Nondilated Ducts Research Articles

Grading the Whipple’s procedure: a strategy for structured skill advancement in surgical training

Introduction: The Whipple’s procedure or pancreatoduodenectomy (PD), is recognized for its technical intricacy in surgical practice. This study aims to categorize PD into four types based on procedural complexity and anticipated postoperative outcomes, intending to integrate this classification into the progressive training of surgical fellows. Methods: In this retrospective cohort study, 242 PDs, performed by a single unit across multiple centers from January 2016 to December 2022, were categorized into four types based on technical complexity and extent of surgical intervention. These types were: Type 1 (dilated duct, firm pancreas), Type 2 (as Type 1 + vascular reconstruction), Type 3 (nondilated duct, soft pancreas), and Type 4 (as Type 3 + vascular reconstruction). The study assessed patient characteristics, surgical parameters, and perioperative morbidity and mortality, comparing the outcomes of the four PD types. Results: Type 1 PD was predominant (65.2%), with the lowest 30-day mortality (2.53%). Conversely, Type 4 PD, though least performed (3.3%), exhibited the highest mortality (25%) and major complications (25%). Statistically significant differences were noted in the incidence of clinically relevant-postoperative pancreatic fistula, delayed gastric emptying, and wound complications among the PD types, with overall surgical morbidity being higher in Types 3 and 4. Conclusion: In conclusion, our data compellingly links morbidity, such as postoperative pancreatic fistula, with the technical challenges of the procedure, even though not all mortality can be attributed solely to surgical factors. The implementation of this system offers a structured approach to surgical training, paving the way for trainees to adeptly navigate and proficiently perform this complex surgical technique.

Improved Outcomes with Minimally Invasive Pancreaticoduodenectomy in Patients with Dilated Pancreatic Ducts: A Prospective Study

Introduction: Little is known about what predicts better outcomes for minimally invasive pancreaticoduodenectomy (MIPD) versus open pancreaticoduodenectomy (OPD). We hypothesized that MIPD patients with dilated pancreatic ducts have improved outcomes compared to OPD. Methods: All patients undergoing pancreaticoduodenectomy were prospectively followed over 47 months; perioperative and pathologic covariates and outcomes were compared. Ideal outcome (IO) was defined as: having no complications, postoperative length of stay < 7 days and negative margins on pathology. Patients with dilated ducts (≥3mm) who underwent MIPD were 1:3 propensity score matched to patients with dilated ducts who underwent OPD. Likewise, patients with non-dilated ducts (<3mm) who underwent MIPD were 1:3 propensity score matched to patients with non-dilated ducts who underwent OPD, and outcomes compared. Results: 371 patients underwent PD– 74 (19.9%) MIPD and 297 (80.1%) OPD. Overall, MIPD patients had significantly less intraoperative blood loss. After 1:3 propensity score matching, MIPD patients with dilated pancreatic ducts (n=45) had significantly lower overall complication and 90-day readmission rates compared to matched OPD patients (n=135) with dilated ducts. MIPD patients with dilated duct were more likely to have IO than patients with OPD (29% vs 15%, p=0.035). There were no significant differences in postoperative outcomes among matched patients with non-dilated pancreatic ducts who underwent MIPD (n=29) compared to matched patients undergoing OPD (n=87) with non-dilated ducts. Conclusions: MIPD is safe with comparable outcomes to OPD. Patients with pancreatic ducts ≥3mm derive the most benefit from MIPD: fewer complications, lower readmission rates and higher likelihood of ideal outcome.

Transcholecystic management of extrahepatic duct stones in poor candidates for endoscopic or transhepatic approaches.

