Is ICG-enhanced image able to help predicting pancreatic fistula in laparoscopic pancreaticoduodenectomy?

Laparoscopic pancreaticoduodenectomy (PD) has been reported to be technically feasible and safe. Successful pancreatico-enteric anastomosis in particular is important for safe PD. Intraoperative perfusion of the remnant pancreas can be evaluated with ICG technology and be applied in pancreatic reconstruction in PD. A 68-year old female patient with distal common bile duct cancer underwent laparoscopic pylorus-preserving pancreaticoduodenectomy. After pancreaticojejunostomy (PJ), we checked perfusion of the anastomosis line using an ICG imaging system and noticed a perfusion defect at the anterior wall. The patient developed a grade A postoperative pancreatic fistula, but was discharged without major sequelae. Even though pancreatic perfusion after laparoscopic PJ appeared adequate based on white light, hypo-perfusion was noted under infrared light. Our experience suggests that ICG technology may be more sensitive than white light for detecting pancreatic perfusion in pancreatic anastomoses. However, the clinical implications of this require further investigation.     

Fracture of the pancreas in two patients after a go-kart accident

Background

After blunt abdominal trauma, an isolated injury to the pancreatic duct is uncommon. Physical signs and laboratory parameters are often inaccurate, and missing this diagnosis can cause serious clinical problems.

Case outlines

Two young women (aged 18 and 20 years) are reported who sustained isolated trauma to the pancreatic duct in go-kart accidents. Each patient sustained a fracture of the pancreas.This injury was diagnosed only after a period of clinical observation with repeated laboratory parameters, ultrasound and CT scan. Pancreatic tissue was conserved by performing a pancreaticojejunostomy.

Discussion

After any episode of blunt abdominal trauma, isolated injury to the pancreatic duct should be considered. Serum analysis, ultrasonography and CT scanning can be helpful in early diagnosis. Preservation of pancreatic tissue can be achieved with a good clinical outcome.     

一种新型胰腺空肠吻合方法——空肠浆肌层鞘捆扎法

目的介绍一种改进的胰腺空肠端端吻合方法。方法首先将空肠断端去粘膜化后形成浆肌层鞘,将胰腺断端和粘膜层进行第一层缝合。打结后将空肠浆肌层鞘套入胰腺断端,将胰腺断端和浆肌层鞘进行第二层缝合,打结前将一根捆扎丝线在第二层缝线中间包绕胰腺套入部,再进行第二层的打结,将空肠浆肌层鞘固定于胰腺上。最后将捆扎丝线打结,使浆肌层鞘和胰腺之间紧密相贴。临床应用3例,均为胰头十二指肠切除术患者。结果胰腺空肠吻合时间分别为5,8,10 min,无胰漏发生。结论空肠浆肌层鞘捆扎法简单易行,能缩短手术时间,初步结果显示无胰漏发生。     

Obstructed pancreaticojejunostomy partly explains exocrine insufficiency after pancreatic head resection

Objective. The majority of patients with long-term survival after pancreatic head resection suffer from pancreatic exocrine insufficiency. The objective of this study was to investigate whether this is due to glandular malfunction or obstructed pancreaticojejunal anastomosis. Material and methods. Twenty-six patients (10 M, 16 F, mean age 61 years, range 34–81 years) were re-examined a median of 52 months (range 3–76 months) after pancreatic head resection and end-to-end invaginated pancreaticojejunostomy. Pancreatic exocrine function was measured by fecal elastase-1 assay. The size of the pancreatic remnant, glandular secretion and the flow through the anastomosis were analyzed with secretin-stimulated dynamic magnetic resonance pancreatography (D-MRP). Results. All patients had pancreatic exocrine insufficiency, 24 (92%) of them having severe insufficiency. Eighteen patients (69%) reported moderate to severe diarrhea. Lowest fecal elastase-1 concentrations were associated with the initial diagnosis of chronic pancreatitis or ductal adenocarcinoma, suggesting preoperative primary or secondary chronic pancreatitis as important determinants. The size of the remnant gland did not correlate with the fecal elastase-1 concentrations. D-MRP failed in three patients. Severe glandular malfunctions were found in 7 (30%) of the 23 successful D-MRP examinations. The anastomosis was totally obstructed in 5 patients (22%) or partially obstructed in 6 (26%) but remained perfectly open in 5 patients (22%). The five patients with perfect anastomoses had the highest measured median fecal elastase-1 activity. Conclusions. Although late diarrhea and pancreatic exocrine insufficiency may be partly induced already by the disease treated with resection, at least half may be explained by obstructed anastomosis. To obtain better late functional results, improvements may be required in the surgical techniques.     

