To compare the outcomes of pancreaticojejunostomy and pancreaticogastrostomy reconstruction after pancreaticoduodenectomy: A prospective observational study

BackgroundWe have been in constant search of novel innovations to decrease the high morbidity after Pancreaticoduodenectomy (PD). Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the two different methods of reconstruction after PD. However, the existing data is ambiguous in supporting either of them as the preferred technique of reconstruction.MethodsThis was a single-center prospective observational study that included 64 patients who underwent PD over two years. We compared PG with PJ as a method of reconstruction after PD. The primary objective was to assess whether PG decreases the rate of postoperative pancreatic fistula (POPF) rates or not. Secondary objectives comprised analysis of perioperative outcomes, 30-day and 90-day mortality.ResultsPancreatic fistula was significantly lower in PG as compared to the PJ group (24% vs. 47%) with a p-value of 0.027. The incidence of clinically pertinent (grade B) fistula was only 3% in the PG group and 32% in the PJ group. PG group had a higher incidence of post pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE). No statistically significant difference was seen between either group need for blood transfusion, re-exploration, re-admissions, ICU stay, or length of hospital stay, and 30-day and 90-day mortality. Pancreatic texture and high BMI were independent predictors for pancreatic fistula.ConclusionPG when compared to PJ for reconstruction after PD, decreases the rate of POPF significantly; however, it is associated with an elevated risk of DGE and PPH. There was no difference in 30-day and 90-day mortality between both the treatment groups.     

套入式胰胃双层吻合在胰十二指肠切除术中的临床应用

目的探讨胰十二指肠切除术中采用套入式胰胃吻合重建的手术指征、方法及疗效。方法回顾性分析我院1999年1月至2011年6月期间施行的胰十二指肠切除并行套入式胰胃吻合的39例患者的临床资料,均采用胰管内放置支撑引流管套入式胰胃双层间断吻合法。结果本组患者均顺利完成手术,平均手术时间为362min,术中输血量平均为330mL;术后住院时间平均为24d。住院期间1例（占2．5％）患者肺部感染、呼吸衰竭死亡;术后并发症5例（占12．8％）,肺部感染2例,并胰胃吻合口出血1例,经抑酸止血治疗出血停止,切口感染3例,并切口裂开1例。结论套入式胰胃双层吻合是一种可靠有效的胰腺残端重建方式,合理地选择套八式胰胃吻合可以最大程度地减少胰十二指肠切除术后胰瘘的发生。     

Pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials

Background

The best reconstruction method for the pancreatic remnant after pancreaticoduodenectomy remains debatable. We aimed to investigate the perioperative outcomes of 2 popular reconstruction methods: pancreaticogastrostomy and pancreaticojejunostomy.

Data Sources

Randomized controlled trials comparing pancreaticogastrostomy versus pancreaticojejunostomy were identified from literature databases (MEDLINE/PubMed, EMBASE, Web of Science, Cochrane Library).The meta-analysis included 8 studies: 607 patients who underwent pancreaticogastrostomy and 604 who underwent pancreaticojejunostomy. Postoperative pancreatic fistula and intra-abdominal fluid collection rates were significantly lower after pancreaticogastrostomy compared with pancreaticojejunostomy. No statistically significant differences were found in the incidence of delayed gastric emptying, biliary fistula, hemorrhage, reoperation, wound infection, overall morbidity, mortality, and length of hospital stay.

Conclusions

Our meta-analysis suggests that pancreaticogastrostomy not only reduces the rate of postoperative pancreatic fistula but also decreases its severity. Pancreaticogastrostomy is associated with a lower rate of intra-abdominal fluid collection. Our results suggest that pancreaticogastrostomy should be the preferred reconstruction method.     

Considerations on pancreatic exocrine function after pancreaticoduodenectomy

The pancreaticoduodenectomy (PD) procedure may lead to pancreatic exocrine and endocrine insufficiency. There are several types of reconstruction for this kind of operation. Pancreaticogastrostomy (PG) was introduced to reduce the rate of postoperative pancreatic fistula. Although some randomized control trials have shown no differences regarding pancreatic leakage between PG and pancreaticojejunostomy (PJ), recently some reports reveal benefits from the PG over the PJ. Some surgeons concern about the performing of the PG and inactivation of pancreatic enzymes being in contact with the gastric juice, and the detrimental results over the exocrine pancreatic function. The pancreatic exocrine function can be measured with direct and indirect tests. Direct tests have the highest sensitivity and specificity for detection of exocrine insufficiency but require tube placement. Among the tubeless indirect tests, the van de Kamer stool fat analysis remains the standard to diagnose fat malabsorption. The patient compliance and time consuming makes it not so suitable for its clinical use. Fecal immunoreactive elastase test is employed for screening of exocrine insufficiency, is not cumbersome, and has been used to study pancreatic function after resection. We analyze the FE1 levels in our patients after the PD with two types of reconstruction, PG and PJ, and we discuss some considerations about the pancreaticointestinal drainage method after pancreaticoduodenectomy.     

