Binding Pancreaticojejunostomy Research Articles

Nomogram predicts CR-POPF in open central pancreatectomy patients with benign or low-grade malignant pancreatic neoplasms.

Central pancreatectomy (CP) is a standard surgical procedure for benign and low-grade malignant pancreatic neoplasms in the body and neck of the pancreas. Higher incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) after CP than after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has been reported, but no nomogram for prediction of CR-POPF after open CP has been previously established. Patients undergoing open CP for benign or low-grade malignant pancreatic neoplasms in the department of Hepatobiliary and Pancreatic (HBP) surgery of Shanghai Changhai Hospital affiliated to Naval Medical University between January 01, 2009 and December 31,2020 were enrolled. Pre-, intra- and post-operative parameters were analyzed retrospectively. A total of 194 patients, including 60 men and 134 women, were enrolled with median age of 52 years (21~85 years). 84 patients (43.3%) were overweight (BMI>23.0 Kg/m2) and 14 (7.2%) were obese (BMI>28.0 Kg/m2). Pathological diagnoses ranged from serous cystic neoplasm (32.5%), solid pseudopapillary neoplasm (22.2%), pancreatic neuroendocrine tumor (20.1%), intraductal papillary mucinous neoplasm (18.0%) to mucinous cystic neoplasm (5.2%). All patients had soft pancreatic texture. Main pancreatic duct diameters were ≤0.3cm for 158 patients (81.4%) and were ≥0.5cm in only 12 patients (6.2%). A stapler (57.7%) or hand-sewn closure (42.3%) were used to close the pancreatic remnant. The pancreatic anastomosis techniques used were duct to mucosa pancreaticojejunostomy (PJ)-interrupted suture (47.4%), duct to mucosa PJ-continuous suture (43.3%), duct to mucosa "HO" half-purse binding PJ (5.2%) and invaginating pancreaticogastrostomy (4.1%). Post-surgical incidences of CR-POPF of 45.9%, surgical site infection of 28.9%, postpancreatectomy hemorrhage of 7.7% and delayed gastric emptying of 2.1% were found. Obesity and pancreatic anastomosis technique were independent risk factors of CR-POPF, with a concordance index of 0.675 and an Area Under the Curve of 0.678. This novel nomogram constructed according to obesity and pancreatic anastomosis technique showed moderate predictive performance of CR-POPF after open CP.

Binding Pancreaticojejunostomy: Is It Safe?

Background:Postoperative pancreatic fistula (POPF) or leak from pancreaticojejunostomy (PJ) is one of the most common complications after pancreaticoduodenectomy (PD), with an incidence of 5%–30%. Various techniques have been advocated to bring down the incidence of POPF, but there is still none that can be called the “gold standard”. Peng's binding PJ (BPJ) was proposed as a good method of performing PJ with low fistula rates; we present our results with BPJ.Methods:The data of all patients who underwent PD with BPJ between January 2016 and March 2018 were retrospectively analyzed for demographics, clinical features, type of procedure performed, complications (especially POPF), hospital stay, morbidity, and mortality.Results:A total of 24 patients (18 males and 6 females) were identified. The mean age at the diagnosis was 65.5 ± 6.4 years. Majority of the patients had ampullary carcinoma (62.5%). The most common postoperative complication was delayed gastric emptying seen in 10 patients, whereas only 2 (8.33%) had POPF and there was one mortality.Conclusion:BPJ is safe and is associated with a low incidence of POPF.

Pancreatogastrostomy vs pancreatojejunostomy after pancreaticoduodenectomy: An updated meta-analysis of RCTs and our experience.

