The effect of atrophied pancreas as shown in the preoperative imaging on the leakage rate after pancreaticoduodenectomy.

Objective To explore the effect of modified parachute-like pancreaticojejunostomy on incidence of pancreatic fistula after pancreatoduodenectomy. Methods The clinical data of 123 patients undergoing pancreatoduodenectomy with application of duct-to-mucoca pancreaticojejunostomy were analyzed retrospectively. Interrupted suture technique and modified parachute suture technique were performed in 61 and 62 patients, respectively. Postoperative complications, data during and after pancreatoduodenectomy between two groups were compared. Results There were no significant differences in pancreatic texture, pylorus preservation, pancreatic duct drainage, intraoperative blood loss, and operating time between two groups (P>0.05). No significant differences between two groups were observed on postoperative morbidity of gastrointestinal or intraabdominal hemorrhage, delayed gastric emptying, and intraabdominal abscess (P>0.05). Although there was no significant difference in the incidence of postoperative pancreatic fistula (P>0.05), the grades B/C postoperative pancreatic fistula in modified parachute suture group was significantly less than in interrupted suture group (P<0.05). Conclusions Modified parachute-like pancreaticojejunostomy technique in pancreatoduodenectomy can reduce the incidence of severe postoperative pancreatic fistula. Key words: Pancreaticojejunostomy/MT; Pancreaticoduodenectomy/AE; Pancreatic fistula/ET/PC; Intestinal fistula/ET/PC

Objective To investigate the effect of end-to-side pancreaticojejunostomy with pocket-insertion on the incidence of pancreatic fistula after pancreaticoduodenectomy. Methods The clinical data of 581 patients undergoing pancreaticoduodenectomy from Dec. 2012 to Sep. 2018 in Cangzhou Central Hospital were retrospectively analyzed, including 327 cases of open pancreaticoduodenectomy (OPD) , 175 cases of laparoscopic assisted pancreaticoduodenectomy (LAPD) , and 79 cases of total laparoscopic pancreaticoduodenectomy. End-to-side pancreaticojejunostomy with pocket-insertion was used in all cases. The incidence of pancreatic fistula after operation was analyzed. Results The overall incidence of grade B or C pancreatic fistula was 3.10% (18/581) after end-to-side pancreaticojejunostomy with purse-pocket insertion. The incidence of grade B or C pancreatic fistula in OPD group was 2.75% (9/327) . The incidence of grade B or C pancreatic fistula in LAPD group was 2.29% (4/175) . The incidence of grade B or C pancreatic fistula in TLPD group was 6.33% (5/79) . The three groups were divided into two subgroups according to the pancreatic texture. There was significant difference in pancreatic duct diameter between subgroups (P 0.05) . Conclusion End-to-side pancreaticojejunostomy with pocket insertion has the advantages of simple operation, strong adaptability, safety and high efficiency, and can control the incidence of pancreatic fistula after pancreaticoduodenectomy at an ideal level. Key words: Pancreatoduodenectomy; Pancreaticoduodenectomy; Pancreatic fistula

