Invagination Pancreaticojejunostomy Research Articles

An improved invagination pancreaticojejunostomy technique associated with a lower incidence of pancreatic fistula: A single-center study

PurposeThis study compared the incidence of postoperative pancreatic fistula (POPF) between standard invagination pancreaticojejunostomy (PJ) and an improved PJ technique after pancreaticoduodenectomy and evaluated the clinical utility of the improved PJ procedure. MethodsClinical and postoperative data of 363 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Soochow University from February 2018 to October 2021 were analyzed retrospectively. In our cohort, 155 patients underwent the improved PJ technique (group A), and 208 underwent standard invagination PJ (group B). Data on demographic characteristics, pathological nature, intraoperative factors, and postoperative complications, including POPF, were collected and analyzed. ResultsThere were no significant between-group differences in demographic characteristics (p > 0.05). The improved PJ technique was associated with a significantly lower incidence of clinically relevant POPF (CR-POPF) in the total cohort (11.6 % vs. 26.4 %, p < 0.001) and in the subgroup with high fistula risk scores (16.0 % vs. 38.6 %, p < 0.001). ConclusionThe improved invagination PJ technique reduces the incidence of CR-POPF and improves prognosis.

Safety and feasibility of modified duct-to-mucosa pancreaticojejunostomy during pancreatoduodenectomy: A retrospective cohort study.

Pancreatoduodenectomy (PD) is the most effective surgical procedure to remove a pancreatic tumor, but the prevalent postoperative complications, including postoperative pancreatic fistula (POPF), can be life-threatening. Thus far, there is no consensus about the prevention of POPF. To determine possible prognostic factors and investigate the clinical effects of modified duct-to-mucosa pancreaticojejunostomy (PJ) on POPF development. We retrospectively collected and analyzed the data of 215 patients who underwent PD between January 2017 and February 2022 in our surgery center. The risk factors for POPF were analyzed by univariate analysis and multivariate logistic regression analysis. Then, we stratified patients by anastomotic technique (end-to-side invagination PJ vs modified duct-to-mucosa PJ) to conduct a comparative study. A total of 108 patients received traditional end-to-side invagination PJ, and 107 received modified duct-to-mucosa PJ. Overall, 58.6% of patients had various complications, and 0.9% of patients died after PD. Univariate and multivariate logistic regression analyses showed that anastomotic approaches, main pancreatic duct (MPD) diameter and pancreatic texture were significantly associated with the incidence of POPF. Additionally, the POPF incidence and operation time in patients receiving modified duct-to-mucosa PJ were 11.2% and 283.4 min, respectively, which were significantly lower than those in patients receiving traditional end-to-side invagination PJ (27.8% and 333.2 minutes). Anastomotic approach, MPD diameter and pancreatic texture are major risk factors for POPF development. Compared with traditional end-to-side invagination PJ, modified duct-to-mucosa PJ is a simpler and more efficient technique that results in a lower incidence of POPF. Further studies are needed to validate our findings and explore the clinical applicability of our technique for laparoscopic and robotic PD.

End-to-end invaginated pancreaticojejunostomy during minimally invasive pancreatoduodenectomy: technical description and single center experience.

Remarkable progress has been made in pancreatic surgery over the last decades with the introduction of minimally invasive techniques. Minimally invasive pancreatoduodenectomy (MIPD) remains one of the most challenging operations in abdominal surgery and it is performed in a few centers worldwide. The treatment of the pancreatic stump is a crucial step of this operation; however, the best strategy to perform pancreatic anastomosis is still debated. In this article, we describe the technical details of our original technique of modified minimally invasive end-to-end invaginated pancreaticojejunostomy (EIPJ) using video footage. In the current study, we retrospectively analyzed a pilot series of 67 consecutive cases of minimally invasive (7 robotic/60 fully laparoscopic) MIPD operated on at the General Surgery Department of the Panico Hospital, Tricase (Italy) between March 2017 and October 2022.The reconstruction phase involved an EIPJ, tailored using an intra-ductal anastomotic plastic stent. The aim of this study was to describe the technique and evaluate the short-term outcomes of patients undergoing MIPD with EIPJ. The mean operative time to perform the EIPJ was 21.57 ± 3.32min. Seven patients (10.5%) developed biochemical leaks and 13 (19.4%) developed clinically relevant pancreatic fistulas (grade B or C according to the definition of the International Study Group on Pancreatic Surgery). The early results confirm that this anastomosis is safe, easy to perform, and effective in the hands of hepatobiliopancreatic (HBP) surgeons with experience in minimally invasive surgery.