To investigate transcholecystic management of extrahepatic duct (EHD) stones using balloon ampulloplasty in patients who are poor candidates for endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) and assess its efficacy and safety. Forty-one patients who were unable to undergo ERCP or had failed ERCP with non-dilated intrahepatic ducts (IHD) between February 2019 and October 2020 were retrospectively enrolled. After clinical improvement with percutaneous cholecystostomy (PC), EHD stones were managed through cystic duct passage, guidewire unwinding, sheath insertion, and EHD stone removal using balloon ampulloplasty. If the transcholecystic route failed, a transhepatic approach was used according to the pre-existing cholangiogram obtained via PC. We evaluated the technical success rate and complications of each step. The technical success rate for the transcholecystic-only approach was 80.5%. The remaining cases were successfully managed with transhepatic conversion. Multiple stone removal sessions were required in 22% of the cases. One patient with combined IHD stones was initially converted to a transhepatic approach without any transcholecystic removal trial. The technical success rates for each step were as follows: cystic duct passage (38/40, 95%), guidewire unwinding (36/38, 94.7%), sheath insertion (36/36, 100%), and stone removal using balloon ampulloplasty (33/36, 91.7%). The overall clinical success was 97.6% (40/41) without major procedure-related complications. Thereafter, cholecystectomy was successfully performed in patients with concomitant gallstones (n = 20). No postprocedural complications occurred during the follow-up (1-70days). Percutaneous EHD stone removal through transcholecystic and transhepatic routes after PC is effective and safe in poor candidates for PTBD or ERCP. • This study shows the safety and efficacy of extrahepatic duct (EHD) stones in patients who are poor candidates for initial percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography. • The overall technical success for the transcholecystic-only approach was 80.5% (33/41). Including transhepatic conversions, it was 100% (41/41). Stone removal was successful in one session in 78% (32/41) of the patients and in multiple sessions in 28.1% (9/41) of the patients. • Balloon ampulloplasty with stone expulsion using an occlusion balloon catheter is also a safe and effective method for removing EHD stones.

Improved outcomes with minimally invasive pancreaticoduodenectomy in patients with dilated pancreatic ducts: a prospective study.

BackgroundLittle is known about what factors predict better outcomes for patients who undergo minimally invasive pancreaticoduodenectomy (MIPD) versus open pancreaticoduodenectomy (OPD). We hypothesized that patients with dilated pancreatic ducts have improved postoperative outcomes with MIPD compared to OPD.MethodsAll patients undergoing pancreaticoduodenectomy were prospectively followed over a time period of 47 months, and perioperative and pathologic covariates and outcomes were compared. Ideal outcome after PD was defined as follows: (1) no complications, (2) postoperative length of stay < 7 days, and (3) negative (R0) margins on pathology. Patients with dilated pancreatic ducts (≥ 3 mm) who underwent MIPD were 1:3 propensity score-matched to patients with dilated ducts who underwent OPD and outcomes compared. Likewise, patients with non-dilated pancreatic ducts (< 3 mm) who underwent MIPD were 1:3 propensity score-matched to patients with non-dilated ducts who underwent OPD and outcomes were compared.Results371 patients underwent PD—74 (19.9%) MIPD and 297 (80.1%) underwent OPD. Overall, patients who underwent MIPD had significantly less intraoperative blood loss. After 1:3 propensity score matching, patients with dilated pancreatic ducts who underwent MIPD (n = 45) had significantly lower overall complication and 90-day readmission rates compared to matched OPD patients (n = 135) with dilated ducts. Patients with dilated duct who underwent MIPD were more likely to have an ideal outcome than patients with OPD (29 vs 15%, p = 0.035). There were no significant differences in postoperative outcomes among propensity score-matched patients with non-dilated pancreatic ducts who underwent MIPD (n = 29) compared to matched patients undergoing OPD (n = 87) with non-dilated ducts.ConclusionsMIPD is safe with comparable perioperative outcomes to OPD. Patients with pancreatic ducts ≥ 3 mm appear to derive the most benefit from MIPD in terms of fewer complications, lower readmission rates, and higher likelihood of ideal outcome.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-021-08611-x.

Continuous suture is a risk factor for benign hepaticojejunostomy stenosis after pancreatoduodenectomy in patients with a non-dilated bile duct.