BACKGROUNDPancreatoduodenectomy (PD) is one of the most important operations in hepatobiliary and pancreatic surgery.AIMTo evaluate the advantages and disadvantages of pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG).METHODSThis meta-analysis was performed using Review Manager 5.3. All clinical randomized controlled trials, in which patients underwent PD with pancreatico-digestive tract reconstruction via PJ or PG, were included.RESULTSThe search of PubMed, Wanfang Data, EMBASE, and the Cochrane Library provided 125 citations. After further analysis, 11 trials were included from nine counties. In all, 909 patients underwent PG and 856 underwent PJ. Meta-analysis showed that pancreatic fistula (PF) was a significantly lower morbidity in the PG group than in the PJ group (odds ratio [OR] = 0.67, 95% confidence interval [CI]: 0.53-0.86, P = 0.002); however, grades B and C PF was not significantly different between the two groups (OR = 0.61, 95%CI: 0.34-1.09, P = 0.09). Postoperative hemorrhage showed a significantly lower morbidity in the PJ group than in the PG group (OR = 1.47, 95%CI: 1.05-2.06, P = 0.03). Delayed gastric emptying was not significantly different between the two groups (OR = 1.09, 95%CI: 0.83-1.41, P = 0.54).CONCLUSIONThere is no difference in the incidence of grades B and C PF between the two groups. However, postoperative bleeding is significantly higher in PG than in PJ. Binding PJ or binding PG is a safe and secure technique according to our decades of experience.

Risk factors analysis of pancreatic fistula after pancreaticoduodenectomy

Objective To investigate the risk factors of pancreatic fistula after pancreaticoduodenectomy. Methods The retrospective case-control study was conducted. The clinicopathological data of 310 patients who underwent pancreaticoduodenectomy in the First Affiliated Hospital of Sun Yat-Sen University between January 2011 and December 2015 were collected. Observation indicators: (1) follow-up situations; (2) risk factors analysis of pancreatic fistula after pancreaticoduodenectomy. Follow-up using outpatient examination and telephone interview was performed to detect occurrence of pancreatic fistula and pancreatic fistula-induced rehospitalization or death up to June 2016. The univariate and multivariate analyses were respectively done using the chi-square test and logistic regression model. Results (1) Follow-up situations: 310 patients were followed up for 6-60 months, with a median time of 31 months. During the follow-up, 65 patients were complicated with pancreatic fistula, including 59 in grade B and 6 in grade C. Twenty-four patients received conservative treatment, and 41 received B ultrasound-guided catheter drainage. Of 65 patients, 63 were improved and then discharged form hospital; 2 in grade C of pancreatic fistula died of pancreatic fistula-related complications. (2) Risk factors analysis of pancreatic fistula after pancreaticoduodenectomy: univariate analysis showed that combined hypertension, cases with pancreaticoduodenectomy, operation time and pancreaticojejunostomy method were related factors affecting pancreatic fistula after pancreaticoduodenectomy (χ2=5.986, 13.006, 9.025, 21.561, P 6 hours and end-to-end telescopic pancreatico-jejunostomy or binding pancreaticojejunostomy were independent risk factors affecting pancreatic fistula after pancreaticoduodenectomy (Odds ratio=2.465, 1.880, 2.719, 6.190, 95% confidence interval: 1.253-4.850, 1.025-3.448, 1.254-5.894, 2.309-16.592, P<0.05). Conclusion The combined hypertension, operation time > 6 hours and end-to-end telescopic pancreaticojejunostomy or binding pancreaticojejunostomy are independent risk factors affecting pancreatic fistula after pancreaticoduodenectomy. Key words: Pancreatic diseases; Pancreatic neoplasms; Pancreatic cancer; Pancreaticoduodenectomy; Pancreatic fistula; Pancreaticojejunostomy; Risk factors

Binding versus Conventional Pancreaticojejunostomy in Preventing Postoperative Pancreatic Fistula: A Systematic Review and Meta-Analysis

Background: The aim of this study was to compare the safety and efficacy of a new technology, binding pancreaticojejunostomy (BPJ), with conventional pancreaticojejunostomy (CPJ) after pancreaticoduodenectomy in preventing postoperative pancreatic fistula (POPF). Methods: Randomized controlled trials and observational studies were retrieved from literature searches. Pooled OR with 95% CI for dichotomous variables and weighted mean difference with 95% CI for continuous variables were calculated. Fixed-effect and random-effect models as well as subgroup analysis were used for sensitivity analysis. Results: No statistically significant differences were found in the incidence of POPF, delayed gastric emptying, postpancreatectomy hemorrhage, reoperation, morbidity, mortality, operation time, intraoperative blood loss, blood transfusion, and hospital stay between 2 groups. However, the total costs of hospitalization and ordinary stay were higher in BPJ group (€10,513 ± €6,536 vs. €8,238 ± €4,687, p = 0.002; €7,946 ± €5,023 vs. €5,700 ± €2,902, p = 0.015, respectively). Conclusions: Our study showed BPJ was as safe as CPJ. However, no significant superiority was found in BPJ group regarding the incidence of POPF. The total costs of hospital stay were higher for patients undergoing BPJ. Surgeons can prefer to perform the digestive tract reconstruction of their choice.