Novel end-to-side one-layer continuous pancreaticojejunostomy vs. end-to-end invaginated pancreaticojejunostomy in pancreatoduodenectomy: A single-center retrospective study.

Postoperative pancreatic fistula (POPF) is the most common critical complication after pancreatoduodenectomy (PD) and is the primary reason for increased mortality and morbidity after PD. We aim to investigate the clinical significance of a novel approach, i.e., end-to-side one-layer continuous pancreaticojejunostomy, for patients with PD. The clinical data of 65 patients who underwent pancreatoduodenectomy at the Xiangya Hospital, Central South University, from September 2020 to December 2021 were retrospectively analyzed. Forty patients underwent end-to-end invaginated pancreaticojejunostomy, and 25 underwent the novel end-to-side one-layer continuous pancreaticojejunostomy. No significant differences were observed in pancreatic fistula, intraperitoneal infection, intraperitoneal bleeding, reoperation, postoperative hospital stay, or perioperative death between the two groups. However, the novel end-to-side one-layer continuous pancreaticojejunostomy group had significantly shorter operation duration (32.6 ± 5.1 min vs. 8.3 ± 2.2 min, p < 0.001). The incidence of pancreatic fistula in the novel pancreaticojejunostomy group was 12%, including two cases of grade A POPF and only one case of grade B POPF. No cases of grade C POPF occurred. No deaths were observed during the perioperative period. The novel anastomosis method leads to a shorter operation duration than the traditional anastomosis method and does not increase postoperative complications. In conclusion, it is a simplified and feasible method for pancreatic anastomosis.

Impact of pancreatic fat infiltration on postoperative pancreatic fistula occurrence in patients undergoing invagination pancreaticojejunostomy

BackgroundNo studies to date have determined the impact of pancreatic fat infiltration on postoperative pancreatic fistula (POPF) occurrence in patients undergoing invagination pancreaticojejunostomy (IV-PJ). MethodsThe medical records of patients with a soft pancreas who underwent pancreatoduodenectomy followed by IV-PJ were reviewed . The pancreatic fat ratio on computed tomography (CT) images (I-PFR) was determined using preoperative CT and verified by histologic examination. The relationship between the I-PFR and POPF occurrence was determined. Patients were classified into 2 groups based on I-PFR value (fatty and non-fatty pancreas). Postoperative outcomes were compared between the two groups, and specifically among patients who developed POPF. ResultsOf 221 patients, POPF occurred in 67 (30.3%). I-PFR was positively correlated with histologic-calculated fat ratio (ρ = 0.517, p < 0.001). This index was shown to be an independent predictor of POPF. Based on an I-PFR cut-off value of 3.2%, 92 patients were classified in the fatty pancreas group. Subgroup analysis of the patients who developed POPF showed that incidence of abscess formation and hemorrhage tended to be higher in patients with fatty pancreas than in those with non-fatty pancreas. ConclusionsPancreatic fat infiltration is highly associated with POPF and possibly causes subsequent serious complications in patients undergoing IV-PJ.

In adults undergoing pancreatoduodenectomy, how does duct-to-mucosa compare with invagination pancreaticojejunostomy for the prevention of postoperative pancreatic fistula?

In adults undergoing pancreatoduodenectomy, how does duct-to-mucosa compare with invagination pancreaticojejunostomy for the prevention of postoperative pancreatic fistula?

Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy.

Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain. To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques. We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021). We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy. Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes. We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes. The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.

The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy.

