Roux-en-Y reconstruction using staplers during pancreaticoduodenectomy: Results of a prospective preliminary study

Purpose  The aim of this study was to reveal the utility of alimentary reconstruction using staplers during pancreaticoduodenectomy (PD), focusing on the occurrence of delayed gastric emptying. Methods  Between 2003 and 2007, 72 PDs with alimentary reconstruction were performed by a single surgeon. Since August 2006, the new Roux-en-Y reconstruction methods using staplers were applied in 26 of the patients. We compared their clinical outcomes with those of the 46 patients who underwent PD using the conventional hand-sewn reconstruction methods. Results  The results of upper gastrointestinal study showed improvement within 10 postoperative days (PODs; P = 0.03): the patients resumed eating their regular diet sooner (13 vs 6 days, P < 0.001), and both the incidence of delayed gastric emptying (43% vs 19%, P = 0.04) and the hospital stay (27 vs 21 days, P = 0.008) were reduced significantly in patients with stapled reconstruction. Despite the fact that operative costs were significantly higher for patients with stapled reconstruction (P = 0.009), hospital costs were significantly lower (P = 0.049) for those who underwent the conventional method. Conclusions  Our retrospective analysis shows that stapled reconstructions might reduce the incidence of delayed gastric emptying; however, further study will be necessary to evaluate the utility of this new method.     

Impact of internal biliary drainage after pancreaticoduodenectomy

Background  Bile acid has an important role in protecting immune systems related to gut-associated lymphoid tissue. This study was designed to evaluate the effects of internal biliary drainage after a pancreaticoduodenectomy (PD) on postoperative nutrition and complications in a randomized study. Methods  The authors compared the morbidity, mortality, and postoperative nutritional status of 46 patients who had a hepaticojejunostomy (HJ) with a stented external biliary drainage (group E) or with a non-stented internal biliary drainage (group I) after a PD. Results  Systemic infection was recognized in four patients in group E, while no patients in group I. Transthyretin at postoperative 28 days in group I was 15.6 ± 6.2, higher than that in group E. Retinol-binding protein at postoperative 28 days in group I was 2.6 ± 1.0 and also higher than that in group E. Conclusion  HJ with no-stented internal biliary drainage was not associated with systemic infections and mortality, but showed the possibility of improving nutritional status.     

胰管空肠连续吻合联合肠腔外引流预防胰十二指肠切除术后胰瘘

目的 对胰十二指肠切除术的胰肠吻合缝合技术和置管引流方法进行改进,以防止胰瘘的发生.方法 对2004年6月至2007年9月138例胰十二指肠切除术患者的胰肠吻合采用降落伞式胰管空肠连续吻合和吻合口下方肠腔减压外引流的临床资料进行回顾性分析.结果 降落伞式胰管空肠连续吻合时间平均11min,手术时间明显缩短,全部病例均未出现胰肠吻合口漏,术中出血平均353±61ml,平均住院日19.2d.6例患者出现肺部感染,3例上消化道出血考虑为应激性溃疡,2例患者出现胃排空障碍,均保守治疗痊愈,无手术死亡.结论 降落伞式胰管空肠连续吻合和吻合口局部肠腔减压外引流,操作简便、省时、并发症少,是胰肠吻合术的一种有效改进.     

彭氏胰胃吻合术-Ⅰ型与Ⅱ型的比较（兼论Ⅲ型和Ⅳ型）

目的：介绍并比较4种类型捆绑式胰胃吻合术（binding pancreaticogastrostomy,BPG）,探讨其临床应用价值。方法：2008年5月至2009年5月,共施行Ⅰ型BPG21例,均行胰十二指肠切除术;施行Ⅱ型BPG26例．除2例胰腺颈部肿瘤行胰腺中段切除外,其余均行胰十二指肠切除术。这两型在操作中均切开胃前壁或胃残端（该切口可用作胃肠吻合口）,将胰腺残端拉入胃腔后进行捆绑吻合。在此期间,同时设计了Ⅲ型BPG和Ⅳ型BPG,两者均避免切开胃前壁或胃残端,在胃后壁处进行胰胃捆绑吻合。结果：全组手术均顺利完成;其中Ⅰ型BPG术后2例出现少量胸腔积液,1例胃排空障碍,2例胆漏;Ⅱ型BPG术后1例出现腹水,2例胃排空障碍,1例腹腔出血;上述病人均经保守治疗而痊愈;2组均未出现胰胃吻合口漏,无死亡病例。结论：BPG具有胆胰分道、胰腺吻合口处于胃液平面以上有利于愈合、无论胰腺残端大小均可实施等诸多特点;4种类型BPG各具优势,但均可有效避免胰漏的发生,显著提高了胰腺手术的安全性。     

