External Drainage Of Pancreatic Juice Research Articles

Is the enteral replacement of externally drained pancreatic juice valuable after pancreatoduodenectomy?

External drainage of pancreatic juice using a pancreatic duct stent following pancreatoduodenectomy is widely performed. We hypothesized that the replacement of externally drained pancreatic juice would help to prevent postoperative complications, including pancreatic fistulas. Sixty-four patients who underwent pancreatoduodenectomy between 2006 and 2008 were randomly assigned to either a pancreatic juice non-replacement (NR) or replacement (R) group. Eighteen patients were excluded from the analysis because they had unresectable tumors (n = 4), low pancreatic juice output (<100 ml) (n = 11) or for other reasons (n = 3). A total of 46 patients (NR = 24, R = 22) were included in the final analysis. The volume and amylase levels of externally drained pancreatic juice were analyzed on postoperative days 7 and 14. The incidence of postoperative complications, including pancreatic fistulas and delayed gastric emptying, was also assessed. The total amylase secretion from the pancreatic tube on postoperative day 7 was significantly higher in the NR group compared with the R group (P = 0.044). The incidence of pancreatic fistulas (>Grade B) was also significantly higher in the NR group (33.3 vs. 9.1 %, P = 0.046). In cases for whom external pancreatic juice drainage from a stent is applied following pancreaticojejunostomy, enteral replacement of externally drained pancreatic juice may reduce the incidence of postoperative pancreatic fistula formation.

No mortality after 150 consecutive pancreatoduodenctomies with duct‐to‐mucosa pancreaticogastrostomy

The mortality rate after pancreatoduodenectomy (PD) remains 0-5% at major surgical centers with the major cause of operative death being a leak at the pancreaticojejunal anastomosis. The aim of this retrospective study was to evaluate the safety of duct-to-mucosa pancreaticogastrostomy (PG) at a single institute. One hundred fifty consecutive patients with pancreato-biliary diseases undergoing duct-to-mucosa PG following PD between 1995 and 2005 were evaluated. One hundred forty patients underwent a pylorus-preserving PD and 10 patients underwent a conventional PD (Whipple operation). External drainage of pancreatic juice was performed in 77 cases. The mean operating time was 378 min and the mean blood loss was 1,640 ml. Blood transfusion was not required in 97 patients (65%). The morbidity rate was 50% (75/150), but the mortality rate was 0%. Pancreatic fistulae occurred in 11 patients (7%). Gender, age, operative procedure, portal vein resection, external drainage of the pancreatic juice, operative time, blood loss and blood transfusion did not affect the rate of pancreatic fistula. The rate of pancreatic fistulae tended to be lower in pancreatic carcinoma (3%) than non-pancreatic carcinoma (11%). Duct-to-mucosa PG is a safe procedure for reconstruction following PD.

Is major hepatectomy with pancreatoduodenectomy justified for advanced biliary malignancy?

Major hepatectomy with concomitant pancreatoduodenectomy (M-HPD) is usually indicated for the resection of diffuse bile duct cancer or advanced gallbladder cancer. This is the only procedure that can potentially cure such advanced cancers, so both a low mortality rate and long-term survival could potentially justify performing this procedure. Between 1990 and 2005, the morbidity, mortality, and long-term survival of 26 patients with advanced biliary tract carcinoma 14 with diffuse bile duct cancer, 9 with advanced gallbladder cancer, and 3 with hilar bile duct cancer, who underwent hepatopancreatoduodectomy (HPD) were reviewed and analyzed. The overall morbidity and mortality rates were 30.8% and 0%, respectively. Postoperative infectious complications occurred in 6 patients (23.0%). The 5-year survival rate of the 14 patients with diffuse bile duct cancer who underwent HPD was 51.9%, while the 5-year survival rate in the 12 of these patients who underwent M-HPD was 61.4%. Patients with diffuse bile duct cancer without residual tumor and those without lymph node metastasis had 5-year survival rates of 68.6% and 80%, respectively. Thirty-three percent (2 of 6) of the patients who underwent M-HPD for advanced gallbladder cancer survived for more than 5 years. Preoperative biliary drainage, portal embolization, complete external drainage of pancreatic juice, reduction of intraoperative bleeding, and prevention of bacterial colonization of bile may enable the incidence of mortality and hepatic failure to approach zero in patients who undergo HPD. Surgeons should strive for complete clearance of the tumor with a negative surgical margin to achieve long-term survival when performing M-HPD.