Efficacy analysis of double- "U" embedding and pursestring suture and binding pancreaticojejunostomy for the prevention of pancreatic leakage

Objective To investigate the efficacy of double- U embedding and pursestring suture and binding pancreaticojejunostomy for the prevention of pancreatic fistula. Methods The retrospective cohort study was adopted. The clinical data of 208 patients who underwent pancreaticojejunostomy at the Hunan Provincial People′s Hospital from March 2011 to March 2015 were collected. Of 208 patients, 106 patients undergoing double- U embedding and pursestring suture and binding pancreaticojejunostomy were allocated into the double- U group and 102 patients undergoing Child pancreaticojejunostomy were allocated into the Child group. Observation indicators included (1) surgical effects: anastomosis time, postoperative pancreatic leakage, duration of hospital stay, (2) follow-up situations. The follow-up using telephone interview and outpatient examination was performed to detect postoperative long-term complications and recovery of patients by abdominal ultrasound or computed tomography (CT) at every 6 months postoperatively up to September 2015. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed by t test. Count data were analyzed using the chi-square test. Results (1) Surgical effects: 208 patients underwent successful surgery without occurrence of death. The anastomosis time was (13.0±1.5)minutes in the double- U group and (20.0±1.6)minutes in the Child group, with a statistically significant difference between the 2 groups (t=4.713, P<0.05). Two patients in the double- U group were complicated with grade A of pancreatic leakage, including 1 of 36 patients with normal pancreatic remnant and 1 of 70 patients with fibrotic pancreatic remnant. Nine patients in the Child group were complicated with pancreatic leakage, including 6 in grade A, 1 in grade B and 2 in grade C, and there were 6 of 33 patients (4 in grade A, 1 in grade B, 1 in grade C) with normal pancreatic remnant and 3 of 69 patients (2 in grade A, 1 in grade C) with fibrotic pancreatic remnant. There were statistically significant differences in the pancreatic leakage between the 2 groups and among the patients with normal pancreatic remnant in the 2 groups (χ2=2.951, 4.994, P<0.05). The duration of postoperative hospital stay was (13.5±1.2)days in the double- U group and (15.7±2.6)days in the Child group, with a statistically significant difference (t=1.011, P<0.05). No readmission in the 2 groups occurred. (2) Follow-up situations: 91 of 106 patients in the double- U group were followed up for 6-54 months with a median time of 30 months. During the follow-up, 8 patients were dead, 12 patients didn′t undergo reoperation due to multiple metastases in the liver, lung and greater omentum, 4 and 4 patients were respectively complicated with relapsing pancreatitis and refluxing cholangitis, and other patients had good conditions without the occurrence of diabetes, diarrhea, indigestion and hypopancreatism. Eighty-eight of 102 patients in the Child group were followed up for 6-54 months with a median time of 25 months. During the follow-up, 10 patients were dead, 11 patients didn′t undergo reoperation due to multiple metastases in the liver, lung and greater omentum, 6 and 6 patients were respectively complicated with relapsing pancreatitis and refluxing cholangitis, and other patients had good conditions without the occurrence of diabetes, diarrhea, indigestion and hypopancreatism. Conclusion Double- U embedding and pursestring suture and binding pancreaticojejunostomy for the prevention of pancreatic fistula can reduce the suture time, incidence of pancreatic leakage and duration of postoperative hospital stay, and it is especially suitable for the patients with normal pancreatic remnant. Key words: Pancreatic diseases; Duodenal papillary neoplasms; Bile duct neoplasms; Double- U embedding and pursestring suture and binding pancreaticojejunostomy; Pancreaticojejunostomy; Pancreatic leakage

A multicentered randomized controlled trial comparing binding pancreaticojejunostomy to a novel binding pancreaticogastrostomy

A multicentered randomized controlled trial comparing binding pancreaticojejunostomy to a novel binding pancreaticogastrostomy

Binding pancreaticogastrostomy in laparoscopic central pancreatectomy: a novel technique in laparoscopic pancreatic surgery.