It is unclear whether hepaticojejunostomy with a continuous suture is suitable for patients with a non-dilated bile duct. Medical records of patients who underwent pancreatoduodenectomy between 2003 and 2013 were retrospectively reviewed, focusing on the incidence of benign anastomotic stenosis and its relationship with suture method (continuous vs interrupted) and common hepatic duct size. Among 336 patients, 172 had a non-dilated (<8mm) duct, and the remaining 164 had a dilated duct. Benign stenosis occurred in 12.2% (21/172) in the former, but in only 0.6% (1/164) in the latter (p<0.001; median follow-up period, 43.5 months). Thus, further analysis was conducted in the 172 patients with a non-dilated duct, among whom 116 received a continuous suture and 56 received an interrupted suture. The cumulative incidence of benign anastomotic stenosis was significantly higher in patients who received a continuous suture vs those who received an interrupted suture (15.6% vs 1.8%, respectively, at 3 years; p=0.006). Multivariable analysis identified continuous suture, male gender, and cholangitis (within 3 months after surgery) as independent risk factors for benign stenosis. In this observational study, the use of a continuous suture was associated with benign anastomotic stricture in patients with a non-dilated hepatic duct.

EUS-guided drainage for a non-dilated pancreatic duct using a re-puncture technique in a patient with stricture-related pancreatitis (with video).

Highlight EUS-guided pancreatic duct drainage has emerged as an effective method for the treatment of post-pancreaticojejunostomy anastomotic stricture, but cases with non-dilated pancreatic duct usually represent a great challenge. Fujigaki and colleagues demonstrate the feasibility of EUS-guided pancreatic duct drainage with the re-puncture technique in a case with non-dilated pancreatic duct.

Percutaneous transhepatic biliary drainage (PTBD) in patients with dilated vs. nondilated bile ducts: technical considerations and complications

ObjectivesThe aim of this study was to compare success, technical complexity, and complication rates of percutaneous transhepatic biliary drainage (PTBD) in patients with dilated vs. nondilated bile ducts.MethodsIn a retrospective analysis, we evaluated all consecutive PTBD performed in our department over a period of 5 years. Technical success, technical data (side, fluoroscopy time, radiation dose, amount of contrast media, use of disposable equipment), procedure-related complications and peri-interventional mortality were compared for patients with dilated vs. non-dilated bile ducts. Independent t test and χ2 test were used to evaluate the statistical significance.ResultsA total of 253 procedures were performed on 187 patients, of whom 101/253 had dilated bile ducts and 152/253 not. In total, 243/253 procedures were successful. PTBD was significantly more often successful in patients with dilated vs. nondilated bile ducts (150/153 vs. 93/101; p 0.02). Overall complication rate (13%) did not differ significantly between patients with dilated vs. nondilated bile ducts. Procedures in patients with normal, nondilated bile ducts were associated with a significantly higher rate of post-interventional bleeding (5/101 vs. 0/152). Mean fluoroscopy time (42:36 ± 35:39 h vs. 30:28 ± 25:10 h; p 0.002) and amount of contrast media (66 ± 40 ml vs. 52 ± 24 ml; p 0.07) or use of disposables were significantly higher in patients with nondilated ducts. A significantly lower fluoroscopy time and amount of contrast medium were used in left hepatic PTBD.ConclusionDespite the higher technical complexity, PTBD with nondilated bile ducts was associated with similar overall complication rates but higher bleeding complications compared with PTBD with dilated bile ducts.Key Points• PTBD was associated with similar overall complication rates in patients with dilated vs. nondilated bile ducts.• Although overall complication rates were low, PTBD in patients with nondilated bile ducts was associated with a higher incidence of post-interventional bleeding.• PTBD in patients with nondilated bile ducts is technically more complex.

