Pancreaticoenteric Reconstruction Research Articles

Decision-making and practice habits from international expert surgeons regarding operative techniques and mitigation strategies to reduce pancreatic fistula following pancreatoduodenectomy

Presenter: Fabio Casciani MD | University of Pennsylvania Background: Employment of pancreatic fistula mitigation strategies during pancreatoduodenectomy (PD) offers numerous decision-making points. Particularly, despite ample retrospective studies and RCTs, no consensus exists concerning optimal anastomotic techniques and use of adjuncts for risk mitigation. Methods: A questionnaire was sent to a select panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their thought-processes and practice regarding pancreatico-enteric anastomotic technique and fistula mitigation strategy employment were explored through checkbox questions, free-text responses, and situational clinical vignettes. Results: 60 surgeons from 22 countries, encompassing 73,304 career pancreatic resections (median pancreatectomy/PD volume: 1200/705, median career duration: 22 years), contributed. When asked to report their usual fistula mitigation strategy employment, 55% always use PJ, whereas PG is never adopted by 58%. (Table) Concerning PJ technique, 80% use duct-to-mucosa reconstruction frequently/always (≥75% of the time) - more often by Cattel-Warren technique rather than Blumgart (45 vs. 33%). Trans-anastomotic stents are always placed by few experts (17%), with the internal type preferred. Roux-en-Y limb reconstruction, biological sealants and tissue patches are exceedingly rarely applied. Similarly, prophylactic somatostatin-analogues are infrequently employed (never: 57%; selectively: 38%). Lastly, 45% of authorities selectively employ transperitoneal drainage rather than routinely, but not one absolutely omits drains. However, there is no conformity regarding drain number, type or system. When considering such approaches collectively, the most prevalent “bundle” chosen (47%) is the combination of PJ, no stent, external drainage and omission of Somatostatin-analogue, with two-thirds declaring to be flexible -rather than rigid- in their fistula risk mitigation approaches. In the case of perceived increased fistula risk, the most frequent adjuncts chosen are placement of additional drains (27%), the use of prophylactic Somatostatin (20%), and externalized stents (18%). (Table, bottom) Conversely, total pancreatectomy is opted by just 10%, while a PG (rather than PJ) by only 5%. This was confirmed throughout clinical vignettes depicting stepwise increasing risk scenarios: the use of dunking/invaginating PJ, stents, drains and Somatostatin-analogues increased accordingly (+146%, +94%, +39% and +380%, respectively). Conversely, the employment of PG reconstruction and Roux limb orientation remained uncommon (≈6%). Finally, facing a challenging scenario where the pancreatic tissue is easily disrupted when placing stitches in a soft, thick parenchyma with an eccentric < 1mm duct, most specialists would perform a new anastomosis after cutting back the pancreas (42%), whereas others directly perform a dunking/invagination PJ (27%). Again, constructing a PG (12%) or converting to a total pancreatectomy (10%) are both rarely considered. Other, additive mitigation strategies employed in such a challenging situation are: stents (58%), additional drain placement and Somatostatin-analogue administration (37% each), autologous tissue patches (23%) and jejunal/gastrostomy tubes to optimize nutrition (20%). Conclusion: A tension between a rigid versus a flexible approach to fistula risk mitigation during PD is tangible among experts. Most vary their practice according to perceived, advanced risk, with dunking/invaginating PJ (rather than PG), stents, drains and Somatostatin-analogues each being modestly advocated in such circumstances. These insights indicate that approaches to pancreatico-enteric reconstruction are variable, and optimal, absolute solutions for high-risk anastomoses are still unresolved.

Robotic Central Pancreatectomy for Well-Differentiated Neuroendocrine Tumor: Parenchymal-Sparing Procedure.