Even though more and more cases of laparoscopic central pancreatectomy (LCP) are reported (Machado et al. in Surg Laparosc Endosc Percutan Tech 23(6):486-490, 2013; Hong et al. in World J Surg Oncol 10:223, 2012; Gonzalez et al. in JOP 14(3):273-276, 2013, Zhang et al. in J Laparoendosc Adv Surg Tech A 23(11):912-918, 2013; Sucandy et al. in N Am J Med Sci 2(9):438-441, 2010; Sa Cunha et al. in Surgery 142(3):405-409, 2007), the management for pancreatic stumps remains the most technically challenging part which is the same as in pancreatoduodenectomy (PD), making it the bottleneck for laparoscopic pancreatic surgery. In open surgery, various pancreatic reconstruction techniques designed for either pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) have been attempted to reduce the postoperative pancreatic fistula (POPF), including the binding anastomosis, invented by our team, i.e., binding PG (BPG) and binding PJ, which have been proved to be effective to reduce the POPF (Hong et al. 2012; Peng et al. in Ann Surg 245(5):692-698, 2007; Peng et al. in Updates Surg 63(2):69-74, 2011). However, despite of this, few reports are seen addressing such technique for laparoscopic surgery even though laparoscopic pancreatic surgery is more performed. After a previous successful laparoscopic BPG in a case of laparoscopic CP (LCP; Hong et al. 2012) and more than 50 cases of open PD and CP (Peng et al. 2011), we further performed laparoscopic BPG in 10 consecutive cases of LCP with satisfactory outcomes. To explore the feasibility and efficacy of LCP with BPG. Between October 2011 and July 2014, LCP with laparoscopic BPG was performed in ten consecutive patients with lesions of benign or low malignancy at the pancreatic neck. Operative and pathological data, complications, hospital stay and details on the surgical techniques were introduced. The operations were successfully performed in all the ten cases, with no conversions. The tumor size ranged from 2.0-3.0 to 2.5-3.0 cm, average (2.50 ± 0.35) to (2.66 ± 0.35) cm, and the diameter of pancreatic duct was (1.6-2.1) mm, average (1.71 ± 0.17) mm. Operation time was 170-250 (198.50 ± 25.82) min, and blood loss was 20-300 (125 ± 107.31) mL. Three cases had grade A pancreatic fistula (PF), and one case had delayed gastric emptying, which were all managed with conservative treatment. Upper GI bleeding occurred in one case which was cured with second operation, time for the recovery of bowl movement was 3-5 (4.2 ± 0.8) days, the time for semifluid dieting was 6-10 (8.2 ± 1.5) days, and the hospital stay was 8-20 (12.8 ± 4.63) days. The postoperative fast blood sugar was (6.3 ± 1.6) mmol/L with the normal diet, which was not significantly different from the preoperative data (5.3 ± 0.5) mmol/L (P > 0.05). The postoperative pathology was as follows: five cases of cystic serous adenoma, one case of intraductal papillary mucinous neoplasm, two cases of neuroendocrine tumor, and two cases of solid pseudopapillary tumor of pancreas. All the patients were followed up for 7-40 months, no recurrence happened, and no new incidence of diabetes or insufficiency of pancreatic exocrine function occurred. LCP with BPG is feasible and safe; the advantages lie in its minimal invasiveness, the efficacy for avoiding PF, and the preservation of the pancreatic endocrine and exocrine function insufficiency, making it an ideal procedure for the benign or low-malignant lesions at the pancreatic neck.