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile. A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistulas (ISGPF) definition of POPF. The main outcomes were POPF and clinically relevant POPF. Three techniques of pancreatic anastomosis following PD were directly compared in 16 RCTs comprising 2365 patients. Overall, 929 patients underwent duct-to-mucosa pancreaticojejunostomy (PJ DTM), 760 patients' invagination pancreaticojejunostomy (PJ Inv), and 676 patients underwent pancreatogastrostomy (PG). The results of comparisons of POPF, clinically relevant POPF, biliary leakage, delayed gastric emptying (DGE), in hospital mortality, internal hemorrhage, reoperation in our network meta-analysis suggested there were no significant differences among the 3 procedures. There are no significant differences among PJ DTM, PJ Inv and PG in the prevention of POPF, clinically relevant POPF, biliary leakage, DGE, internal hemorrhage and reoperation. However, further randomized controlled trials should be undertaken to ascertain these findings.

Interventions to reduce post-operative pancreatic fistula after pancreaticoduodenectomy - do we need a change of direction? a systematic review and meta-analysis

Introduction: Various perioperative interventions designed to reduce postoperative pancreatic fistula (POPF) rate after pancreaticoduodenectomy (PD) have been evaluated, but most are unsuccessful. The aim of this study was to provide a contemporary report of the efficacy of different interventions and identify areas for future investigation in this complex field. Method: A systematic review of the literature for RCTs evaluating perioperative interventions to reduce POPF after PD was performed according to the PRISMA guidelines. Meta-anlayses were performed for each intervention. Results: Some 20 interventions (n=6,628 patients, 56 studies) were identified. Four interventions reduced POPF after PD on MA: external pancreatic stent vs. no stent (OR 0.42; 95%CI: 0.25-0.70); p< 0.005); invagination PJ vs. duct to mucosa PJ (OR 0.60; 95%CI: 0.40-0.90; p=0.01); pancreaticogastrostomy (PG) vs. PJ (OR 0.69; 95%CI: 0.49-0.99; p=0.04) and omission of intraabdominal drains in patients with low risk PJ anastomoses (OR 0.52; 95%CI: 0.34-0.81; p< 0.005). Two interventions with data available from only one RCT were shown to reduce POPF: end to side vs. classic pancreaticojejunostomy (PJ) (OR 0.25; 95%CI 0.07-0.96; p=0.041) and closed suction drainage of pancreatic duct (OR 0.44; 95%CI: 0.2-0.99; p=0.045). One intervention, acute normovolaemic haemodilution, increased POPF rate in one RCT (OR 3.29 95%CI:1.11-9.77; p=0.045). Conclusions: Current evidence for perioperative interventions to reduce POPF after PD is heterogenous and frequently from underpowered RCTs. To further clinical knowledge in this complex field future RCTs should be better powered and flexible enough to involve evaluation of the promising novel strategies identified in this review.

Clinical evaluation of modified invaginated pancreaticojejunostomy for pancreaticoduodenectomy

BackgroundPancreaticoduodenectomy (PD) remains the major curative operation for malignant neoplasm of pancreas or cancerous tumors near the pancreas. Despite advancements in recent years, the postoperative recurrence rate of these neoplasms and tumors remains high. Moreover, overall morbidity remains high due to clinically relevant postoperative pancreatic fistula (POPF).MethodsTo compare the clinical outcomes of modified invaginated anastomosis and mucosa-to-mucosa anastomosis, this retrospective study included 343 patients who underwent PD from January 2008 to January 2019 at Beijing Friendship Hospital, Capital Medical University. The patients’ general conditions and disease status were preoperatively evaluated. The surgical procedure was recorded, and operative management was appropriately performed.ResultsCompared with mucosa-to-mucosa anastomosis, modified invaginated anastomosis resulted in a higher intraoperative blood transfusion rate (P < 0.001) and lower hospitalization expenses (P = 0.049). However, no significant differences were found in operation time (P = 0.790), intraoperative bleeding (P = 0.428), postoperative recovery exhaust time (P = 0.442), time to normal flow of food (P = 0.163), and hospitalization time (P = 0.567). Operation time was a risk factor for POPF (odds ratio 1.010; 95% confidence interval 1.003–1.016; P = 0.003). The incidence of pancreatic fistula (grades B and C) was lower in the patients who underwent modified invaginated anastomosis (14.1%) than in those who underwent mucosa-to-mucosa anastomosis (15.3%). The operation time was greater in the POPF group than in the non POPF group among the patients who received modified invaginated anastomosis (P = 0.003) and mucosa-to-mucosa anastomosis (P = 0.002).ConclusionModified invaginated pancreaticojejunostomy for PD resulted in a decreased incidence of POPF; it may serve as a new approach for PD while managing patients who have undergone PD.

