Techniques for prevention of pancreatic leak after pancreatectomy

Pancreatic resections are some of the most technically challenging operations performed by surgeons, and post-operative pancreatic fistula (POPF) are not uncommon, developing in approximately 13% of pancreaticoduodenectomies and 30% of distal pancreatectomies. Multiple trials of various operative techniques in the creation of the pancreatic ductal anastomosis have been conducted throughout the years, and herein we review the literature and outcomes data regarding these techniques, although no one technique of pancreatic ductal anastomosis has been shown to be superior in decreasing rate of POPF. Similarly, we review the literature regarding techniques of pancreatic closure after distal pancreatectomy. Again, no one technique has been shown to be superior in preventing POPF; however the use of buttressing material on the pancreatic staple line in the future may be a successful means of decreasing POPF. We review adjunctive techniques to decrease POPF such as pancreatic ductal stenting, the use of various topical biologic glues, and the use of somatostatin analogue medications. We conclude that future trials will need to be conducted to find optimal techniques to decrease POPF, and meticulous attention to intra-operative details and post-operative care by surgeons is necessary to prevent POPF and optimally care for patients undergoing pancreatic resection.     

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.     

Pancreatic fistula after left pancreatectomy. Frequency and severity

In order to study the frequency and complications related to pancreatic fistula following distal pancreatectomy we have reviewed 19 patients operated on between January 1st 1981 and February 28 1986. There was no mortality but the incidence of pancreatic fistula was 52%. 40% of these cases developed a subphrenic abscess (21% of the total number of cases). These fistulas closed after an average post-operative period of 42 days. Reoperation for an infected collection was required in 4 cases. The incidence of pancreatic fistula was not related to the initial pancreatic pathology. Splenectomy did not influence the incidence of subphrenic abscess. Different techniques of closure of the distal pancreas after resection have not changed the incidence of this complication. The use of somatostatin appears to favourably influence the course of the fistula. These conclusions tend to confirm the results of other reported series.     

生物膜包裹残端预防胰腺远端切除术后胰漏的实验研究

目的 探讨猪胰腺远端切除后牛心包生物膜包裹残端对术后胰漏的预防作用,评价该材料在胰腺手术中应用的安全性及可行性.方法 小型猪32只随机分成对照组(n=16)与实验组(n=16),2组均接受胰腺远端切除手术,对照组远端胰腺切除后采用传统的单纯手工缝合法,实验组则先用牛心包生物膜包裹住胰腺残端,用同样缝线穿过被裹住的胰腺组织后手工缝合;测定各组术后每日腹腔引流量及引流液淀粉酶水平至术后第10天,判断胰漏情况;术后3周处死动物,观察腹内情况并取残端胰腺组织作病理学检查.结果 实验组胰漏率低于对照组(6.2％比46.7％,P＜0.05),术后引流量实验组低于对照组(25.1 ml比54.2 ml,P＜0.01),术后3周剖腹探查,两组实验动物未见明显差异;胰腺残端组织病理结果两组均显示炎症细胞浸润并伴有少许坏死组织. 结论 胰腺远端切除术后,利用牛心包生物膜包裹残端后缝合可有效减少术后胰漏的发生,是安全可行的.     

胰腺切除术后胰瘘的研究进展

胰腺切除术是治疗胰头及壶腹周围良恶性肿瘤的常规术式.虽然胰腺切除技术要求高、难度大,然而在大的、专业的治疗中心,胰十二指肠切除术术后病死率已降至3%以F,不过术后并发症发病率仍高达50%.胰瘘一直是最常见、最严重的并发症.胰瘘不仅延长住院时间,增加治疗费用,而日往往需要进一步临床干预,甚至危及生命.尽管胰瘘的早期发现和迅速及时合理的治疗是防止其产生严重后果的关键,然而目前还没有统一的胰瘘定义,这非常不利于文献报道的标准化和对不同中心研究结果的客观比较评价.本文就胰瘘定义的演变和胰瘘预防策略作一综述.     

Pancreatic duct ligation reduces lung injury following trauma and hemorrhagic shock