The frequency of pancreatic neuroendocrine tumors (pNETs), representative of benign and borderline malignant pancreatic tumors, has been increasing. For pNETs, pancreas-preserving pancreatectomy can be an appropriate option. Conversely, some articles have recently shown that robotic central pancreatectomy (RCP) is feasible and safe. We demonstrated our standardized technique of RCP. In our technique, pancreaticoenteric reconstruction is performed via a pancreaticogastrostomy to manage the distal pancreatic remnant. We also evaluated our initial experience with four consecutive RCPs for well-differentiated pNETs, retrospectively. In our evaluation, two men and two women had a median age of 45years (range 36-64). Median tumor size was 2.1cm (range 1-5), and median operative time was 315min (range 268-630). No transfusion was given perioperatively. Median hospital stay was 17days (range 13-22). Grade A postoperative pancreatic fistula was identified in two patients, while grade B was identified in the other two patients. One of the patients was managed using an additional percutaneous drainage. No operative mortality was observed. Pathological findings confirmed R0 resection for all well-differentiated pNETs (pT1: two patients; pT2: two patients). Central pancreatectomy can be carefully selected as a relevant surgical option for well-differentiated pNETs circumscribed in the pancreatic isthmus and body. Our robotic procedure might overcome the complexity of central pancreatectomy, a parenchymal-preserving procedure, with adequate oncological outcomes.

Comparative study of Alternative Fistula Risk Score (A-FRS) and Fistula Risk Score (FRS) For Predicting the Risk of Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Introduction: Postoperative pancreatic fistula (POPF) remains the most serious complication after pancreatico-duodenectomy (PD) and the risk of developing POPF is more or less equal with different techniques of reconstruction. Various risk calculation models have been developed for predicting / calculating risk of pancreatic fistula. Fistula risk score (FRS), described in 2013 is the most commonly used scoring system for this purpose. Recently alternative fistula score (a-FRS), was developed and validated in western population. Both FRS & a-FRS are developed and validated in western population with predominantly pancreatic head tumors; whereas, in India we mostly encounter periampullary tumors. Aim: to compare the a-FRS and FRS models for predicting POPF. Method: We performed a retrospective analysis from 1stJanuary 2011 to 31stMarch 2018. All the patients undergoing PD with pancreatico-enteric reconstruction by PJ method were included and patients undergoing distal /median/ total pancreatectomy were excluded. A-FRS and FRS scores were calculated and compared with the actual POPF rates (defined by 2016 ISGPS definition). Result: study cohort contained 825 patients with male preponderance. Median age of the study cohort was 55 years. 61.8% tumors were located in periampullary region and 77.4% were adenocarcinoma. Overall CR-POPF rate in our study population was 16.8% and was represented with more accuracy by a-FRS model (p value-0.003). The performance of each model was assessed byarea under the receiver operating curve (AUC) and calibration plots. Conclusion: a-FRS model performed better in as compared to FRS model (AUC- 0.70 Vs 0.65, p value-0.003) for prediction of POPF but, AUC’s of both the models were still not the best for the perfect prediction model.

Outcome of 150 Consecutive Blumgart's Pancreaticojejunostomy After Pancreaticoduodenectomy.

Postoperative pancreatic fistula (POPF) is the most feared complication after pancreaticoduodenectomy (PD) that leads to intra-abdominal abscess, sepsis, or bleeding and remains the single most important source of morbidity and mortality after PD. To minimize this dreaded complication, various surgical techniques and modifications of pancreaticoenteric reconstruction have been proposed. However, still POPF does occur even in experienced hands. We herein describe the outcome of 150 post PD patients who underwent duct-to-mucosa (DM) pancreaticojejunostomy (PJ) using a special technique, Blumgart's "through & through" U transpancreatic sutures. The technique is described in detail. Postoperative octreotide and metoclopramide were used in all patients for 3days. An enhanced recovery (ERAS) protocol was followed in a subset of patients. All patients were ASA grade 1 and had adenocarcinoma of the periampullary region/pancreatic head and underwent standard pylorus resecting PD after due optimization. Eighty-eight (58.7%) patients had pancreatic duct < 3mm and pancreatic texture was soft to very soft in 112 (74.6%) patients. There was only one International Study Group of Pancreatic Surgery (ISGPS) grade C POPF with concomitant hemorrhage. Five patients developed ISGPS grade B and two grade C, delayed gastric emptying (DGE). There was no 30-day mortality. The average length of hospital stay was 7.3 ± 4.2days with a median of 6days in the ERAS subset of patients. Blumgart's "through & through" DMPJ technique is very helpful in reducing the POPF and other complications even in high-risk pancreas (i.e., soft with a small pancreatic duct) and is easy to learn and perform.