Interventional pancreaticojejunostomy after pancreatoduodenectomy

Leakage from the pancreaticoenteric anastomosis after pancreatoduodenectomy (PD) is closely associated with intra-abdominal hemorrhage with ensuing high mortality. Interventional pancreaticojejunostomy was performed in 10 patients with external drainage of pancreatic juice after two-staged PD or leakage from pancreaticojejunostomy after PD. The jejunum was punctured using a 22-gauge needle into the pancreatic fistula during endoscopic observation of the jejunal lumen, followed by the insertion of two 0.35-inch guide-wires into the jejunum and pancreatic fistula. Finally, a stenting tube was placed between the jejunum and pancreatic fistula. No severe complications developed. Oral intake was instituted the following day in 8 of 10 patients, and on the 7th day in the remaining two patients. This interventional procedure is considered to be safe and easy to perform, and in the future, it may permit a reduction in the number of second laparotomies in pancreatic fistula.

Jejunal Loop Drainage Versus Direct Pancreatic Duct Drainage After Pancreatic Head Resection

Perioperative mortality after pancreatic head resection has fallen to below 5% in high-volume centers, but dehiscence of the pancreatojejunostomy remains a major concern. Despite various methods of protection, insufficiency rates still range from 6% to 19%. External drainage of pancreatic juice from the anastomotic site has shown promising results in the last decade. We compared the morbidity and mortality of two widely used drainage systems. The subjects were 143 patients who underwent pancreatic head resection, followed by jejunal loop drainage with the top of the drain being placed between the pancreatojejunostomy and hepaticojejunostomy in 89, and by direct drainage of the pancreatic duct in 54. The median age was similar in both groups. Pancreatic fistula developed in 3 (5%) patients with a pancreatic drain and 6 (7%) with a loop drain. Breakdown of the pancreatojejunostomy occurred in 1 (2%) patient with a pancreatic drain and 2 (2%) with a loop drain. The overall perioperative mortality was 0.7%. The surgical and medical complications and postoperative course were similar in the two groups. The choice of drainage system did not impact on the number or severity of postoperative complications or survival, indicating that loop drainage is as safe and effective as direct pancreatic duct drainage.

Two-staged pancreatoduodenectomy with external drainage of pancreatic juice and omental graft technique

Although operative mortality after pancreatoduodenectomy (PD) has been reduced dramatically by improvements in surgical techniques and perioperative care and the indications for PD have been expanded to more risky cases such as the very aged or emergency patients, 1-3 pancreatic leakage, once it has occurred, may cause severe infection and subsequent fatal bleeding from the stumps of the major vessels, contributing to postoperative mortality. High-risk patients with severe chronic liver diseases such as liver cirrhosis (LC) have been excluded as candidates for PD. Here, we report a successful two-staged PD with external drainage of pancreatic juice and omental graft technique in a patient with LC receiving anticoagulant therapy after cardiac valve replacement. TECHNIQUE

Outcome of Major Hepatectomy with Pancreatoduodenectomy for Advanced Biliary Malignancies

In patients with advanced biliary malignancies a chance of curability is obtained by performing only major hepatectomy with concomitant pancreatoduodenectomy. This aggressive procedure carries two major risks: hepatic failure and pancreatic anastomotic leakage. Ten patients with advanced biliary malignancies were treated by major hepatectomy with pancreatoduodenectomy. Nine patients underwent right portal venous embolization before hepatectomy. Complete external drainage of pancreatic juice followed by second-stage pancreatojejunostomy was performed in five patients. Three of these five underwent concomitant resection of the hepatic artery, portal vein, or both. Pancreatogastrostomy was chosen for five patients who required no concomitant vascular resection. There were no hospital deaths or hepatic failures. Leaks from pancreatogastrostomy occurred in two patients. In five patients who underwent external drainage of pancreatic juice, there were no complications related to the pancreatic stump, although one had ischemic necrosis of the jejunal segment and laparotomy was repeated. Mean survival time was 31.8 months (range 13-59 months). Portal venous embolization and complete external drainage of pancreatic juice followed by late stage pancreatojejunostomy are recommended surgical procedures for patients undergoing major hepatectomy with pancreatoduodenectomy, especially when concomitant vascular resection is required for curative resection of the tumor in patients with a soft pancreatic parenchyma and thin pancreatic duct.

Second-stage pancreatojejunostomy following pancreatoduodenectomy in high-risk patients

Tube pancreatostomy for complete external drainage of pancreatic juice following pancreatoduodenectomy and a subsequent second-stage pancreatojejunostomy were carried out in four high-risk patients without morbidity. This procedure avoids the fatal outcome associated with pancreatojejunal anastomotic leakage following pancreatoduodenectomy in emergency and high-risk cases.