Pancreaticoduodenectomy For Periampullary Carcinoma Research Articles

A prospective observational study on the impact of sarcopenia on perioperative outcomes following pancreaticoduodenectomy for periampullary carcinoma

A prospective observational study on the impact of sarcopenia on perioperative outcomes following pancreaticoduodenectomy for periampullary carcinoma

Drain Amylase Level as a Predictor for Postoperative Pancreatic Fistula after Pancreaticoduodenectomy for Periampullary Carcinoma

Drain Amylase Level as a Predictor for Postoperative Pancreatic Fistula after Pancreaticoduodenectomy for Periampullary Carcinoma

The Impact of Involved Resection Margin on Recurrence and Survival After Pancreaticoduodenectomy for Periampullary Carcinoma, with Emphasis on Pancreatic Head Carcinoma.

The supposed adverse effect of involved resection margin during pancreaticoduodenectomy (PD) for periampullary carcinoma or pancreatic head carcinoma (CaP) on long-term oncological outcomes is still inconclusive. This is a retrospective study on periampullary carcinoma undergoing PD. Patients with R0 (margin clear) resection were compared to patients with R1 (microscopically directly involved margin) resection. Patients with gross involved margin (R2 resection) were excluded. Long-term oncological outcomes measured included incidence and site of recurrent disease, overall survival (OS) and disease-free survival (DFS). A subgroup analysis was made on patients with CaP. Between January 2003 and December 2019, 203 PD were identified for present study. The incidence of R1 resection was common (12% in periampullary carcinoma and 20% in CaP). In periampullary carcinoma, R1 resection had greater proportion of CaP, lesser proportion of carcinoma of ampulla (CaA), more perineural invasion, more lymph node (LN) metastasis. R1 group had a shorter OS and DFS, but no difference in the incidence and site of recurrent disease. In the subgroup of CaP (91 patients), R1 group did not differ from R0 group except for more LN metastasis. There was no difference in incidence and site of recurrent disease, OS and DFS. On multivariable analysis, R1 resection was not an independent factor for OS and DFS for periampullary carcinoma or for CaP only. Involved resection margin was not uncommon. It was not associated with higher incidence of recurrent disease including local recurrence, and was not an independent prognosticator for OS and DFS.

Outcomes of early reoperation in severe pancreatic fistula and/or haemorrhage after pancreaticoduodenectomy

Although advances in multidisciplinary management reduce the mortality after pancreaticoduodenectomy (PD) from medical complications, postoperative pancreatic fistula (POPF) and/or postpancreatectomy haemorrhage (PPH) still remain as common morbidities and main causes of mortality. The morbidity of POPF and/or PPH after PD in our centre, Yangon Specialty Hospital, is 18-30% per year. And there are still ongoing disputes regarding management of POPF and/or PPH after PD. It is a hospital based prospective descriptive study carried out between 2018 January and 2020 April in surgical units at Yangon General Hospital, New Yangon General Hospital and our centre. Total 28 reoperated patients with POPF and/or PPH patients after PD were included in the study. The indications for reoperation in this study were patients with SIRS together with drain amount more than 300 ml/day and/or blood in drain/ NGT with Hb drop ≥ 3 g% or sentinel bleed. Preoperative CECT scan was done if condition was favorable. In this study, demographic distribution, proportion of reoperation, timing of reoperation, types of procedure were also recorded while outcomes of reoperation was emphasized in this eposter. There were 56 patients who suffered from POPF and/or PPH after PD for periampullary carcinoma during this study period. Although reoperation was advised to 34 patients, who met the indications for reoperation, six of them declined operation for various reasons. Therefore, total 28 patients were reoperated (50%). Fig. 1 showed the intraoperative findings of POPF and PPH patient. Median timing of reoperation was 9 days (2-25 days) and 71% were reoperated within 10 days. While external tube wirsungosotmy (Fig. 2) was performed in majority of POPF cases as a damage control surgery, PPH patients ended up with mainly laparotomy and GDA ligation for arrest of haemorrhage because of lack of interventional radiology (IR) support at present. Among reoperated patients, 14 patients (50%) survived and 14 patients (50%) expired. Therefore, overall in-hospital mortality was 50% in reoperated cases. The main cause was multi-organ failure due to severe sepsis. According to the Fig. 3, in-hospital mortality rate of POPF was 16% and that of PPH was 66% while that of POPF and PPH was 80% in this study. Gangl et al. (2011) [1] reported that the combination of pancreatic fistula and severe hemorrhage was a strong predictor of postoperative mortality (relative risk (RR), 22.75). And Tamijmarane et al. (2006) [2] pointed out that patients themselves are in such a moribund condition that their associated mortality rate ranges between 38 and 50%. In addition, it was surprisingly found that all six patients, who needed reoperation, died with conservative management in this study. It is found that reoperation is necessary in patients when it is indicated i.e. mainly clinical based. Early reoperation and damage control surgery is found to have better outcomes in especially POPF patients before organ failure or haemorrhage supervenes. And it is hard to say the accurate timing of reoperation and optimal procedures because this study has some limitations like small sample size, and limited resources for multidisciplinary management. Therefore, further study with larger sample size and optimal resources and management will be necessary for better and more significant results. Showing intraoperative findings of POPF and PPH. Showing method of external tube Wirsungostomy insertion. Outcomes of reoperative management.