A propensity score analysis of over 12,000 pancreaticojejunal anastomoses after pancreaticoduodenectomy: does technique impact the clinically relevant fistula rate?

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) remains a major cause of morbidity in patients undergoing pancreatic surgery. Controversy exists as to whether there is any difference in CR-POPF with a Duct-to-Mucosa (DTM) versus an Invagination (IG) pancreaticojejunostomy (PJ). MethodsDemographic, perioperative, intraoperative, and postoperative data were captured from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2014–2017 databases. Potential confounders were included in a logistic regression and a propensity score model. The primary outcome was CR-POPF. ResultsA total of 12,361 pancreaticojejunal anastomoses were performed with 11,168 patients undergoing DTM (90%) and 1193 undergoing IG (10%) after pancreaticoduodenectomy. Amongst all patients, there was no significant difference in CR-POPF between DTM and IG on multivariate (OR = 0.95, p = 0.64) or propensity score analysis (OR = 0.99, p = 0.93). After stratification by pancreatic gland texture and duct size, there was a decrease in CR-POPF with DTM amongst patients with duct size greater than 6 mm on multivariate analysis (OR = 0.35, p = 0.009) and propensity score analysis (OR = 0.40, p = 0.018). There were no significant differences in any other strata. ConclusionDTM or IG technique are not associated with CR-POPF for patients with average size pancreatic ducts; however, DTM is preferable in patients with large pancreatic duct diameter (>6 mm).

Comparison of Blumgart Anastomosis with Duct-to-Mucosa Anastomosis and Invagination Pancreaticojejunostomy After Pancreaticoduodenectomy: A Single-Center Propensity Score Matching Analysis

The Blumgart anastomosis is a method of pancreaticojejunostomy after pancreaticoduodenectomy (PD) which combines the principle of duct-to-mucosa anastomosis with an invagination technique of the pancreas. Retrospective study involving consecutive patients who underwent pancreaticoduodenectomy for pancreatic head cancer. Data predictive of pancreatic fistula and postoperative outcomes were collected. The patients were divided into three groups and were compared based on the type of pancreatic anastomosis performed: Blumgart anastomosis (BA), duct-to-mucosa anastomosis (DtoM), and invagination pancreaticojejunostomy (PJ). The primary endpoint was to determine the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF). The secondary endpoints were to determine whether postoperative pancreatic fistula grade C (POPF C) and/or severe complications occurred as well as to determine the reoperation rate and 30- and 90-day mortality. A propensity score matching analysis was used. Using propensity score matching (PSM), the occurrence of CR-POPF was not significantly different between the BA (21.6%) and the other pancreatic anastomoses (all 31.1%, DtoM = 27.0%; PJ = 35.1%). However, the BA significantly reduced (1) severe complications (0 versus 35.1%; P < 0.001) and 90-day mortality (0% versus 12.2%; P = 0.028) with respect to all anastomoses; (2) severe complications (0% versus 29.7%; P < 0.001), POPF grade C (0% versus 16.2%; P = 0.025), and reoperation (2.7% versus 16.2%; P = 0.056) with respect to DtoM; and (3) severe complications (0% versus 40.5%; P < 0.001) and 90-day mortality (0% versus 13.5%; P = 0.054) with respect to PJ. Applying the PSM analysis for the first time, the present study seemed to suggest that the BA succeeded in minimizing severe complications after PD.

