Pancreatoduodenectomy as a source of human small intestine for Ussing chamber investigations and comparative studies with rat tissue

A clear understanding of oral drug absorption is an important aspect of the drug development process. The permeability of drug compounds across intact sections of small intestine from numerous species, including man, has often been investigated using modified Ussing chambers. The maintenance of viable, intact tissue is critical to the success of this technique. This study therefore aimed to assess the viability and integrity of tissue from patients undergoing pancreatoduodenectomy, for use in cross-species Ussing chamber studies. Electrical parameters (potential difference, mV; short-circuit current, μA.cm(-2) ; resistance, Ω.cm(2) ) were monitored over the duration of each experiment, as was the permeability of the paracellular marker atenolol. The permeability values (Papp; cm/s × 10(-6) ) for a training-set of compounds, displaying a broad range of physicochemical properties and known human fraction absorbed values, were determined in both rat and human jejunum, as well as Caco-2 cell monolayers. The results indicate that human jejunum sourced from pancreatoduodenectomy remained viable and intact for the duration of experiments. Permeability values generated in rat and human jejunum correlate well (R(2) = 0.86), however the relationship between permeability in human tissue and Caco-2 cells was comparatively weak (R(2) = 0.58). Relating permeability to known human fraction absorbed (hFabs) values results in a remarkably similar relationship to both rat and human jejunum Papp values. It can be concluded that human jejunum sourced from pancreatoduodenectomy is a suitable source of tissue for Ussing chamber permeability investigations. The relationship between permeability and hFabs is comparable to results reported using alternative test compounds.     

POSSUM评分在胰十二指肠切除术后并发症精准化护理干预中的应用

目的:探讨基于生理学和手术严重性评分（POSSUM评分）的针对胰十二指肠切除术后并发症的精准化护理干预方案的应用效果。方法:将行胰十二指肠切除术的824例患者随机分为观察组和对照组各412例,对照组给予普外科常规护理,观察组在常规护理基础上应用POSSUM评分预测并发症风险,并对高风险患者给予针对性干预。结果:观察组术后并发症发生率低于对照组（P<0.01）。2组并发症预测发生率差异无统计学意义（P>0.05）。观察组患者的实际并发症发生率低于POSSUM评分预测发生率（P<0.01）,而对照组患者的实际并发症发生率与POSSUM预测发生率差异无统计学意义（P>0.05）。结论:应用POSSUM评分预测胰十二指肠切除术风险准确且有价值,能有效减少并发症发生,改善患者预后。     

The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy

BACKGROUND:A number of definitions have been used for delayed gastric emptying(DGE) after pancreatoduodenectomy and the reported rates varied widely.The International Study Group of Pancreatic Surgery(ISGPS) definition is the current standard but it is not used universally.In this comprehensive review,we aimed to determine the acceptance rate of ISGPS definition of DGE,the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence.DATA SOURCE:We searched PubM ed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition,DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles.RESULTS:Out of 435 search results,178 were selected for data extraction.The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7%(range:0-100%;median:18.7%) and 14.3%(range:1.8%-58.2%;median:13.6%),respectively.Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates.Although pyloric dilatation,Braun's entero-enterostomy and Billroth Ⅱ reconstruction were associated with significantly lower DGE rates,pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies.CONCLUSIONS:ISGPS definition of DGE has been used in majority of studies published after 2010.Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications.Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.     

Three-dimensional models of arteries constructed using multidetector-row CT images to perform pancreatoduodenectomy safely following dissection of the inferior pancreaticoduodenal artery

Background/purpose

During a pancreatoduodenectomy (PD) it is important that the anatomy of the arcade of blood vessels in the head of the pancreas is fully understood before the surgery in order to reduce intraoperative bleeding. In most of the patients our group has treated, the inferior pancreaticoduodenal artery (IPDA), one of the efferent arteries of the head of the pancreas, has formed a short common trunk with the first jejunal artery (FJA). Thus, by first locating the origin of the FJA, it was easier to locate the IPDA. There are two ways to locate the IPDA: (1) by measuring the distance between the origin of the superior mesenteric artery (SMA) and that of the FJA; (2) by measuring the distance between the origin of the middle colic artery (MCA) and that of the FJA. Here, we report our measurements of both distances using three-dimensional (3D) models of arteries constructed with multidetector-row computed tomography (MD-CT) images and discuss which is the better measurement to determine the location of the IPDA during PD.

Methods

A total of 140 patients underwent 64-MD-CT imaging to acquire early and late arterial phase scans. The distance between the origin of the SMA and that of the FJA and the distance between the origin of the MCA and that of the FJA origin were measured.

