁，预防胰、胆瘘的作用，是一种简便、实用、有推广价值的新方法     

Intraductal papillary mucinous tumors of the pancreas confined to secondary ducts show less aggressive pathologic features as compared with those involving the main pancreatic duct

Intraductal papillary mucinous tumors (IPMTs) of the pancreas are rare tumors characterized by a malignant potential. Because of the progress of imaging procedures, smaller cystic pancreatic lesions are now detected and some of them correspond to IPMTs that involve ectatic pancreatic branch ducts but spare the main pancreatic duct. To investigate differences in morphology and clinical behavior of branch and main duct types of IPMT, a surgical series of 43 cases was studied. All pathologic specimens of IPMT, surgically resected in our institution between October 1987 and July 1998, were analyzed. In all cases, the entire pancreatic specimen was systematically examined. IPMT of the branch type was found in 13 (30%) patients, whereas IPMT of main pancreatic duct type that involved the main pancreatic duct and branch ducts was observed in 30 (70%) patients. Patients with IPMT of the branch type were younger (median age, 55 yrs vs 64 yrs), and all but one of the lesions were located in the head and neck of the pancreas (vs 17 of 30 patients with the main duct type). The size of the cysts ranged from 4 to 55 mm, and the major duct showed a mild dilation in most cases. In contrast to the main pancreatic duct type, which showed invasive carcinoma and in situ carcinoma in 11 (37%) of 30 patients and 6 (20%) of 30 patients, respectively, IPMT of the branch type showed significantly less aggressive histologic lesions with five (39%) patients with simple hyperplasia, six (46%) patients with atypical hyperplasia, and two (15%) patients with in situ carcinoma. No invasive carcinoma was observed in this group. IPMT of the branch type occurs in younger patients and is associated with less aggressive histologic features than is the main pancreatic duct type. Our findings raise the difficult issue of clinical management of IPMT of the branch type as a distinctive group.     

The role of magnetic resonance cholangiopancreatography (MRCP) after resection of the pancreas

Magnetic resonance cholangiopancreatography (MRCP) was performed in 35 patients to evaluate the feasibility of its use as a postsurgical imaging technique after resection of the pancreas. The surgical procedures performed were: pancreatoduodenectomy in 22 patients, segmental pancreatectomy in 1, distal pancreatectomy in 7, and pyroluspreserving pancreatoduodenectomy in 5. The pancreatic duct was shown in its entirety in 24 of the 35 patients (68.6%) and was partially visualized in 8 patients (22.9%), but the intrahepatic and extrahepatic bile ducts were visualized completely in all patients. Furthermore, MRCP was able to demonstrate lesions in 3 of 6 patients who had shown clinical evidence of recurrence. The visualization of the pancreatic and bile duct system was satisfactory despite anatomical changes brought about by resection of the pancreas. Thus, we conclude that MRCP is an appropriate follow-up screening test for patients with suspected abnormalities of the biliary and pancreatic duct system.     

胰十二指肠切除术后胰漏危险因素的Meta分析

目的 分析探讨国内胰十二指肠切除术后胰漏的危险因素,为临床有效降低术后并发症提供理论依据.方法 运用Meta分析方法对我国自1980年1月至2010年1月期间公开发表的有关胰十二指肠术后胰漏危险因素的16篇文献资料进行合并分析.结果 年龄、性别、有无糖尿病与胰漏发生无统计学意义(P＞0.05);术前黄疸水平大于171 ...     

Fusion variations of pancreatic ducts in patients with anomalous arrangement of pancreaticobiliary ductal system

Fusion variations of the pancreatic ducts were studied to elucidate the significance of such variations. We classified structural fusion anomalies of the main and accessory pancreatic ducts on endoscopic retrograde cholangio-pancreatography (ERCP) in 37 patients with anomalous arrangement of the pancreaticobiliary ductal system (AAPB). The fusion variations of the pancreatic ducts were classified into five types: common, ansa pancreatica, branch fusion, looped, and separated. These fusion variations, except for common type, were found in 68% of the 37 patients with AAPB on ERCP. Fusion variations of the pancreatic ducts were very frequent (93%) in the 30 patients with congenital cystic dilatation of the common bile duct (CCD). The branch confluence fashion, in which the terminal bile duct communicated with a pancreatic duct branch, was found only in patients with cystic dilatation cyst of the CCD, and it appeared that cystic dilatation cyst of CCD might differ from spindle or cylindrical cyst originating from embryonic formation of an anomalous confluence. It was also suggested that in patients with fusion variations of the pancreatic ducts, the flow of pancreatic juice might be disordered, leading to the development of acute pancreatitis or pancreatic dysfunction. Consequently, it appears to be necessary to carefully examine patients with AAPB for the presence or absence of any fusion variations of the pancreatic ducts and to observe such patients with long-term monitoring by ERCP, and computed temography, and with pancreatic function tests. Received for publication on Jan. 7, 1998; accepted on April 28, 1998     