Objective To investigate the choice of surgical methods and short-term therapeutic efficacy of laparoscopic pancreaticoduodenectomy. Methods A retrospective analysis was performed on the clinical data of 188 cases who underwent laparoscopic pancreaticoduodenectomy (LPD) from December 2015 to December 2017 in Cangzhou Central Hospital. Total laparoscopic pancreaticoduodenectomy (TLPD) was performed in 102 patients whose diameter of pancreatic duct was greater than or equal to 3 mm, and end-to-side anastomosis of pancreatic duct and jejunum was used to reconstruct the digestive tract (TLPD group). Laparoscopic assisted pancreaticoduodenectomy (LAPD) was performed in 86 patients with pancreatic duct diameter less than 3 mm, and the digestive tract was reconstructed by end-to-side pancreaticoduodenectomy with pocket-insertion (LAPD group). The clinical data of the two groups were analyzed and compared. Results There were no significant differences on sex, age, ASA grade, preoperative total bilirubin, alanine aminotransferase and serum albumin levels between the two groups(P>0.05), which was comparable. The total incision length and hospitalization time in TLPD group were significantly shorter than those in LAPD group [(8.2±1.4)cm vs (12.9±2.6)cm]; [(10.9±5.9)d vs (14.3±6.5)d], while the time of pancreaticojejunostomy was significantly longer than that in LAPD group [(36.1±14.7)min vs (14.0±4.2)min]. The incidence of pancreatic fistula after operation was significantly higher than that in LAPD group (30.4% vs 10.5%). The difference was statistically significant (all P<0.05). There were no significant differences on mean operation time, intraoperative bleeding volume, number of lymph node dissection, R0 resection rate, ICU admission time, eating time, total complication rate and 6-month disease-free survival rate between the two groups. Conclusions TLPD has the advantages of less trauma and quicker recovery. But for pancreatic duct diameter less than 3 mm, the choice of LAPD can increase the safety of operation and reduce the incidence of postoperative pancreatic fistula. Key words: Pancreaticoduodenectomy; Laparoscopy; Pancreatic fistula

Objective To investigate the influence of different pancreaticojejunostomy on the incidence of postoperative pancreatic (PF) fistula in pancreaticoduodenectomy (PD). Methods The clinical data of 343 patients undergoing radical PD from January 2011 to December 2015 were collected. 343 patients were divided into 3 groups, including 124 cases of continuous lamellar duct-to-mucosa pancreaticojejunostomy (CL-DMP) (group A), 111 cases of invaginated pancreaticojejunostomy (group B) and 108 cases of binding pancreaticojejunostomy (group C). The rates of postoperative PF and related complications, length of postoperative hospital stay, perioperative mortality and hospitalization costs were compared between the 3 groups. Results There was no statistical difference in the size of pancreatic duct between the 3 groups (P>0.05). The postoperative PF incidence of group A was 4.84%, significantly lower than 13.51% in group B and 15.74% in group C, respectively (P<0.05). The anastomosis took less time and postoperative hospital stay was shorter in group A than that in the other 2 groups (P<0.05). Conclusion CL-DMP is time-saving, safe and effective method of pancreaticojejunostomy during the process of pancreaticoduodenectomy. Key words: Pancreaticoduodenectomy; Pancreaticojejunostomy; Pancreatic fistula

Objective To investigate the effects of improved end-to-end invagination pancreaticojejunostomy on the occurrence of pancreatic fistula after pancreaticoduodenectomy. Methods The clinical data of 396 patients who received pancreaticoduodenectomy at the Cancer Hospital of Shandong Province from January 2001 to January 2011 were retrospectively analyzed. All patients were divided into the improved group （235 patients） and tradi- tional group （161 patients） according to different anastomotic methods. All tile operations were done by the same surgical group, and the digestive tract was reconstructed by the Child method. Patients in the improved group received improved end-to-end invagination pancreaticojejunostomy, and patients in the traditional group received traditional end-to-end anastomosis. The volume of operative bleeding, operation time, incidence of pancreatic fistula and duration of hospital stay of the 2 groups were compared. All data were analyzed using the t test, chi- square test or Fisher exact probability. Results The operative blood loss, operation time and duration of hospital stay were （383 ±56）ml, （7.2 ± 1.0）hours, （21±3）days in the improved group, and （381±39）ml, （7.0 ± 0.5） hours, （22 ± 5 ）days in the traditional group, with no significant difference between the 2 groups （t = 0. 388, 1. 680, - 1. 835, P 〉 0.05 ）. No operative death was detected in the 2 groups, and the overall incidence of pancreatic fistula was 7.6% （30/396）. The incidence of pancreatic fistula of the improved group was 0 （0/235）, which was significantly lower than 18.6% （30/161） of the traditional group （ P 〈 0.05 ）. Patients complicated with pancreatic fistula in the traditional group were cured by drainage, somatostatin administration and parenteral nutrition. Conclusion hnproved end-to-end invagination pancreaticojejunostomy can significantly reduce the incidence of pancreatic fistula after pancreaticoduodenectomy. Key words: Periampullary neoplasms ; Pancreaticoduodenectomy; Pancreaticojejunostomy; Pancre-atic fistula