Results

In patients whose IPDA formed either a common trunk with the FJA or arose directly from the SMA, the IPDA or the common truck was located in parallel with the SMA at a very short distance of approximately 18 mm from the MCA origin towards the center. The distance between the SMA origin and the IPDA was significantly longer (approximately 36 mm). Therefore, locating the MCA origin during PD helped determine the location of the IPDA. However, in patients whose anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) arose separately, the distance between the AIPDA origin and the MCA origin was approximately 18 mm, the distance between the AIPDA origin and the PIPDA origin was approximately 19 mm, and the distance between the PIPDA origin and the SMA origin was 19 mm. Thus, locating the SMA helped determine the location of the IPDA during PD in these patients.

Conclusion

Based on our findings that the distance between the IPDA origin and the MCA origin was short, we have shown that it is effective to locate the MCA origin in order to determine the location of the IPDA.     

Long-Term Postoperative Functional Evaluation of Pylorus Preservation in Imanaga Pancreatoduodenectomy

Our purpose was to determine whether pylorus-preservation in the Imanaga (PpPDI) method minimizes postoperative impairment of gastrointestinal function. Nine patients who had undergone PpPDI (postoperative years: 5.7 ± 2.6) and nine patients who had undergone conventional Imanaga pancreatoduodenectomy (PDI) (postoperative years: 6.8 ± 2.0) were evaluated for symptoms, nutritional parameters, and physiologic function of the biliary tract and residual stomach using gastric emptying and hepatobiliary scintigraphy. The body weight recovered to 99.3% ± 3.8% of pre-illness body weight in PpPDI, showing a significantly better recovery than in patients after the PDI procedure (91.0% ± 6.4%, P < 0.05). The mean gastric emptying half-time (GET1/2) in the upright position after PDI was significantly shorter (42.3 min) than after PpPDI (80.8 min, P < 0.05). Mixture of food with bile was conserved better in the PpPDI group than in the PDI group. In the long term, the pylorus-preserving Imanaga-type procedure minimizes disruption of gastric function and asynchrony between ingested food and bile.     

Surgical approach to tumor recurrence and metastatic lesions of the liver in a patient with malignant endocrine tumors of the pancreas: case report

We describe herein a 72-year-old woman with tumor recurrence in the residual pancreas and metastasis to the liver following a pylorus-preserving pancreatoduodenectomy for multiple endocrine tumors in the head of the pancreas. Abdominal ultrasonography performed 7 years after the initial surgery detected new lesions in the residual pancreas and liver. After recurrence of endocrine tumors of the pancreas and metastasis to the liver were diagnosed, the lesions were successfully resected by total pancreatectomy with distal gastrectomy and both lateral segmentectomy and partial resection of segment 8. Genetic analysis using a blood specimen showed that this patient carried the multiple endocrine neoplasia type 1 (MEN1) gene mutation. One year after the second resection, the patient remains in good health using insulin and has not shown any sign of recurrence. This case report describes successful surgical resection for recurrence and metastasis of malignant endocrine tumors in a patient with the MEN1 gene mutation.     

腹腔镜胰十二指肠切除术中肠系膜上血管的应用解剖

目的:为腹腔镜胰十二指肠切除术(laparoscopic pancreatoduodenectomy,LPD)中探查、显露、分离肠系膜上血管提供解剖学依据。方法:10例已固定成人尸体腹部标本,2例新鲜成人尸体。全组男7例,女5例。进行解剖观测,并行模拟腹腔镜操作。结果:⑴肠系膜上静脉(superior mesenteric vein,SMV)的十二指肠水平部段长(3.80±0.72)cm、胰头钩突部段长(1.76±0.25)cm、胰颈后段长(3.81±0.64)cm、胰颈上段长(4.73±1.31)cm,其中胰头钩突部段属支最多;⑵胃网膜右静脉汇入SMV有6种类型;⑶肠系膜上动脉(superior mesenteric artery,SMA)距腹腔干下方(1.12±0.15)cm起自腹主动脉前壁,主干长(3.97±0.54)cm,外径(0.69±0.03)cm,胰十二指肠下动脉和第1空肠动脉起源SMA的有5种类型。结论:(1)SMV的胰头钩突部段最短,属支最多,显露分离最难;(2)LPD中以胃网膜右静脉为标志来探查、显露SMV较好;(3)对肠系膜上动、静脉的显露分离应采用不同的主操作孔来进行;(4)充分利用腹腔镜的放大作用和超声刀的精确切割特性是可以探查、显露和分离好肠系膜上血管的。