Improved outcomes with minimally invasive pancreaticoduodenectomy in patients with dilated pancreatic ducts: A prospective study

Presenter: Sanket Srinivasa MD, PhD | Washington University, St. Louis Background: There is little known about what factors predict better outcomes for patients who undergo minimally invasive pancreaticoduodenectomy (MIPD) versus open pancreaticoduodenectomy (OPD). Identifying such characteristics may guide patient selection in MIPD. We hypothesized that patients with dilated pancreatic ducts have improved postoperative outcomes with MIPD compared to OPD. Methods: All patients undergoing pancreaticoduodenectomy between April 2016 and July 2019 were prospectively followed, and perioperative and pathologic covariates and outcomes were compared. Patients with dilated pancreatic ducts (≥3mm) who underwent MIPD (Robotic/ Laparoscopic) were propensity score matched to patients with dilated ducts who underwent OPD and outcomes compared. Likewise, patients with non-dilated pancreatic ducts ( < 3mm) who underwent MIPD were 1:3 propensity score matched to patients with non-dilated ducts who underwent OPD and outcomes compared. Multivariate logistic regression analysis was used to control for potential confounders and the primary outcome was a composite measure termed the ideal outcome (IO) which required patients to achieve negative margins; experience no complications or readmission and be discharged within seven days. Results: 312 patients underwent PD– 51 (16.4%) MIPD and 212 (83.7%) OPD. Patients who underwent MIPD had significantly longer operative times, less intraoperative blood loss, less postoperative urinary retention, and a lower rate of 90-day readmission. After 1:3 propensity score matching, patients with dilated pancreatic ducts who underwent MIPD (n=30) had significantly increased intraoperative times, less intraoperative blood loss, less postoperative bleeding/anemia complications, lower overall complication rate, and were discharged from the hospital 3.5 days faster compared to matched OPD patients (n=90) with dilated ducts. Among propensity score matched patients with non-dilated pancreatic ducts, patients undergoing MIPD (n=21) had significantly less intraoperative blood loss compared to matched patients undergoing OPD (n=63) with non-dilated ducts, but there were no other significant differences in outcomes. In total, 39 (14.9%) patients had IO with OPD and 11 (21.6%) patients had IO with MIPD (p=0.276). With multivariate analysis, there was a significant interaction between operative approach (MIPD vs OPD) and pancreatic duct size (non-dilated [ < 3mm] vs dilated [≥ 3mm]) with respect to these variables’ association with IO (p=0.042). MIPD in patients with dilated pancreatic ducts was independently associated with increased IO (OR= 3.04, p=0.021) (Table 3). However, MIPD in patients with non-dilated pancreatic ducts was not associated with IO (OR=0.82, p=0.802). Conclusion: MIPD is safe with comparable perioperative and oncologic outcomes to OPD. Patients with pancreatic ducts ≥3mm appear to derive the most benefit from MIPD in terms of less complications and shorter hospital stay.

An unusual case of steatorrhea

Partial agenesis of the pancreas is a rare developmental anomaly of the pancreas which can lead to exocrine and endocrine insufficiency. We report a 61-year-old male patient with steatorrhea who was found to have complete agenesis of the dorsal pancreas. He presented with a history of loose stools for 5 years, and the stools were at times oily in nature without mucus or blood. His clinical examination was unremarkable. Seventy-two hour stool fat was increased (21.4 g, normal 200), and computed tomography of the abdomen revealed a normal head and uncinate process of the pancreas, abscence of body and tail of pancreas associated with a nondilated duct system. He was put on pancreatic enzyme supplements and he responded to the treatment, and on follow-up after 6 months, his stool frequency had declined and his fecal elastase had improved.