Clinical value of penetrating-suture type of pancreaticojejunostomy after pancreaticoduodenectomy

Objective To investigate the clinical value of penetrating-suture type pancreaticojejunostomy (PPJ) after pancreaticoduodenectomy (PD).Methods The clinical data of 77 patients who received pancreaticoduodenectomy from Taixing People's Hospital from June 2002 to March 2012 were retrospectively analyzed.Of all the patients,34 received PPJ after PD (PPJ group),and the other 43 patients received PJ anastomosis (control group) based on the texture and size of the pancreas,pancreatic duct diameter (duct-to-mucosa pancreaticojejunostomy for pancreatic duct diameter ≥ 4 mm,end-to-end or binding pancreaticojejunostomy for pancreatic duct diameter ≤3 mm).Pancreatic fistula was diagnosed according to the criteria of the International Study Group on Pancreatic Fistula,including grade B or C pancreatic fistula with clinical value.Patients were followed-up through outpatient examination and telephone interview till May 2012.Data were presented by x ± s or median (range) and the t-test and Wilcoxon rank-sum test were used to evaluate quantitative data with or without normal distribution,respectively.Qualitative data were analyzed using Pearson x2 test or Fisher's exact test.Results The mean diameter of the pancreatic duct was 3 mm for both the PPJ group and the control group.The external drainage via the pancreatic duct stent was not used in the PPJ group,compared with 4 cases in the control group,showing a statistically significant difference between the 2 groups (x2=3.632,P ＜ 0.05).The duration of pancreaticojejunostomy was 12 minutes (range,8-25 minutes) in the PPJ group,while no records in the control group.The operation time and intraoperative blood loss in the PPJ group and the control group were (304 ± 60)minutes and (475 ± 75) mL,(304 ± 60) minutes and (500 ± 97) mL,respectively.Twenty-four (70.6％) patients in the PPJ group and 29 (67.4％) patients in the control group received intraoperative blood transfusion,with volume of 400 mL (range,300-800 mL) and 600 mL (range,300-1 200 mL),respectively.The median duration of postoperative hospital stay were 18 days (range,11-32 days) in the PPJ group and 20 days (range,9-44 days) in the control group.None of these comparisons were statistically significant between the 2 groups (t =1.293,0.619,x2=0.088,Z =0.165,0.074,P ＞0.05).The rate of grade B or C pancreatic fistula were 0 for the PPJ group and 27.9％ (12/43) for the control group,and the mortality rate of patients who had pancreatic fistula were 0 and 11.6％ (5/43) for the PPJ group and the control group,with statistical significance (x2=11.232,4.237,P ＜0.05).The overall incidence of bile leakage,peritoneal bleeding and delayed gastric emptying in the PPJ group and the control group were 5.9％ (2/34),2.9％ (1/34),5.9％ (2/34) and 11.6％ (5/43),7.0％ (3/43),14.0％ (6/43),with no significance difference (P ＞0.05).Fifty-six patients were followed up after operation from 9 months to 5 years.Pancreatic duct dilation was detected by imaging examination for 26 patients in the control group.Conclusions PPJ is a simple and feasible approach with better clinical efficacy after PD. Key words: Pancreaticoduodenectomy; Pancreaticojejunostomy; Penetrating-suture type pancreaticojejunostomy; Pancreatic fistula

A meta-analysis of pancreaticojejunostomy on pancreatic fistula after pancreaticoduodenectomy