肠内营养在胰十二指肠切除术中的应用

目的回顾分析胰十二指肠切除术中采用胰胃吻合及空肠造瘘行肠内营养疗效。方法1998年1月～2007年1月共进行胰十二指肠切除胰胃吻合手术46例,采用胰胃双层套入式吻合法,胰管内放置支撑引流管,加空肠造瘘术行肠内营养。结果患者术后无胰瘘、胆瘘发生。结论胰十二指肠切除术中采用胰胃双层吻合安全、有效,明显减少胰瘘的发生,空肠造瘘行肠内营养支持应是胰十二指肠切除手术患者手术后的首选营养支持方案。     

胰胃吻合术在胰十二指肠切除术中的应用

目的 探讨胰胃吻合术在胰十二指肠切除术中的应用效果.方法 对胰十二指肠切除术中应用胰胃吻合术的245例临床资料进行回顾性分析.结果 本组均行胰十二指肠切除胰胃吻合术.术后监测血糖4.0～6.9 mmol/L.术后胰漏发生率为0.82％,胃排空障碍发生率为0.82％,腹腔积液发生率为1.22％,腹部切口感染发生率为2.04％,病死率为1.22％.结论 胰胃吻合术是一种安全、可靠、有效的胰腺残端重建术式.     

胰十二指肠切除后消化道重建方式的思考与改进

Digestive tract reconstruction is one of the important steps following pancreatoduodenectomy.Traditional methods of digestive tract reconstruction,such as Whipple,Child and Cattel method,had disadvantages of bringing damage to the normal physiological structure and raising the incidence of complications.In this review,the improvements of the digestive tract reconstruction in recent years were introduced,and their benefits and shortcomings were also analyzed.     

胰十二指肠切除术后胰胃吻合术与胰空肠吻合术前瞻性对照试验的荟萃分析

目的 比较胰十二指肠切除术(PD)后胰胃吻合术(PG)与胰空肠吻合术(PJ)的安全性.方法 检索2010年12月以前EMBASE、MEDLINE、Cochrane Library、Cochrane协作网随机对照试验注册数据库、中国期刊全文数据库(CNKI)、中国生物文献数据库(CBM)等数据库,纳入前瞻性对照试验,评估文献质量并提取数据资料,应用RevMan5.0对其进行荟萃分析.结果 纳入6个前瞻性对照试验,其中4个随机对照试验(RCT),2个非随机的前瞻性对照试验,共867例PD病例,行PG手术患者440例,PJ手术患者426例.采用前瞻性研究(包括RCT)和单纯RCT分组进行荟萃分析:前瞻性对照试验组(包括RCT)荟萃分析中PG在术后并发症[OR0.53,95％ CI(0.30,0.95),P=0.03]、胰瘘[OR 0.47,95％ CI(0.22,0.97),P=0.04]、腹腔积液[OR 0.42,95％CI(0.25,0.72),P=0.001],这3项指标中明显优于PJ,腹腔内并发症、病死率等指标上两种吻合方式差异未见统计学意义;RCT研究组荟萃分析中PG在术后腹腔积液[OR 0.46,95％ CI(0.26,0.79),P=0.005]这项指标中明显优于PJ,在术后并发症、胰瘘、腹腔内并发症、病死率、胃排空延迟这些指标上两种吻合方式差异未见统计学意义.结论 前瞻性对照试验进行荟萃分析后可以发现PG在术后并发症、胰瘘、腹腔积液方面优于PJ.单纯对RCT进行荟萃分析后发现PG仅在术后腹腔积液方面优于PJ.表明PG在安全性上并不低于PJ.     

胰肠吻合和胰胃吻合在胰十二指肠切除术后临床疗效的Meta分析

目的以循证医学证据评价胰肠吻合(pancreaticojejunostomy,PJ)和胰胃吻合(pancreaticogastrostomy,PG)在胰十二指肠切除术(panereatieoduodenectomy,PD)后的临床疗效。方法通过计算机检索PubMed数据库、EMBASE、万方数据库、中国全文期刊数据库和维普数据库,并结合文献追溯的方法,收集关于胰肠吻合和胰胃吻合在胰十二指肠切除术后临床疗效的随机前瞻性对照试验（RCT)或非随机前瞻性对照试验（NRCT）,并按 Cochrane协作网推荐的方法对符合纳入标准的 6个研究共866例患者进行Meta分析,发表偏倚用漏斗图评估。结果Meta分析结果显示,与胰肠吻合组相比,胰胃吻合组能降低胰十二指肠切除术后胰瘘发生率（P=0.003）、术后并发症的发生率（P=0.04）和腹腔内积液的发生（P=0.01）,但两者在术后胆瘘发生率（P=0.08）和围手术期死亡率（P=0.14)方面差异均无统计学意义。结论在胰十二指肠切除术后胰瘘、术后并发症发生率及腹腔内积液等方面,PG优于PJ,但是两者在胆瘘及围手术期死亡率等方面,疗效相当。且纳入的研究存在选择偏倚、发表偏倚及测量偏倚的可能性,这势必会影响结果的论证强度,所以进一步结论需要更多高质量的随机对照试验来进一步探讨、论证。