The effect of bilateral U-sutures in pancreaticojejunostomy in 75 consecutive cases

Background: Various technical interventions have been suggested to decrease the frequency of postoperative pancreatic fistulas but the effect is not particularly satisfactory. We have analyzed our application of bilateral U-sutures in pancreaticojejunostomy.Methods: The pancreatic stump is freed over approximately 2 cm, an appropriate diameter silicone catheter with 2–4 lateral holes was inserted into the remnant pancreatic duct (>2 mm in diameter is required) over 2–3 cm as a stent in 69 patients. In six patients with soft pancreas and very small pancreatic duct (<2 mm in diameter), the silicone catheter was not used. An incision was made on the side of the distal section of the jejunum and end-to-side an invaginated pancreaticojejunostomy was performed using bilateral U-sutures.Results: Only two (2.67%) cases developed pancreatic ‘biochemical leaks’. None of the 75 patients developed grade B and grade C pancreatic leakage. The overall morbidity was 29.33%. The anastomosis time was 14 minutes on average. There were no symptoms such as abdominal discomfort, dyspepsia and diarrhea, and no dilatation of pancreatic duct was found by CT in 75 patients after discharge from hospital.Conclusions: Bilateral U-sutures are a safe, simple, and effective technique in pancreaticojejunostomy, preventing the primary complication of anastomotic leakage, and worthy of wide use.

Chen’s continuous suture technique for invaginated pancreaticojejunostomy following pancreaticoduodenectomy with no grade B/C POPF and zero motality in 644 patients with soft pancrease and small pancreatic duct

Introduction: Internationally, postoperative pancreatic fistula (POPF) remains a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). In order to reduce the POPF incidence, a number of technical modifications for pancreato-enteric anastomosis after PD has been proposed. In 1995, we established a new suture technique for end-to-end or end-to-side invaginated pancreaticojejunostomy (PJ) following PD, and the preliminary results were quite encouraging. This study aims to review this new surgical approach, the Chen’s continuous suture technique for invaginated PJ, to evaluate the effectiveness of this approach in reducing the incidence of POPF. Method: To evaluate this new approach, 1852 patients from 8 medical center in China receiving the Chen’s continuous suture technique after a open PD from Jan. 2016 to Jan. 2019 were reviewed. Among them, 644 (34.8%) patients were with soft pancrease and small duct (small than 3 mm in diameter) and were included in this study. The postoperative morbidity and mortality including the POPE incidence were analyzed. Result: The postoperative morbidity was 27% (174/644) and mortality was 0% (0/644). The POPF rate was 8.8% (57/644) for Grade A, and no Grade B and Grade C POPF occurred. Conclusion: Chen’s continuous suture technique is a simple method and provides excellent outcomes in lowering POPF incidence following PD in the patients with the soft pancrease and a small pancreatic duct.

Selection of pancreaticojejunostomy technique after pancreaticoduodenectomy: duct-to-mucosa anastomosis is not better than invagination anastomosis: A meta-analysis.

Background:One of the most clinically significant current discussions is the optimal pancreaticojejunostomy (PJ) technique for pancreaticoduodenectomy (PD). We performed a meta-analysis to compare duct-to-mucosa and invagination techniques for pancreatic anastomosis after PD.Methods:A systematic search of PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to June 1, 2018 was performed. Randomized controlled trials (RCTs) comparing duct-to-mucosa versus invagination PJ were included. Statistical analysis was performed using RevMan 5.3 software.Results:Eight RCTs involving 1099 patients were included in the meta-analysis. The rate of postoperative pancreatic fistula (POPF) was not significantly different between the duct-to-mucosa PJ (110/547, 20.10%) and invagination PJ (98/552, 17.75%) groups in all 8 studies (risk ratio, 1.13; 95% CI, 0.89–1.44; P = .31). The subgroup analysis using the International Study Group on Pancreatic Fistula criteria showed no significant difference in POPF between duct-to-mucosa PJ (97/372, 26.08%) and invagination PJ (78/377, 20.68%). No significant difference in clinically relevant POPF (CR-POPF) was found between the 2 groups (55/372 vs 40/377, P = .38). Additionally, no significant differences in delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, operation time, or length of stay were found between the 2 groups. The overall morbidity and mortality rates were not significantly different between the 2 groups.Conclusion:The duct-to-mucosa technique seems no better than the invagination technique for pancreatic anastomosis after PD in terms of POPF, CR-POPF, and other main complications. Further studies on this topic are therefore recommended.

Leakage of an Invagination Pancreaticojejunostomy May Have an Influence on Mortality.