胰十二指肠切除行贯穿缝合式胰肠吻合术后的护理体会

目的探讨胰十二指肠切除行贯穿缝合式胰肠吻合术后的护理方法。方法回顾性分析31例采用贯穿缝合式胰肠吻合法的胰十二指肠切除患者术后所采取的护理措施。结果 31例患者均痊愈,无1例发生胰瘘或者出血。结论密切观察病情、注重心理沟通、保持管道通畅、必要时配以肠内营养是胰十二指肠切除术后高质量护理的关键。     

Clinical Study on Suspension Pancreatic-Duct-Jejunum End-to-Side Continuous Suture Anastomosis in Pancreaticoduodenectomy

Objective To study the influence of Suspension Pancreatic-Duct-Jejunum End-to-Side Continuous Suture Anastomosis(SPDJCS) on the incidence of pancreatic fistula after pancreaticoduodenectomy,and to analyze its applicability,safety,and efficacies.Methods A prospective controlled trial was conducted with 165 cases receiving pancreaticoduodenectomy in the Department of Hepatopancreatobiliary Surgery from January 2010 to May 2012.The patients were divided into Group A(end-to-end/end-to-side invaginated anastomosis,n=52),Group B(end-to-side mucosal anastomosis,n=48),and Group C(SPDJCS,n=65).The preoperative data,intraoperative data,and operative outcomes(incidence of pancreatic fistula,operation time,intraoperative blood loss,peritoneal drainage,peritoneal hemorrhage,peritoneal abscess,delayed gastric emptying,pulmonary infection,postoperative infection,blood transfusion,and perioperative mortality) were compared among the 3 groups.Results The total incidence of pancreatic fistula was 13.9%(23/165) in all the 165 patients.The incidence in Group A and Group B was 23.1%(12/52) and 18.8%(9/48),both higher than that in Group C [3.1%(2/65),both P<0.05].Group C showed significantly better outcomes than group A and B in terms of the operation time(5.5±1.2 hours vs.6.1±1.1 hours,5.5±1.2 hours vs.6.3±1.5 hours),volume of blood loss(412.0±205.0 mL vs.525.0±217.0 mL,412.0±205.0 mL vs.514.0±217.0 mL),and postoperative drainage amount of plasma tubes(175.0±65.0 mL vs.275.0±80.0 mL,175.0±65.0 mL vs.255.0±75.0 mL)(all P<0.05),while Group A and Group B displayed no difference in these aspects(P>0.05).As complications other than pancreatic fistula were concerned,the three groups were not different from each other(P>0.05).Conclusions SPDJCS may have the effect of reducing the incidence of pancreatic fistula after pancreaticoduodenectomy.It could be safe,practical and convenient technique of anastomosis for pancreaticojejunostomy.     

陈氏贯穿纵向“U”型胰肠吻合术的理论与实践

华中科技大学同济医学院附属同济医院陈孝平院士在深入的理论和临床研究基础上，创建了一种贯穿纵向“U”型胰肠吻合术。该术式通过全层贯穿胰腺实质和肠壁的间断交锁“U”型缝合或者连续缝合，将胰腺断端的主胰管、副胰管、小叶导管引流的胰液全部引流入肠腔内无遗漏。经过多家大通量胰腺外科中心的大样本临床病例验证，该术式操作简便，能显著降低术后胰瘘和出血的发生率，在临床上得到了广泛应用，是一种能有效降低胰腺消化道重建术后胰瘘、出血等严重并发症发生率的吻合技术，适用于各种类型的胰腺残端。     

Mattress sutures for the modification of end-to-end dunking pancreaticojejunostomy

Despite the improvement of surgical techniques, the rate of anastomotic failure of pancreaticojejunostomy remains high (30%–50%). Here we describe the use of vertical mattress sutures in the modification of dunking pancreaticojejunal anastomosis. In 7 patients who used this technique, neither anastomotic failure nor any major postsurgical complication developed. This technique is an easy, safe, and promising for the performance of pancreaticojejunostomy.     

Management of the pancreatic stump after pancreaticoduodenectomy

The aim of the present study was to review the current evidence in the management of the pancreatic stump after pancreaticoduodenectomy (PD). A literature search was conducted using the following key words: PD, Whipple's operation, pancreaticojejunostomy (PJ), pancreaticogastrostomy (PG), dunking, duct to mucosa (DTM) and pancreatic stent. Emphasis was made on randomized, controlled trials and meta‐analyses. Simple ligation or occlusion of the pancreatic duct was abandoned due to a high complication rate. Most surgeons fashioned a PJ or PG to restore drainage of pancreatic juice. Dunking and DTM were the two major ways to construct anastomosis. The superiority of the binding technique still needs to be proved. However, Blumgart's modified DTM technique achieved a favourable outcome in some non‐randomized trials. Pancreatic fistula was not decreased by internal stent, but an external stent might be helpful. No single type or technique of pancreaticoenteric anastomosis is able to demonstrate significant superiority to others. Similar controversy also occurs in the use of pancreatic stent. For the successful management of the pancreatic stump, no matter which type of anastomosis is employed, a meticulous surgical technique with optimization of blood supply to the anastomosis cannot be overemphasized.     

Wrapping double-mattress anastomosis for pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy can significantly reduce postoperative pancreatic fistula rate compared with conventional pancreaticojejunostomy in open surgery: An analysis of a propensity score-matched sample

BackgroundMinimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD.MethodsThe current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group.ResultsThe patients’ preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004).ConclusionThe novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.