Objective To investigate the application value of double-layer continuous suture in pancreatic jejunum anastomosis of pancreatoduodenectomy (PD). Methods A retrospective analysis of 114 consecutive patients (67 men and 47 women) who underwent PD from June 2012 to July 2013 were conducted. There were 79 patients who were treated by double-layer continuous suture technique and 35 patients by double-layer interrupted suture technique. The incidence of pancreatic fistula and other complications after PD with two different suture techniques were compared. Results The operation time of double-layer continuous suture group and double-layer interrupted suture group is respectively (284±5) and (288±7) mins, the intraoperative bleeding volume is respectively (236±29) and (282±49) ml, the differences between two groups were no statistical significance. The postoperative fasting time in two group was respectively (7.8±0.5) and (9.7± 0.5) days, the length of hospital stay time was respectively (14.0±1.0) and (17.2±10.0) days, the incidence of postoperative pancreatic fistula (POPF) was respectively 17.1%(6/35) and 39.2%(31/79), the differences between two groups were statistically significant(all P<0.05). Grade A POPF was found in 4 patients (11.4%) from the double-layer continuous suture group and in 5 patients (6.3%) from the double-layer interrupted suture group. Grade B POPF was identified only in 1 patients (2.9%) from the double-layer continuous suture group and in 23 patients (29.1%) from the double-layer interrupted suture group. The presence of Grade C POPF was only documented in 1 patient from the double-layer continuous suture group and in 3 patients from the interrupted suture group. Conclusions Continuous suture can be safely used in the duct-to-mucosa pancreatojejunostomy. The double-layer continuous suture can be more effective in reducing pancreatic fistula, improving the feeding time, and reducing the length of hospital stay, and it is worthy of clinical popularization and application. Key words: Pancreatoduodenectomy; Pancreaticojejunostomy; Suture techniques

To define a simple and reproducible classification of complications following pancreaticoduodenectomy (PD) based on a therapy-oriented severity grading system. While mortality is rare after PD, morbidity rates remain high. The lack of standardization in evaluating morbidity after PD has severely hampered meaningful comparisons over time and among centers. We adapted a novel classification of complication to stratify morbidity by severity after PD, to test whether the incidence of pancreatic fistula has changed over time, and to identify risk factors in a single North American center. The classification was applied to a consecutive series of 633 patients undergoing PD between February 2003 and August 2005. Another series of 141 patients treated between 1987 and 1990 was also analyzed to identify changes in the incidence and severity of fistula. Univariate and multivariate analyses were performed to link respective complications with preoperative and intraoperative parameters, length of hospital stay, and long-term survival. A total of 263 (41.5%) patients did not develop any complication, while 370 (58.5%) had at least one complication; 62 (10.0%) patients had only grade I complications (no need for specific intervention), 192 patients (30.0%) had grade II (need for drug therapy such as antibiotics), 85 patients (13.5%) had grade III (need for invasive therapy), and 19 patients (3.0%) had grade IV complications (organ dysfunction with ICU stay). Grade V (death) occurred in 12 patients (2.0%). A total of 57 patients (9.0%) developed pancreatic fistula, of which 33 (58.0%) were classified as grade II, 17 (30.0%) as grade III, 5 (9.0%) as grade IV, and 2 (3.5%) as grade V. Delayed gastric emptying was documented in 80 patients (12.7%); half of them were scored as grade II and the other half as grade III. A significant decrease in the incidence of fistula was observed between the 2 periods analyzed (14.0% vs. 9.0%, P < 0.001), mostly due to a decrease in grade II fistula. Cardiovascular disease was a risk factor for overall morbidity and complication severity, while texture of the gland and cardiovascular disease were risk factors for pancreatic fistula. This study demonstrates the applicability and utility of a new classification in grading complications following pancreatic surgery. This novel approach may provide a standardized, objective, and reproducible assessment of pancreas surgery enabling meaningful comparison among centers and over time.