Robotic Double Purse-String Telescoped Pancreaticogastrostomy: How I Do It.

Some articles have recently shown that robotic pancreaticoduodenectomy (PD) is feasible and can be a safe method. On the other hand, pancreatic fistulas (PF) remain the most dreaded complication after PD, and a secured pancreaticoenteric reconstruction may be essential in this regard. Previous articles have highlighted the usefulness of telescoped pancreaticogastrostomy (PG) in open PD to reduce the risk of postoperative PF. Additionally, in 2016, Addeo et al. described a double purse-string telescoped PG (DPS-PG), simplified from previous techniques, with favorable short-term results. The attached video reports our standardized technique for robotic DPS-PG, which is based on Addeo's approach. The main characteristic of this technique is an easy placement of two seromuscular purse-string sutures without the need for gastric wall dissection or deep pancreatic parenchymal sutures. We modified and developed Addeo's technique to suit the robotic PD. In our robotic DPS-PG, there is no need to perform the opening of the distal gastric stump, the anterior gastrostomy, or the suture fixation of the pancreatic parenchyma to the stomach, as it could lead to a rupture of the pancreas, particularly when the parenchyma is soft. We consider that our technique of robotic DPS-PG might be feasible and can be safely performed, just as a previously described technique in open surgery. Further evaluation with clinical trials is required to validate its real benefits.

Historical review of pancreatico-enteric reconstruction follow-ing pancreatoduodenectomy

The pancreatico-enteric anastomisis has always been a great concern in pancreatoduodenectomy, even been called Achilles heel . Pancreatic surgeons are interested in improving the anastomosis technique to prevent the pancreatic fistula rate. More than a hundred of anastomosis techniques were reported, authors reviewed the history of pancreatico-enteric anastomisis and divided it into three historical stages, as well as summarized the characteristics of each stage. At the same time, auhors introduced the most representative anastomotic techniques and concepts in each period. Key words: Pancreatic neoplasms; Pancreatoduodenectomy; Digestive tract reconstruction; Pancreaticojejunostomy; Pancreaticogastrostomy; Historical stages

Different types of pancreatico-enteric anastomosis.

The pancreatico-enteric anastomosis has widely been regarded as the 'Achilles heel' of the modern day, single-stage, pancreatoduodenectomy (PD). A review of the literature was carried out to address the evolution of the pancreatico-enteric anastomosis following PD, the spectrum of anastomoses performed around the world, and finally present the current evidence in support of each anastomosis. Pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are the most common forms of pancreatico-enteric reconstruction following PD. There is no difference in postoperative pancreatic fistula (POPF) rates between PG and PJ, as well as individual variations, except in a high-risk anastomosis where performance of a PJ may be preferred. The routine use of glue, trans-anastomotic stents or omental wrapping is of no proven benefit. Externalised trans-anastomotic stents may have a role in mitigating the risk of a clinically relevant POPF in high-risk anastomoses. Pancreatico-enteric anastomosis is an important component of reconstruction following PD even though it is fraught with the risk of development of a POPF. Adherence to the tenets of anastomotic reconstruction and performance of a safe and reproducible anastomosis with a low clinically-relevant POPF rate remain the mainstay of achieving the best outcomes. Appropriate selection and opportune use of fistula mitigation strategies may help provide optimal outcomes when faced with the need to perform a high-risk pancreatico-enteric anastomosis.