A Reduction in Delayed Gastric Emptying by Classic Pancreaticoduodenectomy with an Antecolic Gastrojejunal Anastomosis and a Retrogastric Omental Patch

Background  Delayed gastric emptying (DGE) continues to be a major cause of morbidity following pancreaticoduodenectomy (PD). A change in the method of reconstruction following PD was instituted in an attempt to reduce the incidence DGE. Methods  Patients undergoing PD from January 2002 to December 2008 were reviewed and outcomes determined. Pylorus-preserving pancreaticoduodenectomy (PPPD) with a retrocolic duodenojejunal anastomosis (n = 79) or a classic PD with a retrocolic gastrojejunostomy (n = 36) was performed prior to January 2008. Thereafter, a classic PD with an antecolic gastrojejunal anastomosis and placement of a retrogastric vascular omental patch was undertaken (n = 36). Results  A statistically significant decrease in DGE was noted in the antecolic group compared to the entire retrocolic group (14% vs 40%; p = 0.004) and compared to patients treated by classic PD with a retrocolic anastomosis alone (14% vs 39%; p = 0.016). On multivariate analysis, the only modifiable factor associated with reduced DGE was the antecolic technique with an omental patch, odds ratio (OR) 0.3 (confidence interval (CI) 0.1–0.8) p = 0.022. Male gender was associated with an increased risk of DGE with OR 2.3 (CI 1.1–4.8) p = 0.026. Conclusion  A classic PD combined with an antecolic anastomosis and retrogastric vascular omental patch results in a significant reduction in DGE.     

Reduced Postoperative Pancreatic Fistula Rate After Pancreatogastrostomy Versus Pancreaticojejunostomy

Introduction  Metaanalysis of retrospective studies employing various definitions of pancreatic fistulas demonstrated a reduced postoperative pancreatic fistula rate after pancreatogastrostomy versus pancreaticojejunostomy. Prospective trials failed to do so, which causes an ongoing debate on the superiority of one or the other procedure. The aim of this study was to compare the two types of anastomosis at our institution with regard to postoperative pancreatic fistula and other complications. Materials and Methods  From 2001 to 2007, 114 pancreatogastrostomies and 115 pancreaticojejunostomies were performed. For retrospective analysis, the ISGPS definitions were employed. Primary endpoint was the occurrence of postoperative pancreatic fistula grade B or C. Secondary endpoints were postpancreatectomy hemorrhage, delayed gastric emptying, intraabdominal fluid collection, reoperation, and mortality. Operative time, intensive care unit stay, and overall hospital stay were also compared. Results  With pancreatogastrostomy, there were significantly less postoperative pancreatic fistulae grade B and C (pancreatogastrostomy (PG) versus pancreaticojejunostomy (PJ), 11.4% versus 22.6%, p = 0.03), more intraluminal hemorrhage (PG versus PJ, 10.5% versus 0%, p < 0.001) and more delayed gastric emptying grade B and C (PG versus PJ, 18.3% versus 7.9%, p = 0.03). Operative time was shorter (PG versus PJ, median 420 versus 450 min, p < 0.01), and intensive care unit stay was longer (PG versus PJ, median 4 days versus 5 days, p < 0.01), with a tendency toward reduced overall hospital stay (PG versus PJ, median 17 versus 19 days, p = 0.08). Conclusion  Surgeons should be aware of a higher rate of delayed gastric emptying and perform meticulous hemostasis to prevent intraluminal bleeding with pancreatogastrostomy. Pancreatogastrostomy is superior to pancreaticojejunostomy in terms of relevant postoperative pancreatic fistula.     

Vascular Resection in Pancreatic Cancer Surgery: Survival Determinants

Introduction

Pancreaticoduodenectomy (PD) is the standard operation for cancer of the pancreatic head. To achieve complete tumor resection and, thus, improve long-term survival, venous resection of the portal or superior mesenteric vein with reconstruction has become routine for advanced pancreatic adenocarcinoma (PDAC). However, its clinical benefit still remains controversial. The aim of this study was to investigate morbidity, mortality, and survival of patients with advanced PDAC following PD with venous resection and to identify significant survival determinants.

Material and Methods

From October 2001 to December 2007, 488 patients with PDAC of the pancreatic head underwent PD at our department. Venous resection was performed in 110 patients (22.5%). Clinical data, surgical techniques, perioperative parameters, and histopathologic data were analyzed on a prospective database.

Results

Major venous reconstruction was accomplished through primary lateral venorrhaphy in 18 patients (16.3%), polytetrafluoroethylene grafting (n?=?14, 12.7%), primary end-to-end anastomosis (n?=?72, 65.5%), an autologous saphenous venous graft patch (n?=?4, 4.6%) or a Goretex® patch (n?=?2, 2.3%). In 78.1% histopathologic examination revealed cancer invasion of the vein, whereas the remainder had peritumoral inflammation extending to the vessel wall. Perioperative morbidity rate was 41.8%; and the mortality rate 3.6%. The 1-, 2-, and 3-year survival rates were 55.2%, 23.1%, and 14.4%, respectively. Operating time (>420 min) and advanced age (>70 years) were the only prognostic variables, which significantly diminished survival on multivariate analysis.