Background Whipple is currently the procedure of choice in the treatment of localized pancreatic cancer. Isolated Roux-en-Y loop pancreaticojejunostomy was proposed as a method of reconstruction following pancreaticoduodenectomy. The idea is to isolate the bile from pancreatic secretions to minimize pancreatic enzyme activation and ultimately pancreatic fistula formation. It was also proposed that if a pancreatic fistula develops, it will be a pure fistula and thereby more benign as opposed to a mixed pancreatic fistula containing bile. Objective To estimate the incidence of pancreatic fistula in patients undergoing isolated Roux-en- Y hepaticojejunostomy reconstruction following pancreaticoduodenectomy. Patients and Methods In this prospective observational study, our aim is to calculate the incidence of post-operative pancreatic fistula in 20 patients that underwent Roux-en-Y isolated biliary limb reconstruction following pancreaticoduodenectomy for the treatment of pancreatic cancer. The study includes patients that underwent this procedure at Ain Shams University Hospitals in the period between January 2021 and July 2022 with a post-operative follow up period of 3 weeks. Patients were diagnosed with pancreatic cancer using MRI or CT scans with some of them also undergoing endoscopic US with biopsy. They were then admitted to one of the two main Ain Shams University Hospitals for pre-operative preparation. Results Our study did no estimate post-operative complications such as delayed gastric emptying and wound infection. Pancreaticoduodenectomy is a major surgery that carries a significant burden in terms of morbidity and mortality. Post-operative pancreatic fistula can be fatal as it can lead to vascular pseudoaneurysms that may fatally rupture. The idea behind using isolated biliary limb roux-en-y reconstruction is to alleviate the morbidity caused by post-operative pancreatic fistula. Conclusion Further comparative studies with a higher number of patients are recommended to assess and compare the value of isolated biliary limb reconstruction when compared to conventional reconstruction.

ObjectiveThe objective of this study is to investigate the association between the incidence of pancreatic fistula after pancreaticoduodenectomy (PD) and the degree of pancreatic fibrosis. MethodBetween January 2013 and December 2016, the analysis of the clinical data of 529 cases of pancreaticoduodenectomy patients of our hospital was performed in a retrospective fashion. The univariate analysis and multivariate analysis were done using the Pearson chi-squared test and binary logistic regression analysis model; correlations were analyzed by Spearman rank correlation analysis. The value of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy was evaluated by the area under the receiver operating characteristic (ROC) curve. ResultsThe total incidence of pancreatic fistula after pancreaticoduodenectomy was 28.5% (151/529). Univariate analysis and multivariate analysis showed that BMI ≥ 25 kg/m2, pancreatic duct size ≤ 3 mm, pancreatic CT value< 30, the soft texture of the pancreas (judged during the operation), and the percent of fibrosis of pancreatic lobule ≤ 25% are prognostic factors of pancreatic fistula after pancreaticoduodenectomy (P < 0.05); the pancreatic CT value and the percent of fibrosis of pancreatic lobule in pancreatic fistula group were both lower than those in non-pancreatic fistula group (P < 0.05). Results indicated that there is a negative correlation between the severity of pancreatic fistula and the pancreatic CT value or the percent of fibrosis of pancreatic lobule (r = − 0.297, − 0.342, respectively). The areas under the ROC curve of the percent of fibrosis of pancreatic lobule and the pancreatic CT value were 0.756 and 0.728, respectively. ConclusionThe degree of pancreatic fibrosis is a prognostic factor which can influence the pancreatic texture and the incidence of pancreatic fistula after pancreaticoduodenectomy. The pancreatic CT value can be used as a quantitative index of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy.