Continuous dunking pancreaticojejunostomy: our experience with first fifty cases

Introduction- Different techniques and modifications have been described to bring down the incidence of pancreatic fistula rate. However, no techniques have been accepted as a gold standard. Since 2011, we have been performing pancreaticojejunostomy by continuous dunking technique. Here, we intend to present our experience with the defined technique.Methods: Prospectively maintained medical records of the patients (operated between Sept 2011 to Jan 2016) undergoing pancreaticoduodenectomy and pancreaticoenteric reconstruction by continuous dunking techniques were reviewed and analyzed. Postoperative complications mainly, incidence of post pancreatectomy fistula (POPF), hemorrhage (PPH) and delayed gastric emptying (DGE) along with other major complications were analyzed. Subgroup analysis was also performed to find the difference in fistula rate in patients with or without addition of Braun’s anastomosis. ISGPS definition was used to define the major, surgery specific complications of pancreaticoduodenectomy.Results: Total 51 patients underwent pancreaticojejunostomy with the defined technique with Male to female ratio of 23:28. Total 13.7% (7/51) patients received preoperative biliary drainage. Overall, clinically significant fistula rated was 15.6% (8/51), PPH 13.7% (7/51) and 0% clinically significant DGE (overall DGE 13.7%, 7/51). Mortality rate was 5.8% (3/51). Subgroup analysis performed between patients with or without addition of Braun’s anastomosis revealed 0% clinically significant fistula rate with no mortality in the group.Conclusion: Surgery specific complications following pancreaticoduodenectomy and pancreaticoenteric reconstruction with our technique are comparable to published results from high volume centers. Addition of Braun’s anastomosis is a promising modification to bring down the POPF rate to a minimum.

Outcomes of Pancreatogastrostomy With Gastric Partition After Pylorus-Preserving Pancreaticoduodenectomy With Gastric Partition

IntroductionPylorus-preserving pancreatoduodenectomy with gastric partition (PPPD-GP) seems to be associated to a better postoperative outcome than conventional pancreaticojejunostomy in the setting of a prospective-randomised study. The aim of this study is to further evaluate the surgical outcome in a series of 129 consecutive patients. MethodsBetween 2007 and June 2013, 129 patients with periampullary tumours surgically treated with PPPD-GP were retrospectively analysed. Surgical complications (Clavien–Dindo score), as well as pancreatic and non-pancreas related complications were analysed. ResultsOverall postoperative complication rate was 77%, although 50% of complications were graded I–II by the Clavien–Dindo classification. Incidence of clinically relevant pancreatic fistula was 18%: ISGFP type B: 12%, and type C: 6%. Other pancreas specific complications such as delayed gastric emptying and pospancreatectomy haemorrhage were 27% and 15%, respectively, similar to results published in the literature. Overall perioperative mortality rate was 4.6%. ConclusionPPPD-GP results show that it is a technique with an acceptable morbidity, low mortality and pancreatic fistula rate similar to other techniques currently described of pancreaticoenteric reconstruction.

Resultados de la pancreatogastroanastomosis con bipartición gástrica después de duodenopancreatectomía con preservación pilórica

IntroductionPylorus-preserving pancreatoduodenectomy with gastric partition (PPPD-GP) seems to be associated to a better postoperative outcome than conventional pancreaticojejunostomy in the setting of a prospective-randomized study. The aim of this study is to further evaluate the surgical outcome in a series of 129 consecutive patients. MethodsBetween 2007 and June 2013, 129 patients with periampullary tumors surgically treated with PPPD-GP were retrospectively analyzed. Surgical complications (Clavien-Dindo score), as well as pancreatic and non-pancreas related complications were analyzed. ResultsOverall postoperative complication rate was 77%, although 50% of complications were graded I-II by the Clavien-Dindo classification. Incidence of clinically relevant pancreatic fistula was 18%: ISGFP type B: 12%, and type C: 6%. Other pancreas specific complications such as delayed gastric emptying and pospancreatectomy haemorrhage were 27 and 15%, respectively, similar to results published in the literature. Overall perioperative mortality rate was 4.6%. ConclusionPPPD-GP results show that it is a technique with an acceptable morbidity, low mortality and pancreatic fistula rate similar to other techniques currently described of pancreaticoenteric reconstruction.

