Factors influencing insulin secretion after pancreatoduodenectomy

Preoperative patients with periampullary cancer had a higher mean Σ IRI value than that of normal controls, and also had a delayed pattern of insulin response and a lower insulinogenic index during oral-GTT. Σ IRI levels after pancreatoduodenectomy were similar to those of normal controls when the pancreatic remnants were histologically intact at the time of surgery. Postoperative Σ IRI levels could not be predicted based on the extent of histological fibrosis of the distal pancreas at the time of surgery. Patency of pancreatojejunostomy was obtained with the modified Warren's method in 39 out of 40 patients, and Σ IRI levels were maintained up to 5 years postoperatively. No significant difference was found in Σ IRI levels between pancreatoduodenectomised patients with the conventional Roux-en-Y procedure and those with the inverted Roux-en-Y with jejunal interposition. The mean insulin peak value and Σ IRI level were higher in pancreatoduodenectomised patients than in normal controls, and higher in gastrectomised patients than in pancreatoduodenectomised patients. Pancreatoduodenectomy with superior mesenteric arterial dissection resulted in remarkably low Σ IRI levels.     

Pancreatic division by electrocautery in pancreatoduodenectomy

To assess whether electrocautery is appropriate for cutting the pancreas in pancreatoduodenectomy, we compared leakage of the pancreatojejunostomy (PJ-stomy) in patients who underwent pancreatic division by electrocautery and with a conventional scalpel, in a retrospective study. Eighty-four patients with invaginating end-to-end PJ-stomies (performed in the period 1986—1996) were enrolled in this study; 34 patients underwent pancreatic division with a conventional scalpel (group A) and 50 by electrocautery (group B). Of the 84 patients, 12 (14%) had leakage from the PJ-stomies. In relation to consistency of the pancreatic parenchyma, the incidence of leakage in patients with hard pancreas (1/28; 3.6%) was significantly lower than that in patients with soft or moderate pancreas consistency (11/56; 20%) (P < 0.05). Nine patients (27%) in group A and 3 (6%) in group B presented with leakage. The incidence of leakage was significantly lower in group B than in group A (P < 0.05). Even when patients with hard pancreas were excluded, the incidence of leakage was significantly lower in group B (3/34; 9%) than in group A (8/22; 36%) (P < 0.05). These results suggest that pancreatic division by electrocautery can reduce the incidence of leakage from the pancreatojejunostomy and make pancreatoduodenectomy a safer procedure.     

Do not break up the surgical team! Familiarity and expertise affect operative time in complex surgery

Background

The effects of replacing a surgeon's familiar, experienced certified surgical assistant (CSA) on perioperative outcomes in complex surgery were investigated.

胰十二指肠切除术病人胃电图变化

通过对胰十二指肠切除术病人手术前后体表胃电图的研究，探讨手术对病人胃电及排空功能的影响。结果表明：保留幽门的胰十二指肠切除术病人术前６０％存在胃律紊乱及胃排空障碍，８０％此类病人术后出现胃电及胃排空异常。上述结果提示：对拟行保留幽门的胰十二指肠切除术病人术前胃电图检查表现胃节律紊乱及胃排空障碍者，术中应考虑胃及空肠造瘘。     

Still any role for transduodenal local excision in tumors of the papilla of Vater?

Tumors of the papilla and ampulla of Vater are rare neoplasms which are usually detected at an early stage due to their symptoms. The accurate preoperative histological diagnosis and staging of ampullary tumors is often difficult and inconclusive, leading to controversy over the adequate treatment of these lesions. Three procedures are currently being used to treat such tumors. Pancreatoduodenectomy (PD) is a procedure with low morbidity and mortality at experienced centers, and is considered the treatment of choice for invasive carcinoma and large benign ampullary lesions with suspicion of malignancy. Transduodenal local excision (TDE) of ampullary tumors is a relatively simple procedure with operative morbidity and mortality rates comparable to PD. TDE is challenged at endoscopic centers by endoscopic snare excision (ESE). Due to technical advances, the safety and outcomes of ESE for ampullary tumors have improved in recent years. ESE and TDE represent adequate methods for treatment of benign tumors and also for small malignant tumors detected at an early stage if the diagnosis and stage have been accurately established preoperatively. Due to the safety of PD and the technical advances of ESE, TDE is reserved for selected patients. Randomized controlled studies are needed to establish the correct indications for PD, TDE, and ESE.     

Pylorus-preserving pancreatoduodenectomy is applicable to patients with carcinoma of the head of the pancreas: Studies of lymph node metastasis and quality of life

Metastases to the regional lymph nodes of the stomach were studied in patients in whom carcinoma of the head of the pancreas had been resected (51 standard pancreatoduodenectomy and 26 total pancreatectomy). Involvement of gastric lymph nodes was rare (1.3%–3.9%), except of the subpyloric lymph nodes (9.1%). Carcinoma in the five patients with positive gastric lymph nodes, with the exception of the subpyloric nodes, was clinically far advanced: four of the five had liver metastasis or peritoneal dissemination. This suggests that, in terms of preservation of the regional gastric lymph nodes, only subpyloric node involvement has any significance with respect to surgical treatment of carcinoma of the head of the pancreas. There was no significant difference in survival rates after curative resection between standard pancreatoduodenectomy (n=44) and pylorus-preserving pancreatoduodenectomy (n=17). In the patients who underwent the pylorus-preserving pancreatoduodenectomy for various kinds of periampullary diseases (n=47), postoperative recovery of gastric and small bowel function was temporarily prolonged compared to that after shandard pancreatoduodenectomy (n=44). However, the former group were able to take significantly more calories 6 weeks after the operation. Our study indicates that the pylorus-preserving pancreatoduodenectomy with subpyloric lymph node dissection is applicable to the treatment of patients with carcinoma of the head of the pancreas from the viewpoints of both extent of operation and quality of life.     

Pancreatic invasion is a prognostic indicator after radical resection for carcinoma of the ampulla of Vater

Sixty-three patients who had undergone pancreatoduodenectomy for carcinoma of the ampulla of Vater were analyzed with respect to tumor extent and prognosis. The postoperative mortality rate was 3% and overall survival rates 3 and 5 years after surgery were 55% and 46%, respectively. pTNM stage did not reflect prognosis after resection in patients at stages 2 and 3, while pancreatic invasion and regional lymph node metastasis clearly reflected prognosis after resection. Of the 26 patients who had no pancreatic invasion, regional lymph node metastasis was seen in only 19%, whereas of the 37 patients with pancreatic invasion, 62% exhibited lymph node metastasis. These factors were significantly correlated (P<0.001). Pancreatic invasion appeared to be an indirect indicator of regional lymph node metastasis. We conclude that, to improve prognosis for patients with pancreatic invasion, extended resection including extended lymphadenectomy, is a preferable additional procedure.     

Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy

The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreato-duodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.