Some one-fifth of patients may have accessory spleens (AcS) and require their removal at the time of splenectomy to achieve and maintain hematological response. The purpose of this study was to evaluate the benefit of computed tomography (CT) in patients undergoing laparoscopic splenectomy (LS). All patients who required splenectomy were offered LS and underwent preoperative contrast-enhanced CT scan to detect and locate AcS. The surgeon was not blinded to the result of the CT scan. Patients were followed up to determine if there was recurrent disease. Between 2000 and 2007, 58 consecutive patients (31 men) were referred for splenectomy and all underwent LS. Preoperative CT scan detected 11 AcS in 11 patients (19%), of which 9 were confirmed during LS; the remaining 2 patients suffered with ITP preoperatively and had a good hematologic response to LS. At LS, 14 AcS were found in 13 patients (22%), of which 4 patients had negative preoperative CT scan; those additional AcS were readily found and were located close to the lower pole or hilum of the spleen. All removed AcS were confirmed histologically. In one patient who had LS and removal of AcS for ITP a further AcS within the tail of the pancreas was detected 1 year postoperatively on CT after thrombocytopenia relapsed. The sensitivity and specificity of CT scan for the detection of AcS were 60% and 95.6%, and the corresponding values for laparoscopy were 93.3% and 100%, respectively. Pairwise comparison of the ROC curves identified laparoscopy to be associated with a significantly higher area under the curve compared with CT scan (0.967 vs. 0.673; P = 0.004). Accessory spleens can be readily detected at laparoscopy in the vicinity of the spleen; preoperative CT scan for their detection and localization may not be necessary.

Introduction Pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV) reconstruction are often required to achieve complete (R0) resection for pancreatic head cancer (PHC) with tumor invasion of the SMV. Augmented reality (AR) technology can be used to assist in determining the extent of SMV involvement by superimposing virtual 3-dimensional (3D) images of the pancreas and regional vasculature on the surgical field. Materials and Methods Three patients with PHC and tumor invasion of the SMV underwent AR-assisted PD with SMV resection and reconstruction following preoperative computed tomography scanning. Preoperative imaging data were used to reconstruct 3D images of anatomical structures, including the tumor, portal vein (PV), SMV, and splenic vein (SV). Using AR software installed on a smart phone, the reconstructed 3D images were superimposed on the surgical field as viewed in a smart phone display to provide intermittent navigational assistance to the surgeon in identifying the boundaries of PHC tumor invasion for resection of the vessels involved. Result All patients successfully completed the operation. Intraoperative AR applications displayed virtual images of the pancreas, SMV, bile duct, common hepatic artery (CHA), and superior mesenteric artery (SMA). Two patients required end-to-end anastomosis for reconstruction of the SMV. One patient required allogenic vascular bypass to reconstruct the SMV-PV juncture with concomitant reconstruction of the SV-SMV confluence by end-to-side anastomosis of the SV and bypass vessel. Postoperative pathology confirmed R0 resections for all patients. Conclusion AR navigation technology based on preoperative CT image data can assist surgeons performing PD with SMV resection and reconstruction.

Background: The use of preoperative imaging in anorectal abscesses (AA) is still debated. It is customary to treat AA based solely on clinical findings. Several short- and long-term sequelae of AA have been described such as abscess persistence, recurrence, and anal fistula formation. The current literature does not clarify whether additional preoperative imaging is beneficial. Objectives: This study aims to investigate whether performing a preoperative computed tomography (CT) scan influences the outcome after drainage and AA recurrence. Design: Retrospective cohort study. Settings: Patient files. Patients (Materials) and Methods: All consecutive patients undergoing AA drainage between January 2015 and January 2020 were studied retrospectively. The patients who underwent a preoperative computed tomography (preCTI) were compared to those without preoperative imaging (noCTI). Main Outcome Measures: Abscess persistence requiring re-intervention and AA recurrence. Sample size: Two-hundred and nineteen patients were included in this study. Results: Preoperative CT scans were performed in 93 patients. The median length of stay was 1 day. The overall median follow-up duration was 56 days. Male and obese patients were more likely to undergo preoperative CT scans. There was no difference in re-intervention for abscess persistence or recurrence. More drains were placed in the preCTI group (P = .0001), and postoperative antibiotics were administered more often (P = .0008) in this group. Conclusion: Routine preoperative CT imaging in acute anorectal sepsis has no benefit in terms of outcomes, namely abscess persistence or recurrence after 30 days. In the preCTI group, an additional drain was placed in a greater number of cases, and postoperative antibiotics were administered more frequently.