The safety and efficiency of the Blumgart anastomosis in pancreaticojejunostomy after pancreaticoduodenectomy

Objective To evaluate the impact of the Blumgart anastomosis in pancreaticojejunostomy on the incidence of postoperative pancreatic fistula (POPF) after pancreaticoduodeneetomy (PD),and to study its safety and efficacy.Methods A total of 205 patients who underwent PD between January 2011 and February 2013 were retrospectively studied.The patients were divided into three groups depending on the pancreaticoenteric reconstruction:the Blumgart anastomosis group (n=37),the duct-to-mucosa anastomosis group (n =39) and the traditional invagination group (n=129).Postoperative morbidity were analyzed.Results The incidences of POPF after the Blumgart anastomosis (8.1％) was significantly lower than the duct-to-mucosa anastomosis group (23.1％ ; P=0.037) and the traditional invagination anastomosis group (30.2％ ; P=0.012).Multivariate analysis revealed soft pancreatic texture,pancreatic duct diameter ＜3 mm and non-Blumgart anastomosis were independent risk factors of POPF.On subgroup analysis,the Blumgart anastomosis was superior to the duct-to-mucosa anastomosis in patients with pancreatic duct diameter ＜ 3 mm (P=0.038),and showed advantages over the traditional invagination anastomosis in patients with soft pancreatic texture (P =0.001),as well as in patients with pancreatic duct diameter ＜ 3 mm (P=0.011).Conclusions The Blumgart anastomosis is a safe technique,and it could significantly reduced the rate of POPF.It should be routinely used for pancreatoenteric reconstruction after PD. Key words: Pancreaticoduodenectomy; Pancreaticojejunostomy; Pancreatic fistula

Laparoscopic pancreatic resection without advanced laparoscopic devices.

Laparoscopic pancreatic resection has been slow to develop because of the high degree of technical difficulty and generally expensive laparoscopic devices required. We evaluate our experience with laparoscopic resections for pancreatic pathologies without expensive and advanced laparoscopic devices. A prospective evaluation was carried out of consecutive laparoscopic pancreatic resections performed between July 2003-June 2011. Laparoscopic pancreatic resections were attempted in 13 and performed in 10 patients: 6 laparoscopic spleen-preserving distal pancreatectomy and 4 laparoscopic enucleation. Pathological diagnoses: four insulinomas, two serous cystadenoma, two pancreatic pseudocyst, one microcystic serous cystadenoma, two non-functioning neuroendocrine tumors, one leiomyosarcoma, and one case of solid-pseudopapillary tumor. In the laparoscopic operations the mean operative time was 195min and no blood transfusions were required. The mean postoperative hospital stay was 4.7 days. There were three pancreatic fistulas. No patients required a second operation. There were no deaths. Follow-up was available for all patients. Laparoscopic pancreatic resection is feasible and relatively safe without advanced laparoscopic devices. As with open resections, pancreatic fistula is the dominant morbidity. The best indications for a laparoscopic approach are benign pancreatic tumors that are not inside the neck of the pancreas and do not require pancreaticoenteric reconstruction.