Percutaneous transfistulous pancreatic duct drainage and interventional pancreatojejunostomy as a treatment option for intractable pancreatic fistula

We present 2 techniques for treatment of intractable pancreatic fistula: percutaneous transfistulous pancreatic duct drainage and interventional pancreatojejunostomy. Percutaneous transfistulous pancreatic duct drainage can be effective for intractable fistulas that communicate with the main pancreatic duct. Because drainage itself is not enough for a complete cure of this complication when it occurs in cases after pancreatoduodenectomy (PD), interventional pancreatojejunostomy is applicable.     

Duct-to-mucosa Pancreaticojejunostomy Reduces the Risk of Pancreatic Leakage after Pancreatoduodenectomy

The aim of this retrospective study was to analyze the risk factors for pancreatic anastomotic leakage after pancreatoduodenectomy (PD) and to determine whether duct-to-mucosa pancreaticojejunostomy is superior to the total external tube drainage technique. Between 1990 and 1999, 161 patients underwent PD with end-to-side pancreaticojejunostomy at our institution. Fourteen preoperative and ten intraoperative risk factors for pancreaticojejunal anastomotic leakage were analyzed. Pancreaticojejunal anastomotic leakage was identified in 11% (17/161) of the patients. No preoperative parameters were found to have a significant association with the risk of pancreatic leakage. Three intraoperative parameters were identified as significant by means of univariate analysis: anastomotic technique, pancreatic duct size and texture of the remnant pancreas. A duct-to-mucosa pancreaticojejunostomy with total external tube drainage (3% vs. 15%, p = 0.018). A pancreas without duct dilatation of soft pancreas was more likely to develop pancreatic leakage than one with duct dilatation or atrophy. A multivariate analysis revealed that only anastomotic technique turned out to be an independent risk factor (Odds ratio: 4.15, CI: 1.1-27.4). Sub-analysis of patients with soft pancreas and non-dilated pancreatic duct further supported the finding that the duct-to-mucosa pancreaticojejunostomy technique is safer for patients at high risk. Results indicate that the status of the remnant pancreas and the pancreaticojejunostomy technique are the substantial risk factors for pancreatic leakage after pancreatoduodenecomy. Duct-to-mucosa pancreaticojejunostomy might well be the procedure of choice.     

Focal changes of chronic pancreatitis and duct-arteriovenous relationships: avoiding a diagnostic pitfall

A prior study of pancreatic duct-arteriovenous relationships suggested that finding ducts near muscularized blood vessels without intervening pancreatic acini indicated adenocarcinoma was present. Because focal changes of chronic pancreatitis are often seen at autopsy, it seemed reasonable to use the autopsy to test the hypothesis that this finding might be nonspecific. An unselected, consecutive series of 81 adult decedent pancreases without known pancreas cancer was evaluated for the presence of ducts near muscularized blood vessels, for fibrosis and/or atrophy, for chronic inflammation, and for duct reduplication and/or proliferation. Autolysis precluded assessment of 26% of the cases. Of evaluable cases, 37% displayed ducts near muscularized blood vessels without intervening pancreatic acini, 23% chronic inflammation, 62% fibrosis and/or atrophy, and 55% duct reduplication and/or proliferation. The finding of ducts near muscularized blood vessels was closely associated with fibrosis and/or atrophy (odds ratio = 28.87, chi = 14.59, P = 0.0001), with duct reduplication and/or proliferation (odds ratio = 19.23, chi = 15.88, P = 0.0001), but not with chronic inflammation (odds ratio = 1.41, chi = 0.05, P > 0.30). Because changes of chronic pancreatitis are associated with ducts near muscularized blood vessels and because chronic pancreatitis can mimic pancreas cancer, care should be exercised when using the finding of ducts near muscularized blood vessels without intervening pancreatic acini as a criterion for the diagnosis of pancreas cancer.