Background: The use of somatostatin analogues (SAs) following pancreaticoduodenectomy (PD) is controversial. Method: Literature databases were searched systematically for relevant articles. A meta-analysis of all randomized controlled trials (RCTs) evaluating prophylactic SAs in PD was performed. Results: Fifteen RCTs involving 1,352 patients were included. There was a towards reduced incidences of pancreatic fistulas (p = 0.26), clinically significant pancreatic fistulas (p = 0.08), and bleeding (p = 0.05) in prophylactic SAs group. In subgroup analyses, prophylactic somatostatin significantly reduced the incidence of pancreatic fistulas (p = 0.02), with a nonsignificant trend toward reduced incidence of clinically significantly pancreatic fistulas (p = 0.06). Pasireotide significantly reduced the incidence of clinically significantly pancreatic fistulas (p = 0.03). Octreotide had no influence on the incidence of pancreatic fistulas. Conclusion: The current best evidence suggests prophylactic treatment with somatostatin or pasireotide has a potential role in reducing the incidence of pancreatic fistulas, while octreotide had no influence on the incidence of pancreatic fistulas. High-quality RCTs assessing the role of somatostatin and pasireotide are required for further verification.

Pancreaticogastrostomy is associated with significantly less pancreatic fistula than pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: a meta‐analysis of seven randomized controlled trials

Multiple risk or protective factors for postoperative pancreatic fistula (POPF) have been suggested in the literature of surgical specialities. We aimed to map existing evidence regarding the risk factors for POPF to help guide future clinical treatment. We performed an umbrella review by searching the Web of Science, PubMed, Embase, and Cochrane databases until June 19, 2023. Meta-analyses (MAs) that included ≥2 studies were included. Methodological quality was assessed using AMSTAR2 scores and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tools were used to quantify the strength of the evidence. Of the 42 MAs, 1 was rated as having high methodological quality, and 4 were rated as moderate. Among the 82 outcomes, 6 were supported by high-quality evidence. Moderate-quality evidence was found for 13 outcomes. The remaining outcomes had either low- or very low-quality evidence. In pancreaticoduodenectomy (PD), protective factors for all-grade POPF include pancreaticogastrostomy (PG) [vs. pancreaticojejunostomy (PJ), moderate quality], external pancreatic ductal stent (vs. no stents, high quality). Risk factors for all-grade POPF in PD include pancreatic duct occlusion (vs. no occlusion, moderate quality) and sealant (vs. no sealant, moderate quality). Polyglycolic acid mesh [vs. no mesh, moderate quality] was a protective factor for clinically relevant POPF (CR-POPF) in PD, omental/falciform ligament wrapping (vs. no wrapping, low quality), and artery-first PD (vs. standard, low quality). In distal pancreatectomy (DP), no factors for all-grade POPF were rated as high- or moderate-quality evidence. Polyglycolic acid mesh (vs. no mesh, moderate quality) was a protective factor for CR-POPF in DP. No factors were rated as high- or moderate-quality evidence in other types of pancreatectomy. In addition, high- and moderate-quality evidence showed that there was little difference in the incidence of pancreatic fistula in PD between minimally invasive and open surgery, duct-to-mucosa and invaginated PJ, Roux-en-Y and conservative reconstruction, extended and standard lymphadenectomy, and in the incidence of pancreatic fistula in DP between fibrin sealant patch and no patch. This umbrella review found varying levels of evidence for the associations between different surgery-related risk factors for POPF. Given the wealth of existing evidence of relatively low quality, future research should focus on improving its credibility.