To evaluate the pancreatic fistula affected by different type of pancreaticojejunostomy after pancreaticoduodenectomy. Electronic databases PubMed, EMBase, COCHRANE Library, Wanfang, and VIP etc were used to search for randomized controlled trials or non randomized prospective controlled trials reported before September 2013 on clinical effects of pancreaticojejunostomy after pancreaticoduodenectomy. The statistical analysis was done by Review Manager 5.0. A total of 8 trials were included in this meta-analysis. The effects of duct-to-mucosa pancreaticojejunostomy (dmPJ) and invaginating pancreaticojejunostomy (iPJ) on postoperative complication in five studies were compared, and no statistical significance were found in postoperative pancreatic fistula (POPF) (M-H:OR = 0.77, 95% CI:0.35-1.69, P = 0.52), reoperation (M-H:OR = 1.38, 95% CI:0.64-2.95, P = 0.41) and mortality (M-H:OR = 1.15, 95% CI:0.42-3.13, P = 0.79) between dmPJ and iPJ. The effects of binding pancreaticojejunostomy (bPJ) and conventional pancreaticojejunostomy (cPJ) (including duct-to-mucosa pancreaticojejunostomy and invaginating pancreaticojejunostomy) on postoperative complication were compared, and no statistical significance were found in postoperative pancreatic fistula (POPF) (M-H:OR = 0.57, 95% CI = 0.28-1.17, P = 0.13) , reoperation (M-H:OR = 1.18, 95% CI = 0.48-2.92, P = 0.72) and mortality (M-H:OR = 0.74, 95% CI = 0.27-1.99, P = 0.55) between bPJ and cPJ. There are no significant differences between dmPJ and iPJ in pancreatic fistula reoperation and mortality, and there are also no significant differences between bPJ and cPJ.

200 consecutive pancreatico-duodenectomies with the Finnish binding pancreaticojejunostomy (FBPJ): the prospective trial shows a low frequency of pancreatic fistula

200 consecutive pancreatico-duodenectomies with the Finnish binding pancreaticojejunostomy (FBPJ): the prospective trial shows a low frequency of pancreatic fistula

Reconstruction of pancreatic enteric anastomosis after pancreaticoduodenectomy

Pancreatic enteric anastomosis is an important step during pancreaticoduodenectomy. Based on the anastomosis site, pancreatic enteric anastomosis is classified as pancreaticojejunostomy anastomosis and pancreaticogastrostomy. Depending on the jejunum site, reconstruction can be perform as end-to-end or end-to-side anastomosis. Previous randomized clinical trials, showed no significant differences between pancreaticojejunostomy and pancreaticogastrostomy. Binding pancreaticojejunostomy and binding pancreaticogastrostomy are easy to perform. The rate of pancreatic leakage is related to the texture of the pancreas and the size of the pancreatic duct. It is helpful to reduce pancreatic leakage by placing a pancreatic duct stent. The simple and effective pancreatic enteric reconstruction is the future direction for minimizing leakage.

From the Hypothesis of Pancreatic Fistula to the Clinical Use of Binding Pancreaticojejunostomy

Over the past 100 years, Many techniques have been proposed for the reconstruction of the pancreaticodigestive anastomosis to prevent the development of a postoperative pancreatic fistula, but which is the best approach is still highly debated. The problem with the anastomosis techniques is that there is always a potential gap between the adjacent stitches, which could become the breaking point of pacreaticoenteric anastomosis leakage. Furthermore, there are needle holes on the surface of the anastomotic site after needle penetrating the sero-muscular layer. In case the needle penetrates a small branch of pancreatic duct, pancreatic juice could leak from the needle hole. Such a hypothesis forms the basis of the binding pancreaticojejunostomy. Binding pancreaticojejunostomy is a safe and effective technique that avoids the primary complication of pancreatic anastomosis leakage.

Preliminary results of binding pancreaticojejunostomy.

Backgrounds/AimsThe post-operative complications and clinical course of pancreaticoduodenectomy (PD) largely depend on the pancreaticojejunostomy (PJ). Several methods of PJ are in clinical use. We analyzed the early results of binding pancreaticojejunostomy (BPJ), a technique reported by SY Peng.MethodsWe retrospectively reviewed the clinical results of patients who received BPJ in Inha University Hospital from 2006 to 2011. 21 BPJs were performed with Peng's method. The definition of postoperative pancreatic fistula (PF) was a high amylase content (>3 times the upper normal serum value) of the drain fluid (of any measurable volume), at any time on or after the 3rd post-operative day. The pancreatic fistula was graded according to the International Study Group for Pancreatic Fistula (ISGPF) guidelines.ResultsOf the 21 patients who received BPJ, 11 were male. The median age was 61.2 years. PD surgery included 4 cases of Whipple's procedures and 17 cases of pylorus-preserving PD. According to the post-operative course, 16 patients recovered well with no evidence of PF. A total of 5 patients (23.8%), including 3 grade A PFs and 2 grade C PFs, suffered from a pancreatic fistula. 3 patients with grade A PF recovered with conservative management.ConclusionsThe BPJ appears to be a relatively safe procedure based on this preliminary study, but further study is needed to validate its safety.