Early Experience for the Robotic Duodenum‐preserving Pancreatic Head Resection

The duodenum-preserving pancreatic head resection (DPPHR) has been accepted as a valid surgical alternative to more extensive standard resections for the treatment of benign and low malignant tumors at the head of the pancreas. In this article, a new minimally invasive operation, the robot-assisted laparoscopic technique, is introduced for this procedure. From March 2010 to Dec 2010, four patients (three women and one man), with a mean age of 42.3 years (range: 21-62 years), underwent robot-assisted laparoscopic DPPHR at the Hepato-Bilio-Pancreatic Surgical Department of Rui Jin Hospital in Shanghai, China. The preoperative symptoms include two cases of repeated upper abdominal pain, one case with no obvious preoperative symptoms, and one case of repeated hypoglycemia. The da Vinci Surgical System was used to perform the main steps of the operation. All patients underwent a pancreaticogastrostomy for pancreaticoenteric reconstruction to the distal stump. All four surgeries were successfully performed. There were no deaths. The mean operative time was 298.8 (270-335) min, average blood loss was 425 ml (range: 100-600 ml). The mean postoperative hospital stay was 26.8 days (range: 20-30 days). The one patient with an islet cell tumor has had normal blood glucose levels since the operation, and the other three patients have had no hyperglycemia. Three of the patients developed a pancreatic fistula that was cured by conservative treatment. The robotic surgical system is technically fully capable of performing the complex DPPHR procedure with an acceptable range of surgical complications. It breaks through the bottleneck of the traditional laparoscopic technology and expands the range of its applications. However, this new technology is still at an exploratory stage, and the long-term effect remains to be validated by additional clinical data.

胰十二指肠切除术中胰消化道重建方式对术后胰瘘发生的影响

胰十二指肠切除术被认为是治疗壶腹周围良恶性肿瘤的一种成熟安全的术式，但其术后并发症的发生率仍高，而术后胰瘘是最常见的并发症之一。本文回顾并比较了目前为防止胰瘘发生而设计的各种胰消化道重建术式效果的相关数据，旨在通过对各项大样本研究，meta分析，前瞻性研究，回顾性研究以及随机对照实验进行客观严格的分析而寻找最有效的吻合术式。但遗憾的是，世界范围内目前并没有就任何一种术式较其他方法存在优越性达成共识。 Pancreaticoduodenectomy (PD) has become an increasingly matured and safe operation for selected patients with benign and malignant periampullary disorders. However, the postoperative morbidity rate is still high. Pancreatic fistula (PF) is the most problematic common complication after PD. This article reviews and compares the available data on the outcome of various methods of pancreaticoenteric reconstruction designed for the prevention of PF. This paper is designed to do a critical analysis of clinical literature including large series, meta-analyses, and prospective, randomized controlled trials (RCTs) in order to compare the different pancreaticoenteric anastomosis and get the best management. As a result, there is no universal agreement as to whether one procedure is safer and less prone to PF than the others.

Which is the best technique for pancreaticoenteric reconstruction after pancreaticoduodenectomy? A critical analysis

The definitive surgical management of periampullary tumors is a challenging endeavor. This article reviews the available data on the efficacy of various methods of pancreaticoenteric reconstruction designed for the prevention of pancreatic fistula (PF). A literature search of the Medline database was used to identify randomized controlled trials (RCTs) that compared pancreaticojejunostomy (PJ) with pancreaticogastrostomy (PG) after pancreaticoduodenectomy (PD). A total of two metaanalyses and four prospective RCTs were identified. Individual RCTs comparing PJ and PG allow the surgeons participating in the trial to choose technical modifications of one particular technique. As a result, there is no universal agreement as to whether one particular variation is safer and less prone to PF than the others. In addition, the majority of RCTs failed to stratify patient risk of PF. Further studies are therefore necessary to define the optimal technique of pancreatic reconstruction after PD conducted in high-volume centers by high-volume surgeons.

Robotic central pancreatectomy with stented pancreaticogastrostomy: operative details

Central pancreatectomy (CP) is increasingly being used to treat selected lesions of the central pancreatic segment. A step-by-step technique for robotic CP is described and a literature review provided for this minimally invasive approach. A 55-year-old woman was referred to the authors' center for the treatment of a single 4 cm lesion located at the proximal part of the pancreatic body. The da Vinci Robotic surgical system® with a five trocar technique was used. The pancreatic neck was transected using an endoscopic stapler. The pancreatic body was progressively dissected from the splenic vessels right to left and sectioned with an appropriate oncologic margin. A pancreaticogastrostomy protected by a transanastomotic external stent was constructed to the distal pancreatic stump. Surgery lasted 450 min (8 min docking time) with minimal blood loss. Pathology showed a 28 mm well-differentiated neuroendocrine pancreatic tumor with tumor-free resection margins. The patient was discharged home on postoperative day 15 in good condition. Robotic surgery can be safely used for complex pancreatic resection requiring pancreaticoenteric reconstruction. The experience reported so far is still limited but the results are encouraging; robotics shows the potential to bridge the gap between minimally invasive surgery and advanced pancreatic surgery.