OBJECTIVE: To determine whether pancreatic digestive enzymes released into the ischemic gut during an episode of T/HS are involved in the generation of distant organ injury. This hypothesis was tested by examining the effect of PDL on T/HS-induced intestinal injury, lung injury, and RBC deformability. SUMMARY BACKGROUND DATA: The effect of pancreatic duct ligation (PDL) on distant organ injury following trauma/hemorrhagic shock (T/HS) was examined. PDL before T/HS decreases lung and red blood cell (RBC) injury and exerts a limited protective effect on the gut. Pancreatic proteases in the ischemic gut appear to be involved in gut-induced lung and RBC injury. Based on recent work, it appears that proinflammatory and/or toxic factors, which are generated by the ischemic intestine, play an important role in the pathogenesis of multiple organ failure. The process by which these toxic factors are generated remains unknown. Previous experimental work has clearly documented that intraluminal inhibition of pancreatic proteases decreases the degree of T/HS-induced lung injury and neutrophil activation. One possible explanation for this observation is that the toxic factors present in intestinal lymph are byproducts of interactions between pancreatic proteases and the ischemic gut. METHODS: Male Sprague-Dawley rats were subjected to a laparotomy (trauma) and 90 minutes of sham (T/SS) or T/HS with or without PDL. At 3 and 24 hours following resuscitation, animals were killed and samples of gut, lung, and blood were collected for analysis. Lung permeability, pulmonary myeloperoxidase levels, and bronchoalveolar fluid protein content were used to quantitate lung injury. Intestinal injury was determined by histologic analysis of terminal ileum (% villi injured). To assess RBC injury, RBC deformability was measured, as the RBC elongation index (RBC-EI), using a LORCA device. RESULTS: At 3 and 24 hours following resuscitation, PDL prevented shock-induced increases in lung permeability to both Evans blue dye and protein in addition to preventing an increase in pulmonary myeloperoxidase levels. T/HS-induced impairments in RBC deformability were significantly reduced at both time points in the PDL + T/HS group, but deformability did not return to T/SS levels. PDL did reduce the magnitude of ileal injury at 3 hours after T/HS, but the protective effect was lost at 24 hours after T/HS. CONCLUSIONS: PDL prior to T/HS decreases lung injury and improves RBC deformability but exerts a limited protective effect on the gut. Thus, the presence of pancreatic digestive enzymes in the ischemic gut appears to be involved in gut-induced lung and RBC injury.     

胰管栓塞预防胰十二指肠切除术后胰瘘的作用分析

目的 探讨胰十二指肠切除术(PD)采取胰管栓塞的方法,以达到预防胰瘘的目的。方法 PD术中从胰管断端插管注入“TH”粘胶栓塞胰管,消化道重建按Child术式进行。结果 在PD术中共行胰管栓塞12例,均未发生胰瘘。结论 胰管栓塞可有效地预防PD术后胰瘘,尤适用于基层医院。     

胰体尾切除术后并发胰瘘的防治

目的 探讨胰体尾切除术后胰瘘的预防及治疗措施.方法 回顾性分析2000-2009年124例胰体尾部切除病例,包括胰腺恶性肿瘤86例,胰腺假性囊肿及良性肿瘤12例,胃肠肿瘤侵犯胰体尾18例,慢性胰腺炎合并胰体尾囊肿3例,外伤5例.以单纯间断褥式缝合(A组)处理胰腺残端63例;以改良的主胰管缝扎+间断褥式交锁缝合(B组)处理胰腺残端61例.所有患者均放置负压引流,术后均常规应用生长抑素.结果 A组63例中22例术后发生胰瘘,发生率为34.9％,其中高流量胰瘘10例,低流量胰瘘12例;B组61例中9例术后发生胰瘘,发生率为14.7％,无高流量胰瘘.两组胰瘘患者中,A组住院天数明显延长(P＜0.01),术后医疗费用明显增加(P＜0.01).结论 主胰管缝扎+间断褥式交锁缝合的手术方法可减少术后胰瘘的发生,有助于减少住院天数及术后医疗费用.     

Pancreatic fistula after left pancreatectomy. Risk factors analysis on 68 patients

AIM: The aim of this study was to identify risk factors related to pancreatic fistula after left pancreatectomy, considering the difference between the use of mechanical suture and the manual suture to close the pancreatic stump. METHODS: Sixty-eight patients, undergoing left pancreatectomy, were included in this study during a 10-year period. Eight possible risk factors related to pancreatic fistula were examined, such as demographic data (age and sex), pathology (pancreatic and extrapancreatic), technical characteristics (stump closure, concomitant splenectomy, additional procedures), texture of pancreatic parenchyma, octreotide therapy. RESULTS: Fourty-one patients (60%) underwent left pancreatectomy for primary pancreatic disease and 27 (40%) for extrapancreatic malignancy. Postoperative mortality and morbidity rates were 1.5% and 35%, respectively. Fourteen patients (20%) developed pancreatic fistula: 4 of them were classified as Grade A, 9 as Grade B and only one as Grade C. Three factors have been significantly associated to the incidence of pancreatic fistula: none prophylactic octreotide therapy, spleen preserving and soft pancreatic texture. It's still unclear the influence of pancreatic stump closure (stapler vs hand closure) in the onset of pancreatic fistula. CONCLUSION: In this study the incidence of pancreatic fistula after left pancreatectomy has been 20%. This rate is lower for patients with fibrotic pancreatic tissue, concomitant splenectomy and postoperative prophylactic octreotide therapy.     

Pancreatic regeneration after partial pancreatectomy.