Purpose: No consensus exists regarding the most effective form of pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).Methods: Data were gathered through the American College of Surgeons-National Surgical Quality Improvement Program, Pancreatectomy Demonstration Project. A total of 1781 patients underwent a PD at 43 institutions. After appropriate exclusions, 890 patients were analyzed. Patients were divided into duct-to-mucosa (n = 734, 82%) and invagination (n = 156, 18%) groups and were compared by unadjusted analysis. Type of PJ was included in eight separate morbidity and mortality multivariable analyses.Results: Invagination patients had higher serum albumin (p < 0.01) and lower body mass index (p < 0.01), were less likely to have a preoperative biliary stent (p < 0.01), and were more likely to have a soft gland (p < 0.01). PJ anastomosis type was not associated with morbidity but was associated with mortality (duct-to-mucosa vs. invagination, odds ratio = 0.22, p < 0.01). Among patients who developed a clinically relevant pancreatic fistula, none of the 119 duct-to-mucosa, compared with 5 of 21 invagination, patients died (p < 0.01).Conclusion: Patients who undergo a PJ by duct-to-mucosa or invagination differ with respect to preoperative and intraoperative variables. When an invagination PJ leaks, there may be a greater influence on mortality than when a duct-to-mucosa PJ leaks.

An end-to-side suspender pancreaticojejunostomy: A new invagination pancreaticojejunostomy

BackgroundPostoperative pancreatic fistula (POPF) is a severe complication of the pancreaticoduodenectomy (PD). Recently, we introduced a method of suspender pancreaticojejunostomy (PJ) to the PD. In this study, we retrospectively analyzed various risk factors for complications after PD. We also introduced and assessed the suspender PJ to demonstrate its advantages. MethodsData from 335 patients with various periampullary lesions, who underwent the Whipple procedure (classic Whipple procedure or pylorus-preserving) PD by either traditional end-to-side invagination PJ or suspender PJ, were analyzed. The correlation between either perioperative or postoperative complications and corresponding PD approaches was evaluated by univariate analysis. ResultsA total of 147 patients received the traditional end-to-side invagination PJ, and 188 patients were given the suspender PJ. Overall, 51.9% patients had various complications after PD. The mortality rate was 2.4%. The POPF incidence in patients who received the suspender PJ was 5.3%, which was significantly lower than those who received the traditional end-to-side invagination PJ (18.4%) (P < 0.001). Univariate analysis showed that PJ approach and the pancreas texture were significantly associated with the POPF incidence rate (P < 0.01). POPF was a risk factor for both postoperative abdominal cavity infection (OR = 8.34, 95% CI: 3.99–17.42, P < 0.001) and abdominal cavity hemorrhage (OR = 4.86, 95% CI: 1.92–12.33, P = 0.001). ConclusionsOur study showed that the impact of the pancreas texture was a major risk factor for pancreatic leakage after a PD. The suspender PJ can be easily accomplished and widely applied and can effectively decrease the impact of the pancreas texture on pancreatic fistula after a PD and leads to a lower POPF incidence rate.

Simplified Invagination Pancreatojejunostomy During Pancreatoduodenectomy Which can be Safe in the Training of Young Surgeons

Background: Invagination is one of the useful reconstruction method for pancreatic enteric anastomosis during pancreatoduodenectomy (PD), but it is unclear what is the best. On the other hand, a safe and easy procedure is needed for the stable outcomes and the safe training for young surgeon. The aim of this study was to evaluate our simplified invagination pancreaticojejunostomy. Methods: This is a pilot study about a modified technique. Between January 2012 and March 2015, 22 consecutive cases of pancreatoduodenectomy performed with invagination pancreaticojejunostomy were eligible for inclusion. We retrospectively analyzed the operative courses. Results: The median surgical time was 496 minutes (range 232–755). The median blood loss was 600 ml (range 75–4335). The soft pancreas was nine patients (40.9%). Only one patient developed postoperative pancreatic fistula (Grade B) (4.5%). The median follow-up period was 13 months (range 2–29), and there were no cases of occlusion at the anastomotic site. When comparing inexperienced and skilled surgeons, no statistical significance was observed in the clinical and operative parameters. Conclusion: Our invagination PJ can be an easy and simple method which carries a low incidence of POPF, and safe for training of young surgeons.

Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis.

ObjectiveWe aimed to compare the two most commonly used pancreatico-jejunostomy reconstruction techniques—duct-to-mucosa and invagination.MethodsDatabases, including MEDLINE, EMBASE, Cochrane Library, and several clinical trial registration centers were searched. Randomized controlled trials that compared duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were included and analyzed.ResultsIn total, seven RCTs were included, involving 850 patients. The difference in postoperative pancreatic fistula rate between the duct-to-mucosa and invagination pancreaticojejunostomy was not significant (RR = 1.03, 95% CI = 0.76-1.39, P = 0.86). There was no significant difference in clinically relevant postoperative pancreatic fistula between the two groups (RR = 0.78, 95% CI = 0.15-3.96, P = 0.77). The overall morbidity, overall mortality, delayed gastric emptying, intra-abdominal collection, reoperation rate, and length of hospital stay between the two groups were not significantly different. Sensitivity analysis showed that the meta-analysis was stable. Further, no significant publication bias was seen.ConclusionsDuct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were comparable in terms of postoperative pancreatic fistula incidence and other parameters.

New concepts and techniques of hepato-pancreato-biliary surgery

Surgery is the most effective and preferred treatment for hepato-pancreato-biliary (HPB) tumors. The improvement of HPB surgery technique mainly focus on reducing the amount of bleeding, improving the safety of operation, simplifying the operation, reducing the complications and mortality all the time. As one of the largest HPB centers in China, hepatic center of Tongji hospital has set up a series of new concepts and new techniques of HPB surgery since 1980s. We proposed a new classification standard of hepatocellular carcinoma (HCC) to guide the surgical procedures and evaluation of prognosis. According to this method, HCCs lager than 5 cm were defined as lager (>5 cm and ³ 10 cm). Traditionally, the large/huge HCC patients were thought can’t tolerate hepatectomy because of the insufficient residual liver volume. However, we confirmed the feasibility and safety of the resection of large/huge HCC and applied it in clinic concurrently in 1990s, which greatly extended the inclusion criteria for operation. Serious intraoperative bleeding is another constraint for resection of large/huge HCC. In order to reduce the intraoperative bleeding and increase the safety of major hepatectomies, three new bleeding control techniques for hepatectomy were established: Infrahepatic inferior vena cava clamping combine with occlusion of the portal triad; tying up of inflow and outflow vessels without dissecting the hilus of the liver; and implementation of the liver double-hanging maneuver through the retrohepatic avascular tunnel on the right side of the inferior vena cava. According to the AASLD and the EASL guidelines for HCC management, patients with portal vein tumor thrombosis (PVTT) are excluded from either surgical treatment or TACE, and only palliative therapies are recommended. However, our studies confirmed treating PVTT patient by indicated surgical protocol according to the location and extension of PVTT is safety and effective. Based on the guideline set by western countries, liver resection is contraindicated in patients with portal hypertension. But in China, 85%–90% patients with HCC showed various degrees of liver cirrhosis, and a large proportion of these patients presented clinical signs of portal hypertension. Thus, we set up a surgical treatment strategy (limited liver resection plus splenectomy with or without devascularization of gastroesophageal varices) for HCC combined with portal hypertension. There are still controversies on the optimal extent of hepaticresection to achieve a high percentage of R0 resection for hilarcholangiocarcinoma. We proposed a new concept that treats hilar cholangiocarcinoma using minor liver resection which showed lower operative morbidity and good prognosis. We also created new surgical procedures such as new intrahepatic cholangiojujunostomy for multiple intrahepatic biliary ductal openings and the inserting bilio- jejunostomy for iatrogenic bile duct injury were all invented and proved to be available in clinic. In order to diminish pancreatic leakage, we established Chen’s U-suture technique for end-to-end invaginated pancreaticojejunostomy following pancreaticoduodenectomy. Many end-stage liver disease patients died due to severe shortage of organ donors. To address the shortage, we are the first to establish auxiliary partial orthotopic liver transplantation technique in the world and applied it in clinic successfully.