Lower Rate Of Postoperative Pancreatic Fistula Research Articles

One-half layer pancreaticojejunostomy with the rear wall of the pancreas reinforced: A valuable anastomosis technique.

BACKGROUNDPostoperative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). To effectively reduce the incidence of POPF, we designed a new type of pancreaticojejunostomy (PJ), which was termed one-half layer PJ with the rear wall of the pancreas reinforced.AIMTo explore the clinical application value of this new technique.METHODSWe compared 62 patients who had undergone PD by either the traditional duct-to-mucosa anastomoses or the new one-half layer PJ with the rear wall of the pancreas reinforced method at our hospital from May 2015 to September 2019. All 62 patients were operated by the same surgeon experienced in both procedures. We retrospectively analyzed patient characteristics, perioperative outcomes, and surgical results.RESULTSThere was no significant difference between the two groups in basic information except the postoperative hospital stays, 14.7 ± 5.4 d in the traditional duct-to-mucosa anastomoses group and 12.0 ± 4.2 d in the one-half layer PJ group (P = 0.042). In terms of postoperative complications, the one-half layer PJ group had a lower rate of POPF than the traditional group. The overall number of cases with POPF was 8 (24.2%) in the traditional group and 2 (6.9%) in the one-half layer group (P = 0.017). Additionally, the rate of grades B and C POPF was lower in the one-half layer group (3.4%) compared with that (12.1%) in the traditional group (P = 0.010). One patient died due to hemorrhage caused by severe pancreatic fistula in the traditional group.CONCLUSIONOne-half layer PJ with the rear wall of the pancreas reinforced is a safe and feasible procedure that can successfully reduce the rate of POPF. It may be a promising technique for PJ after PD.

Updated outcomes using clockwise technique for laparoscopic distal pancreatectomy: Optimal treatment of benign and malignant disease of the left pancreas

BackgroundLaparoscopic distal pancreatectomy (LDP) has become the preferred approach for surgical management of left sided pancreas pathology. Our institution previously published its experience with distal pancreatectomies using a clockwise technique with good outcomes. We now reexamine our outcomes across a longer time interval. MethodsFrom August 2008 to November 2020, 364 patients underwent LDP by hepatobiliary surgeons (HA and JS). All procedures were performed using the same clockwise approach, which includes the stepwise slow compression technique. Retrospective descriptive analysis of patient demographic, clinical, operative, and pathologic data was conducted. ResultsOf the 364 patients who underwent LDP using this technique, clinically significant postoperative pancreatic fistula (POPF) was noted in 26 (7.1%) patients, while major morbidity and mortality were reported in 9.9% and 0.3%, respectively. Hand-assisted method was required for 18 (4.9%) patients and unplanned conversion in 20 (5.5%) patients. In a subset analysis of patients with pancreatic adenocarcinoma (n = 90), POPF was noted in 13 (14.4%), with minor complications occurring in 34.4% and major morbidity in 14.4%. ConclusionLDP with a clockwise approach for dissection, combined with the stepwise slow compression technique results in excellent outcomes, with even lower POPF rates than originally reported. Subset analysis of patients with pancreatic adenocarcinoma shows acceptable perioperative outcomes with this technique.

Postoperative risk of pancreatic fistula after distal pancreatectomy with or without spleen preservation.

Outcomes after distal pancreatectomy with or without splenectomy are controversial. The present study aims to investigate differences in short-term and long-term outcomes between spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). In this retrospective review of consecutive patients undergoing distal pancreatectomy with or without splenectomy from January 2011 until December 2017 for benign disease, the primary endpoint was to compare postoperative pancreatic fistula (POPF). The secondary endpoint was to compare duration of surgery, intraoperative blood loss, postoperative complications, length of hospital stay, and long-term outcomes. Patients undergoing SPDP had a lower rate of POPF (13.6% vs 46.1%; p = 0.02). Patients undergoing SPDP (n = 22) were discharged earlier than patients undergoing DPS (n = 26) (8 [4-29] vs 12 [6.48] days; p = 0.003). No differences in other intraoperative and postoperative outcomes were found between groups. Patients undergoing SPDP developed fewer POPF and were discharged earlier compared to patients undergoing DPS.