The ability of the pancreas to regenerate and the effects of trophic hormones on regeneration of the pancreas after partial pancreatectomy are not completely understood. We investigated the effects of the trypsin inhibitor FOY-305 (an agent that stimulates endogenous cholecystokinin) on pancreatic regeneration after partial pancreatectomy in rats. FOY-305 or water was administered for either 13 days or 27 days by gavage feeding, after sham operation or partial pancreatectomy (n = 6 to 8 animals per group). FOY-305 stimulated hypertrophy of the pancreatic remnant at 13 days; prolonged treatment for 27 days produced both hypertrophy and hyperplasia. The magnitude of pancreatic growth after FOY-305 administration was significantly greater at 27 days in the pancreatic remnant than growth of the equivalent pancreatic segment (duodenal and parabiliary) in sham-operated rats treated with FOY-305. Our results suggest that endogenous cholecystokinin released by FOY-305 stimulates regeneration after partial pancreatectomy. The pancreatic remnant is more sensitive to trophic stimulation in comparison to the normal pancreas. FOY-305 may be a useful agent in the treatment of pancreatic insufficiency after extensive subtotal pancreatectomy or chronic pancreatitis.     

Cystic duct directly joining the main pancreatic duct

A unique anomaly of the direct union between the cystic duct and the main pancreatic duct is presented. A 19-year-old man with a history of repeated epigastralgia underwent endoscopic retrograde cholangiopancreaticography that showed a direct union between the cystic duct and the main pancreatic duct. No pancreaticobiliary maljunction was noticed. Cholecystectomy accompanied by resection of the long cystic duct was performed. The excised gallbladder showed cholesterolosis, chronic cholecystitis, and hyperplasia of the pseudopyloric glands microscopically. The patient has been well for 3 years since surgery.     

Predictive factors for pancreatic fistula following pancreatectomy

Background

Postoperative pancreatic fistula is a significant contributor to morbidity following proximal and distal pancreatic resections. In recent decades, the incidence of fistula has ranged from 2 to 33 %; however, the consistent identification of risk factors has been difficult due to significant variability in the definition of pancreatic fistula.

Purpose

The purpose of this study was to use the highest level evidence available in the literature to present risk factors thus far identified as significant predictors of fistula occurrence. Another endpoint will address those risk factors which have been shown to have a clinical impact on the patient. This review will conclude by discussing comprehensive risk models that interpret the aggregate fistula risk for a patient based on the presence of weighted risk factors.

Conclusion

The contemporary surgical literature suggests many risk factors for fistula development, which can be categorized as either endogenous, operative, or perioperative. The advent of the International Study Group of Pancreatic Fistula (ISGPF) scheme created universal definitions for fistula that delineate between biochemical and clinically relevant fistulas. This classification system has allowed for the elucidation of risk factors for clinically impactful fistula and enabled the development of risk scores for predicting fistula occurrence after major pancreatic resections, which are useful in clinical management and comparative research.     

胰管结石与并发胰腺癌

目的 提高胰管结石及合并胰腺癌的诊治水平。方法 报告1979－2000年间43例胰管结石其中8例合并胰癌的临床资料。结果 病因学以性胰腺炎及蛋白质－热卡－营养不良性胰腺炎（热带性胰腺炎）为主，主要症状是腹痛、腰背痛、内外分泌功能障碍，结合BUS，CT，ERCP等影像学诊断依据，如果近期症状加重－－严重腰背痛，出现黄疸，BUS，CT有胰占位，血CEA升高，应考虑癌变。结论 胰管空肠侧侧吻合是首选治疗，如胰头结石取不净，伴有黄疸或术后疼痛消除不明显，可加行胰头切除，癌变者则行胰十二指肠切除或胰体尾部切除术。     

Cystic duct leak after laparoscopic cholecystectomy

Background: Cystic duct leak is a rare complication of laparoscopic surgery. To study the incidence, presentation, and management of cystic duct leak (CDL) after laparoscopic cholecystectomy (LC) a retrospective study of centers doing large numbers of LC was done. Methods: Patient information was obtained by a questionnaire sent to experienced laparoscopic surgeons. This queried demographic information, course of the original operation, presentation, diagnostic studies, and management of CDL after LC. Results: Some 22,165 LCs were performed by 24 surgeons; there were 58 cases of CDL (0.26%); 21% of the surgeons reported no CDLs; 60% of CDLs occurred in the first 25% of each surgeon's experience, but CDLs continue to occur even in their most recent 10% of cases. Preoperative symptoms, prior surgery, and comorbid conditions did not predict CDL. Acute cholecystitis was present at initial surgery in 47%. Symptoms of CDL an average of 3.1 days post-LC were abdominal pain 78%, fever 26%, nausea 35%, vomiting 22%, abdominal distention 26%, and shoulder pain 12%. WBCs and LFTs were elevated in more than two-thirds of the cases. ERCP was most frequently used to diagnose CDL (53%) and was successful in 97%, although sonogram (40%) and HIDA scan (26%) and CT (26%) were also used. Management included ERCP and ductal decompression in 27 patients, percutaneous drainage in 13 patients, open laparotomy in 14, laparoscopy in three, and observation in two. Patients were discharged an average of 7.4 days post discovery of leak. Stents were removed an average of 30 days post ERCP. Ninety-four percent were complete cures. There was one post-treatment abscess. Two deaths due to multisystem failure unrelated to leak occurred. Conclusions: Cystic duct leak is rare and fairly easily diagnosed. It occurs more frequently during the learning curve, but also after much experience. ERCP and ductal decompression play a large role in treatment, but almost all standard methods of treatment yield successful outcomes with low morbidity.