Conclusion

Resection of the superior mesenteric or portal vein to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. However, improved local clearance in these patients cannot achieve a favorable long-term survival for all patients because distant metastases or local recurrence is frequent.     

Reconstruction of the Replaced Right Hepatic Artery at the Time of Pancreaticoduodenectomy

Background  The arterial anatomy supplying the liver is highly variable. One of the most common variants is a completely replaced right hepatic artery which is seen in about 11% of the population. Interruption of arterial flow to the right hepatic artery at the time of pancreaticoduodenectomy has been associated with biliary fistula and the consequent complications, as well as stenosis of the biliary enteric anastomosis. Malignancies of the posterior aspect of the head of the pancreas can encase a replaced right hepatic artery without involvement of other vascular structures. In this situation, it is possible to resect and reconstruct the replaced right hepatic artery to maintain oxygen delivery to the biliary enteric anastomosis. Summary  Herein we describe a technique to reconstruct a replaced right hepatic artery following resection of the vessel en bloc with the tumor during a pancreaticoduodenectomy, using inflow from the gastroduodenal artery.     

Silent Celiac Disease Activated by Pancreaticoduodenectomy

Diarrhea and weight loss are common after pancreaticoduodenectomy, and arise from varying etiologies. An uncommon but important cause for these symptoms is the postoperative activation of silent celiac disease. We sought to describe the clinical presentation, diagnosis, treatment, and follow-up of a series of patients with silent celiac disease unmasked after pancreaticoduodenectomy, and to summarize the existing case reports on this association. A search of the electronic medical record at our institution was performed cross-referencing terms associated with celiac disease and pancreaticoduodenectomy for the years 1976–2004. Cases were then reviewed to ensure that no signs or symptoms attributable to celiac disease were present preoperatively. Seven patients were identified; five were male, and the median age was 56. All patients underwent surgery for a presumed pancreatic or ampullary malignancy. Six patients developed symptoms ultimately attributable to celiac disease immediately after pancreaticoduodenectomy, most commonly diarrhea and weight loss. A single patient had silent celiac disease incidentally diagnosed at pancreaticoduodenectomy that remained silent postoperatively on an unrestricted diet. Symptoms completely resolved in 4 of 6 patients after initiation of a gluten-free diet, with partial improvement in the remaining 2 patients. The median delay from pancreaticoduodenectomy to diagnosis of celiac disease in the 6 symptomatic patients was 6 months. Clinicians should consider celiac disease as a potential diagnosis in patients with failure to thrive and diarrhea after pancreaticoduodenectomy. This entity is uncommon, but may be underrecognized. The underlying mechanism may relate to an increased antigenic load secondary to postsurgical changes in intestinal physiology.     

Safety of pancreatic surgery with special reference to antithrombotic therapy: A systematic review of the literature

BACKGROUNDPostpancreatectomy hemorrhage (PPH) is the most severe type of complication after pancreatic surgery, although the effect of antithrombotic therapy (ATT) on PPH is largely unknown. The safety and efficacy of chemical thromboprophylaxis for venous thromboembolism (VTE) remains controversial. AIMTo elucidate the effect of ATT on PPH. METHODSPublished articles between 2013 and 2020 were searched from PubMed and Google Scholar, and after careful reviewing of all studies, studies concerning ATT and pancreatic surgery were included. Data such as study design, type of surgical procedures, type of antithrombotic drugs, and surgical outcome were extracted from the studies.RESULTSNineteen published articles with a total of 37863 patients who underwent pancreatic surgery were included in the systematic review. Fourteen were cohort studies, with only three being prospective in nature. Two studies demonstrated that in patients receiving chronic ATT, which were mostly managed by heparin bridging, the risk of PPH was higher compared with those without ATT, and one study showed that patients with direct-acting oral anticoagulants managed by heparin bridging had significantly higher postoperative bleeding rates than others. The remaining six studies reported that pancreatic surgery can be safely performed in patients receiving chronic ATT, even under preoperative aspirin continuation. Concerning chemical thromboprophylaxis for VTE, most studies have shown a potentially high risk of PPH in patients undergoing chemical thromboprophylaxis; however, its effectiveness against VTE has not been statistically demonstrated, particularly among Asian patients.CONCLUSIONPancreatic surgery in chronically ATT-received patients can be safely performed without an increase in the occurrence of PPH, although the safety and efficacy of chemical thromboprophylaxis for VTE during pancreatic surgery is still controversial. Further investigation using reliable studies with good design is required to establish definite protocols or guidelines.