Evaluation of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy

Background: Pancreatic fistula (PF) remains the most common and challenging complication following pancreaticoduodenectomy (PD), with an incidence of 2%–28%. The primary objective of this study was to assess the correlation of fatty infiltration and fibrosis of the pancreas with postoperative pancreatic fistula (POPF). Secondary objectives were to investigate the correlations of POPF with the main pancreatic duct size and subjective intraoperative assessment of pancreatic texture and to determine if diabetes mellitus (DM), body mass index, or increased serum bilirubin correlate with POPF. Materials and Methods: This prospective study was performed at Sudhamayi Hospital, Kochi, India. Forty-six patients were included and divided into either the fatty infiltration group (n = 20) or fibrosis group (n = 17); nine patients had neither fatty nor fibrotic glands. Data were analyzed using analysis of variance and Chi-square test, utilizing SPSS software version 20 (IBM Inc., Armonk, NY, USA). Results: Patients with fatty pancreas had a ten times higher incidence of PF than those with fibrotic pancreas (odds ratio, 10.8; 95% confidence interval [CI], 2.2–52.4; P = 0.003). POPF was 7.9 times higher in patients with a nondilated duct compared to patients with a dilated duct (95% CI, 2.118–29.5; P = 0.003). Preoperative elevated serum bilirubin, body mass index, and DM were not found to be significant risk factors for POPF. Conclusion: We demonstrated that fatty pancreas and small pancreatic duct size (≤3 mm) are risk factors for POPF. Preoperative elevated serum bilirubin, body mass index, and DM were not found to be significant risk factors.

Importance of main pancreatic duct dilatation in IPMN undergoing surveillance.

The association between risk of pancreatic cancer and a dilated main pancreatic duct (MPD) in intraductal papillary mucinous neoplasm (IPMN) is debated. The aim of this study was to assess the role of MPD size in predicting pancreatic cancer in resected IPMNs and those kept under surveillance. All patients with IPMN referred to the Pancreas Institute, University of Verona Hospital Trust, from 2006 to 2016 were included. The primary endpoint was the occurrence of malignancy detected at surgery or during follow-up. The final cohort consisted of 1688 patients with a median follow-up of 60 months. Main pancreatic duct dilatation was associated with other features of malignancy in both the resected and surveillance groups. In patients who underwent resection, only a MPD of at least 10 mm was an independent predictor of malignancy. In patients kept under surveillance, MPD dilatation was not associated with malignancy. Fifteen of 71 patients (21 per cent) with malignancy in the resection cohort had a dilated MPD alone, whereas only one of 30 (3 per cent) under surveillance with MPD dilatation alone developed malignancy. Patients with a dilated MPD and other worrisome features had an increased 5-year cumulative incidence of malignancy compared with those with a non-dilated duct (11 versus 1·2 per cent; P < 0·001); however, the risk of malignancy was not significantly increased in patients with a dilated MPD alone (4 versus 1·2 per cent; P =0·448). In patients under surveillance, a dilated MPD alone was not associated with an increased incidence of malignancy in IPMN.

Endoscopic Ultrasound-Guided Rendezvous Procedure for a Nondilated, Leaking Pancreatic Duct

Pancreatic duct (PD) leak leading to pancreatic ascites is a serious complication of chronic pancreatitis. Endoscopic management with endoscopic retrograde cholangiopancreatography (ERCP) has been found to be successful; however, if selective cannulation of the PD is unsuccessful, an endoscopic ultrasound-guided rendezvous procedure can help in bridging PD leaks, provided the duct is dilated. We report a successful endoscopic ultrasound-guided rendezvous procedure in a patient with PD leak, pancreatic ascites, and a nondilated duct with failed ERCP who was a poor candidate for surgery. The pancreatic ascites resolved following the procedure.

1111 Modified Eus-Guided Rendezvous Drainage of an Obstructed Non-Dilated Main Pancreatic Duct (MPD) Due to Chronic Pancreatitis

1111 Modified Eus-Guided Rendezvous Drainage of an Obstructed Non-Dilated Main Pancreatic Duct (MPD) Due to Chronic Pancreatitis

Safer intestinal invagination for a solid pancreatico-jejunal anastomosis in presence of a soft texture pancreatic remnant and non-dilated duct

Pancreatico-jejunal anastomosis after pancreatoduodenectomy still represents the Achilles' heel of the procedure: the failure of this anastomosis is relatively common and it is the main cause of post-operative morbidity and mortality. Studies have described different reconstruction strategies for the control of the development of post-operative pancreatic fistula, but the strategy to obtain a safer pancreatico-jejunal anastomosis is still far from satisfaction. We report a novel variation of the invagination technique based on preliminary clinical experience in 8 patients who underwent pancreatico-jejunal anastomosis after pancreatoduodenectomy in our hepatobiliopancreatic center from 2008 to 2014. The variation could obtain a safer intestinal invagination for a solid pancreatico-jejunal anastomosis even in the presence of soft pancreatic remnant.