Wound Healing after Mesh Inner Embedding and Outer Binding Pancreaticojejunostomy in Piglets

The aim of this study was to introduce a novel technique of pancreaticojejunostomy, namely, mesh inner embedding and outer binding pancreaticojejunostomy, and to evaluate wound healing after this operation in piglets. Thirty-six domestic piglets were randomly divided into 2 groups after pancreaticoduodenectomy: the mesh inner embedding and outer binding pancreaticojejunostomy group (n = 18) and the conventional double-deck invaginated pancreaticojejunostomy group (n = 18). Bursting pressure and breaking strength were assessed on the operative day and on days 7 and 14 postoperatively. The pathologic findings and collagen content of the anastomotic site were evaluated on days 7 and 14 postoperatively. Both the bursting pressure and breaking strength were significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 0, 7, and 14 (P < .01). The collagen content of the anastomotic site was significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 7 and 14 postoperatively (P < .01). The anastomotic site was more completely repaired by connective and granulation tissue in the mesh inner embedding and outer binding pancreaticojejunostomy group on day 7 than in the double-deck invaginated pancreaticojejunostomy group. Mesh inner embedding and outer binding pancreaticojejunostomy significantly enhanced the anastomotic firmness and sped up the wound healing process compared with conventional mesh inner embedding and outer binding pancreaticojejunostomy. Therefore, it may decrease the risk of pancreatic fistulas after pancreaticoduodenectomy.

Pancreaticodigestive anastomosis and the postoperative management strategies to prevent postoperative pancreatic fistula formation after pancreaticoduodenectomy

Over the past 100 years, advances in surgical techniques and perioperative management have reduced the morbidity and mortality after pancreaticoduodenectomy (PD). Many techniques have been proposed for the reconstruction of the pancreaticodigestive anastomosis to prevent the development of a postoperative pancreatic fistula (POPF), but which is the best approach is still highly debated. We carried out a systematic review to determine and compare the effectiveness of various methods of anastomosis after PD. A meta-analysis and most randomized controlled trials (RCTs) showed that the mortality, POPF rate and incidence of other postoperative complications were not statistically different between the pancreaticogastrostomy and pancreaticojejunostomy (PJ) groups. One RCT showed that a binding PJ significantly decreased the risk of POPF and other postoperative complications compared with conventional PJ. External duct stenting reduced the risk of clinically relevant POPF in a meta-analysis and RCTs. The prophylactic use of octreotide after PD does not result in a reduced incidence of POPF. In conclusion, our findings suggest that the successful management of pancreatic anastomoses may depend more on the meticulous surgical technique, surgical volume, and other management parameters than on the type of technique used. However, some new approaches, such as binding PJ, and the use of external stents should be considered in further RCTs.

Hemorrhage from the pancreatic cut end into the jejunum after binding pancreaticojejunostomy: report of a case

Recent studies have described that binding pancreaticojejunostomy (PJ) decreased the incidence of postoperative pancreatic fistulas and complications after pancreaticoduodenectomy. We herein describe the case of a 77-year-old male with papilla of Vater cancer who underwent subtotal stomach-preserving pancreaticoduodenectomy with end-to-side binding PJ. He developed postoperative gastrointestinal bleeding from the pancreatic cut end three separate times. Transcatheter arterial embolization was performed for the first bleeding event. Surgical hemostasis was performed and a temporary jejunostomy was constructed at the jejunal stump for the second event. For the third bleeding event, endoscopic coagulation through the jejunostomy was performed successfully, and no further bleeding was noted.