Effect of Preoperative Internal Biliary Drainage on Postoperative Outcome Following Pancreaticoduodenectomy for Periampullary Carcinoma

Background: Preoperative biliary drainage before pancreaticoduodenectomy is a controversial issue. Proponents are in favor of preoperative biliary drainage by ERCP with stent to reduce surgical jaundice with an anticipation of better surgical outcome.
 Objective: Compare the outcome with or without pre-operative biliary drainage before pancreaticoduodenectomy.
 Materials and Methods: This observational comparative study was conducted in department of Surgery and Hepatobiliary and pancreatic surgery of BSMMU. Twenty three patients presented with obstructive jaundice due to periampulary carcinoma who subsequently underwent pancreaticoduodenectomy were selected by purposive sampling and finalized by eligibility criteria.
 Results: Patients with preoperative biliary drainage (PBD) group required a longer operative time (mean 4.12 hours versus 3.83 hours) and had more intra-operative blood loss (mean 662 mL versus 495 mL) compared with non PBD group (P=0.009 and 0.010). No differences were found with respect to operative mortality (4.3%) and incidence of pancreatic leakage (P=0.281). PBD was significantly associated with positive bile culture (P=0.019) and high incidence of wound infection (p=0.029).
 Conclusion: Preoperative biliary drainage did not increase major postoperative morbidity and mortality but associated with increased operative time, intraoperative blood loss, and incidence of wound infection. Preoperative biliary drainage should be used selectively in patients undergoing pancreaticoduodenectomy.
 KYAMC Journal Vol. 10, No.-4, January 2020, Page 196-201

A rare case of pseudocyst in remnant pancreas after classical pancreaticoduodenectomy- treated by endoscopic drainage

Pancreatic pseudocysts comprise more than 80 % of the cystic lesions of the pancreas. Here we report a 45-year-old female patient who developed a symptomatic pseudocyst in the remnant pancreas following classical pancreaticoduodenectomy for periampullary carcinoma. The pancreatic anastomosis was pancreaticogastrostomy- Dunking technique. She underwent endoscopic cystogastrostomy. Recurrence should always be ruled out before diagnosing pseudocyst in remnant pancreas following pancreaticoduodenectomy for malignant tumors.

Small bowel perforation caused by pancreaticojejunal anastomotic stent migration after pancreaticoduodenectomy for periampullary carcinoma.

Pancreaticoduodenectomy is the gold standard for patients with resectable periampullary carcinoma. The protection of the anastomosis by positioning of an intraluminal stent is a technique used to lower the frequency of anastomotic fistulas. However the use of anastomotic stents is still debated and stent related complications are reported. A fifty-three-year old male underwent pancreaticoduodenectomy (PD) for a T2N0 periampullary carcinoma with a pancreaticojejunal (duct to mucosa) anastomosis protected by a free floating 6 Fr Nelaton stent in the Wirsung duct. Twenty-three months after surgery the patient accessed Emergency Department for severe abdominal pain associated to temperature, high white blood cell count and an significant increase in C reactive protein. Method Abdominal CT scan shown the presence of a tubular stent in the mesogastrium/lower right quadrant. No evident free intra-abdominal air was detected. The patient was submitted to explorative laparotomy. After debridement for localized peritonitis the Nelaton trans anastomotic stent was found in the abdomen. There was no evidence of bowel perforation, but intestinal loops covered with fibrin and suspect for impending perforation were resected. There is a lack of evidence about the true rate of post-operative complications related to pancreatic stenting. We believe that in patients presenting with abdominal pain or peritonitis that previously underwent PD with stent-guided pancreaticojejunal anastomosis, the hypothesis of stent migration should at least be taken into consideration.

The Effect of Epidural Bupivacaine on Induction and Maintenance Doses of Propofol (Evaluated by Bispectral Index) and Maintenance Doses of Fentanyl and Vecuronium

The growing interest in combining local and general anesthesia has led to studies investigating possible interactions between general anesthesia and local anesthetics administered via spinal, epidural, IV, or IM routes. However, no study has evaluated the effect of local anesthetics on all three components of balanced anesthesia, i.e., hypnosis, analgesia, and muscle relaxation. In this prospective, randomized, double-blind study, we investigated the effect of epidural bupivacaine on the dose requirement of propofol (as evaluated by using the bispectral index [BIS]), fentanyl, and vecuronium for general anesthesia. This study consisted of 30 adults, ASA physical status I and II, undergoing Whipple's pancreaticoduodenectomy for periampullary carcinoma lasting >4 h. An epidural catheter was placed between T9-10. Depending on the group allocation, 10 mL of the study drug was administered as a bolus followed by an infusion at 6 mL/h via the epidural catheter. Patients were divided into 2 groups of 15 each. Patients in the control group received epidural normal saline whereas those in the bupivacaine group received epidural bupivacaine 0.1%. Induction of anesthesia was performed with IV fentanyl 2 mug/kg and propofol titrated to achieve BIS between 40-50. Endotracheal intubation was facilitated by the IV administration of vecuronium 0.1 mg/kg and patient's lungs were ventilated with 66% nitrous oxide in oxygen. After intubation, infusion of propofol 1% was titrated to maintain BIS between 40-50. Inadequate analgesia was defined as an increase in systolic blood pressure and/or heart rate by >20% of baseline values in response to surgical stimulus and was treated with bolus fentanyl 0.5 mug/kg. Neuromuscular monitoring was used to assess the need for additional doses of vecuronium. Data were analyzed by using the Student's t-test and P </= 0.05 was considered significant. The requirement of propofol for induction and maintenance of anesthesia in the bupivacaine group was 1.3 +/- 0.3 mg/kg and 2.4 +/- 0.9 mg . kg(-1) . h(-1), respectively, compared with 2.4 +/- 0.6 mg/kg and 4.4 +/- 1.6 mg . kg(-1) . h(-1) observed in the control group (P < 0.05). Significant reduction was also observed in the requirement of vecuronium and fentanyl during maintenance in the bupivacaine group (P < 0.05). We conclude that epidural bupivacaine given before induction of anesthesia reduces the requirement of propofol, fentanyl, and vecuronium during general anesthesia.