Octreotide Does Not Prevent Pancreatic Fistula Following Pancreatoduodenectomy in Patients with Soft Pancreas and Non-dilated Duct: A Prospective Randomized Controlled Trial

BackgroundWhether octreotide prevents pancreatic fistula following pancreatoduodenectomy is controversial and it is believed to be beneficial in soft glands and normal-sized ducts. The aim of this study is to assess the potential value of octreotide in reducing the incidence of pancreatic fistula, postoperative complications, morbidity and hospital stay in patients with soft pancreas and non-dilated ducts. MethodsA total of 109 patients undergoing elective pancreatoduodenectomy with soft pancreas and non-dilated duct were randomized to octreotide group versus no octreotide—the control group. Surgical steps were standardized and incidences of pancreatic fistula, complications, death and hospital stay were assessed. ResultsThere were 55 patients in octreotide group and 54 in the control group. Demographic features and pancreatic duct diameter of the groups were comparable. The rates of clinically significant pancreatic fistulae (grades B and C) were 10.9 and 18.5 % (p = ns), and morbidity was 18 and 29.6 % (p = ns), respectively. Patients who received octreotide resumed oral diet early and had a shorter hospital stay. ConclusionThis study demonstrated no statistical difference in pancreatic fistulae with the use of octreotide, though there was a trend towards fewer incidences of pancreatic fistulae, morbidity and shorter hospital stay.ClinicalTrials.gov Identifier: NCT01301222

Clinical efficacy of endoscopic pancreatic drainage for pain relief with malignant pancreatic duct obstruction.

This study was conducted to investigate the efficacy of pancreatic drainage for pain relief in advanced pancreatic cancer. Seventy-one patients with pancreatic carcinoma were divided into two groups: dilated and non-dilated pancreatic ducts. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic biliary stenting and pancreatic stenting. Visual Analog Scale (VAS) scores, pain remission rates and survival time were evaluated during follow-up. The post-ERCP VAS score of the dilated group was lower than that of the non-dilated group at 1 and 3 months post-ERCP. There was no difference at 6 months. The pain remission rate in the dilated duct group was significantly higher than that in non-dilated duct group in 1 and 3 months post-ERCP. The median survival times were 8.17 and 8.22 months respectively. Endoscopic pancreatic drainage can relieve pain of advanced pancreatic cancer accompanied by safe dilation of the pancreatic duct.

EUS-guided pancreatic duct intervention: outcomes of a single tertiary-care referral center experience

EUS can provide access to the main pancreatic duct (MPD) for therapeutic intervention. The long-term clinical success of EUS-guided MPD interventions is unknown. To determine technical and clinical success rates, predictors of success, and long-term outcomes of EUS-guided MPD intervention. Retrospective, single-center study. Tertiary-care referral center. Forty-five patients. EUS-guided MPD stent retrieval or placement. Technical and clinical success rates, adverse events, and long-term clinical outcomes. Among the 45 patients, 37 had undergone failed ERCP, and 29 had surgically altered anatomy. Median follow-up after initial EUS-guided intervention was 23 months. Two patients underwent EUS for stent removal, and EUS-guided MPD stent placement was attempted in 43 patients. Technical success was achieved in 32 of 43 patients (74%) with antegrade (n = 18) or retrograde (n = 14) stent insertion. Serious adverse events occurred in 3 patients (6%). Patients underwent a median of 2 (range 1-6) follow-up procedures for revision or removal of stents, without adverse events. Complete symptom resolution occurred in 24 of 29 patients (83%) while stents were in place, including all 6 with nondilated ducts. Stents were removed in 23 patients, who were then followed for an additional median of 32 months; 4 patients had recurrent symptoms. Among the 11 failed cases, most had persistent symptoms or required surgery. Retrospective study design, individualized patient management. EUS-guided MPD intervention is feasible and safe, with long-term clinical success in the majority of patients. EUS provides important treatment options, particularly in patients who would otherwise undergo surgery.