Peng's binding pancreaticojejunostomy after pancreaticoduodenectomy. An Italian, prospective, dual-institution study

ObjectiveTo evaluate Peng's binding pancreaticojejunostomy as a safe technique which avoids anastomotic leakage after a pancreaticoduodenectomy. MethodsProspective, observational, dual-institutional study, of patients who underwent a Peng's binding pancreaticojejunostomy was conducted. It was compared with an historical control group of patients who underwent duct to mucosa pancreaticojejunostomy. Overall postoperative mortality, morbidity, postoperative pancreatic fistulas, postpancreatectomy hemorrhage, reoperation, length and costs of hospital stay were collected. Factors related with pancreatic fistula were: sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, type of resection, extension of resection, characteristics of the pancreatic remnant, pathological diagnosis and surgeons. Univariate and multivariate analyzes were carried out. ResultsSixty-nine patients who underwent binding pancreaticojejunostomy were reported. The control group consisted of 52 patients. The mean length of hospital stay was significantly shorter in the control group than in binding group (p = 0.003). Multivariate analyzes showed that soft pancreatic remnant was significantly related to an increasing rate of postoperative pancreatic fistula (OR 3.7-CI 1.1–12.8-P = 0.034) while the type of pancreatic anastomosis was not significantly related with the occurrence of postoperative pancreatic fistula. ConclusionsIn the European population, the binding pancreaticojejunostomy according to Peng did not preclude or reduce the postoperative pancreatic fistula rate.

Is Peng's Pancreaticojejunal Anastomosis More Effective Than Mucosa–Mucosa Anastomosis in Duodenopancreatectomy for Pancreatic and Peri-ampullary Tumours?

IntroductionThe pancreatic fistula is the most feared complication after a duodenopancreatectomy, and is the most common independent factor of post-surgical mortality. Peng et al. recently published a pancreaticojejunal anastomosis technique (binding anastomosis) which showed 0% pancreatic fistulas. The objective of this study is to evaluate and validate this new anastomosis technique compared with the conventional pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis. Material and methodA prospective, non-randomised study was conducted to evaluate and validate this new anastomosis technique compared with the conventional pancreaticojejunal terminolateral duct to mucosa anastomosis. The study included 63 patients who were subjected to a duodenopancreatectomy due to having a pancreatic or periampullary neoplasm.A binding pancreaticojejunostomy according to the technique described by Peng et al. was performed on 30 patients (Group A), and a pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis (conventional technique) was performed on 33 patients (Group B). ResultsWhen the results of the 2 techniques were compared, 2/30 (6%) of patients had a pancreatic fistula with the Peng technique, and 4/33 (12%) with the conventional technique, but this was not statistically significant (P=.674). Nor were there any significant differences between the 2 groups on comparing, morbidity, hospital stay and mortality. ConclusionThe results of this study show that the anastomosis method described by Peng is safe, but is not associated with a lower frequency of pancreatic fistula, general morbidity, or mortality. This leads to the uncertainty of whether it really has any advantages over other techniques.

¿Es la anastomosis pancreato yeyunal de Peng más efectiva que la anastomosis muco-mucosa en la duodenopancreatectomía por neoplasias de páncreas y periampulares?

IntroductionThe pancreatic fistula is the most feared complication after a duodenopancreatectomy, and is the most common independent factor of post-surgical mortality. Peng et al. recently published a pancreaticojejunal anastomosis technique (binding anastomosis) which showed 0% pancreatic fistulas. The objective of this study is to evaluate and validate this new anastomosis technique compared with the conventional pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis. Material and methodA prospective, non-randomised study was conducted to evaluate and validate this new anastomosis technique compared with the conventional pancreaticojejunal terminolateral duct to mucosa anastomosis. The study included 63 patients who were subjected to a duodenopancreatectomy due to having a pancreatic or periampullary neoplasm.A binding pancreaticojejunostomy according to the technique described by Peng et al. was performed on 30 patients (Group A), and a pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis (conventional technique) was performed on 33 patients (Group B). ResultsWhen the results of the 2 techniques were compared, 2/30 (6%) of patients had a pancreatic fistula with the Peng technique, and 4/33 (12%) with the conventional technique, but this was not statistically significant (P=.674). Nor were there any significant differences between the 2 groups on comparing, morbidity, hospital stay and mortality. ConclusionThe results of this study show that the anastomosis method described by Peng is safe, but is not associated with a lower frequency of pancreatic fistula, general morbidity, or mortality. This leads to the uncertainty of whether it really has any advantages over other techniques.