Surgical treatment of secondary pancreatic tumors? single centre experience

Clinically relevant postoperative pancreatic fistula (grades B and C of the ISGPS definition) remains the most troublesome complication after pancreatoduodenectomy. The approach to management of the pancreatic remnant via some form of pancreatico-enteric anastomosis determines the incidence and severity of clinically relevant postoperative pancreatic fistula. Despite numerous trials comparing diverse pancreatico-enteric anastomosis techniques and other adjunctive strategies (pancreatic duct stenting, somatostatin analogues, etc), currently, there is no clear consensus regarding the ideal method of pancreatico-enteric anastomosis.An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the best contemporary literature concerning pancreatico-enteric anastomosis and worked to develop a position statement on pancreatic anastomosis after pancreatoduodenectomy.There is inherent risk assumed by creating a pancreatico-enteric anastomosis based on factors related to the gland (eg, parenchymal texture, disease pathology). None of the technical variations of pancreaticojejunal or pancreaticogastric anastomosis, such as duct-mucosa, invagination method, and binding technique, have been found to be consistently superior to another. Randomized trials and meta-analyses comparing pancreaticogastrostomy versus pancreaticojejunostomy yield conflicting results and are inherently prone to bias due to marked heterogeneity in the studies. The benefit of stenting the pancreatico-enteric anastomosis to decrease clinically relevant postoperative pancreatic fistula is not supported by high-level evidence. While controversial, somatostatin analogues appear to decrease perioperative complications but not mortality, although consistent data across the more than 20 studies addressing this topic are lacking. The Fistula Risk Score is useful for predicting postoperative pancreatic fistula as well as for comparing outcomes of pancreatico-enteric anastomosis across studies.Currently, no specific technique can eliminate development of clinically relevant postoperative pancreatic fistula. While consistent practice of any standardized technique may decrease the rate of clinically relevant postoperative pancreatic fistula, experienced surgeons can have lower postoperative pancreatic fistula rates performing a variety of techniques depending on the clinical situation. There is no clear evidence on the benefit of internal or external stenting after pancreatico-enteric anastomosis. The use of somatostatin analogues may be important in decreasing morbidity after pancreatoduodenectomy, but it remains controversial. Future studies should focus on novel approaches to decrease the rate of clinically relevant postoperative pancreatic fistula with appropriate risk adjustment.

Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized study

BackgroundThe ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD. MethodsConsecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions. ResultsOne hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively. ConclusionInvagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. Clinical Trials. gov IDNCT02142517.

A novel pancreaticogastrostomy method using only two transpancreatic sutures: early postoperative surgical results compared with conventional pancreaticojejunostomy

PurposeTo evaluate the surgical outcomes of pancreaticogastrostomy (PG) using two transpancreatic sutures with a buttress method through an anterior gastrostomy (PGt), and compare these results with our previous experience with pancreaticojejunostomy (PJ) including the dunking and duct to mucosa methods after pancreaticoduodenectomy (PD).MethodsIn this study, 171 patients who had undergone PD between January 2005 and April 2013 were classified into three groups according to the method of the pancreaticoenteric anastomosis: dunking PJ (PJu group; n = 67, 39.1%), duct to mucosa PJ (PJm group; n = 41, 23.9%), and PGt (PGt group; n = 63, 36.8%). We retrospectively analyzed patient characteristics, perioperative outcomes, and surgical results.ResultsBoth groups had comparable demographics and pathology, and there were no significant differences in operative time, estimated blood loss, or postoperative hospital stay. Within the two groups, morbidities occurred in 49 cases (10.7%), and were not significantly different between the two groups, excepting postoperative pancreatic fistula (POPF). The PGt group had a lower rate of POPF (18/63, 28.6%) than the PJu and PJm groups (21/67, 31.3% and 19/41, 46.3%; P = 0.048), especially in terms of grades B and C POPF (4/63 [6.3%] in the PGt group vs. 7/67 [10.4%] in the PJu group and 9/41 [22.0%] in the PJm group, P = 0.049).ConclusionThe PGt method showed feasible outcomes for POPF and had advantages over dunking PJ and duct to mucosa PJ with respect to immediate postoperative results. PGt may be a promising technique for pancreaticoenteric anastomosis after PD.

Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study

ObjectivesThe optimal strategy for the reconstruction of the pancreas following pancreaticoduodenectomy (PD) is still debated. The aim of this study was to compare the outcomes of isolated Roux loop pancreaticojejunostomy (IRPJ) with those of pancreaticogastrostomy (PG) after PD. MethodsConsecutive patients submitted to PD were randomized to either method of reconstruction. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality, and exocrine and endocrine pancreatic functions. ResultsNinety patients treated by PD were included in the study. The median total operative time was significantly longer in the IRPJ group (320min versus 300min; P = 0.047). Postoperative pancreatic fistula developed in nine of 45 patients in the IRPJ group and 10 of 45 patients in the PG group (P = 0.796). Seven IRPJ patients and four PG patients had POPF of type B or C (P = 0.710). Time to resumption of oral feeding was shorter in the IRPJ group (P = 0.03). Steatorrhea at 1 year was reported in nine of 42 IRPJ patients and 18 of 41 PG patients (P = 0.029). Albumin levels at 1 year were 3.6g/dl in the IRPJ group and 3.3g/dl in the PG group (P = 0.001). ConclusionsIsolated Roux loop PJ was not associated with a lower rate of POPF, but was associated with a decrease in the incidence of postoperative steatorrhea. The technique allowed for early oral feeding and the maintenance of oral feeding even if POPF developed.