PTH-067 Yield of Endoscopic Ultrasound (EUS) in Patients with Dilated Common Bile Duct (CBD) and or Pancreatic Duct (PD) with normal Liver Function Test (LFTS) and Cross-Sectional Imaging

IntroductionThe finding of dilated CBD or PD or both (double duct sign) on abdominal cross-sectional imaging (CT or MRI) in patients with normal LFTs frequently leads to further investigation by...

Prompt Repair of Post Cholecystectomy Bile Duct Transection Recognized Intraoperatively and Referred Early: Experience from a Tertiary Care Teaching Unit.

Postcholecystectomy bile duct injuries are a cause of significant morbidity and occasional mortality. Intraoperative recognition and repair of complete biliary transection with hepaticojejunostomy is the recommended treatment; however, it is possible only in few patients as either the injury is not recognized intraoperatively or the center is not geared up to perform an urgent hepaticojejunostomy in these patients with a nondilated duct. Retrospective analysis of data from a tertiary care referral center over a period of 10years from January 2000 to December 2009 to report the feasibility and outcomes of prompt repair was done (defined as repair within 72h of index operation) of postcholecystectomy bile duct injury. Ten patients of postcholecystectomy bile duct injury detected intraoperatively and referred early underwent prompt repair. All patients had a complete transection of the bile duct (type of injuries as per Strasberg classification: Type E V: 1, Type E III: 5, Type E II: 3 and Type E I: 1). The mean duration between injury and bile duct repair in the form of Roux-en-Y hepaticojejunostomy (RYHJ) was 22.7 (range 5-42) hours. The mean diameter of the anastomosis was 1.63 (range1-2.1) cm, and the anastomosis was stented in 7 patients. The mean duration of surgery was 4.6 +1.7h. One patient developed bile leak on the first postoperative day, which settled by day 5. The mean duration of hospital stay was 5.1 (range 4-8) days. With a mean follow-up of 42 (range 24-110) months, all patients had excellent (70%) or good outcome (30%). Prompt RYHJ (within first 72h) for postcholecystectomy biliary transection is an effective treatment and potentially limits the morbidity to the patient.

Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy

Postoperative pancreatic fistula (POPF) remains one of the most common causes of morbidity following pancreaticoduodenectomy (PD). This randomized trial examined whether external stent drainage of the pancreatic duct decreases the rate of POPF after PD and subsequent pancreaticojejunostomy (PJ). Consecutive patients who underwent PD with subsequent construction of a duct-to-mucosa PJ were randomized into a stented and a non-stented group. The primary outcome was the incidence of clinically relevant POPF. Secondary outcomes were morbidity and mortality rates, and hospital stay. Of 114 PD procedures, 93 were suitable for inclusion in the study after informed consent. The rate of clinically relevant POPF was significantly lower in the stented group than in the non-stented group: three of 47 (6 per cent) versus ten of 46 (22 per cent) (P = 0·040). Among patients with a dilated duct, rates of POPF were similar in both groups. Among patients with a non-dilated duct, clinically relevant POPF was significantly less common in the stented group than in the non-stented group: two of 21 (10 per cent) versus eight of 20 (40 per cent) (P = 0·033). No significant differences in morbidity or mortality were observed. Univariable analysis identified body mass index (BMI), pancreatic cancer,pancreatic texture, pancreatic duct size and duct stenting as risk factors related to clinically relevant POPF. Multivariable analysis taking these five factors into account identified high BMI (risk ratio(RR) 11·45; P = 0·008), non-dilated duct (RR 5·33; P = 0·046) and no stent (RR 10·38; P = 0·004) as significant risk factors. External duct stenting reduced the risk of clinically relevant POPF after PD and subsequent duct-to-mucosa PJ.