The analysis of diagnosis and treatment for pancreatic fistula after pancreaticoduodenectomy for 105 periampullary carcinoma cases

Aim: To investigate the ways in which to decrease the morbidity of pancreatic fistula after pancreaticoduodenectomy and corresponding therapy. Methods: Double-layered end-to-side duct-to-mucosa anastomosis was applied in 105 cases of pancreaticoduodenectomy and pancreaticoenteric reconstruction, postoperative pancreatic fistula cases were treated aggressively by early surgery, effective drainage and enteral nutrition. Results: Ten cases of pancreatic fistula occurred among 105 operative cases and required reoperation. The rest of the cases recovered uneventfully, except for five cases of in-hospital death. Conclusion: Aggressively early surgery, effective drainage, comprehensive treatment and continual improvement of operative technique are the key to dealing with postoperative pancreatic fistula.

Robot-Assisted Laparoscopic Middle Pancreatectomy

Middle pancreatectomy has been accepted as a valid surgical alternative to more extensive standard resections for the treatment of benign central pancreatic tumors. In this article, we describe a new minimally invasive approach to this procedure, using a robot-assisted laparoscopic technique. From May 2004 to October 2005, 3 patients (2 female and 1 male), with a mean age of 52 years (range, 44-68), underwent robot-assisted laparoscopic middle pancreatectomies at the Department of General Surgery of Misericordia Hospital in Grosseto, Italy. Two of the patients had symptomatic serous cystadenomas, and 1 patient had a mucinous cystadenoma, which was discovered incidentally. The da Vinci((R)) Surgical System (Intuitive Surgical, Sunnyvale, CA) was used to perform the main steps of the intervention. All patients underwent a pancreaticogastrostomy for pancreaticoenteric reconstruction to the distal stump. The mean operative time was 320 minutes (range, 270-380). Mean blood loss was 233 mL (range, 100-400). There were no mortalities. One patient developed a postoperative pancreatic fistula, which was managed conservatively. The postoperative hospital stay was 9 days for 2 patients and 27 days for the third patient. No endocrine or exocrine deficiencies were observed in the patients during a mean follow-up of 44 months (range, 38-48). Robot-assisted laparoscopic middle pancreatectomy presents an interesting, less-invasive option for resection of benign tumors of the neck and proximal body of the pancreas. In benign disease, it allows for the preservation of functional pancreatic parenchyma and, subsequently, reduced operative trauma.

A Single-Institution Prospective Study of Laparoscopic Pancreatic Resection

Laparoscopic pancreatic resection can safely duplicate all of the open pancreatic procedures. A prospective evaluation of laparoscopic pancreatic resection. Surgical procedure, postoperative course, and follow-up data were collected. Department of Abdominal Surgery at Haut-Lévêque Hospital, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France. Sixty patients with presumed pancreatic neoplasms. Final diagnoses were benign disease in 57 patients (95%) and malignant pancreatic disease in 3 patients (5%). Complication and success rates of resections. Twenty percent of procedures were switched to open laparotomy. Laparoscopically successful procedures included 20 distal pancreatectomies with spleen preservation, 5 distal splenopancreatectomies, 16 enucleations, 5 medial pancreatectomies, 1 pancreatoduodenectomy, and 1 total pancreatectomy. Postoperative death occurred in 1 patient (1.6%). The overall postoperative complication rate was 36%, including a 13% rate of clinical fistulae. In successful laparoscopic operations, the mean (SD) postoperative hospital stay was 12.7 (6) days. Multivariate, stepwise analysis identified pancreatic consistency and pancreatic resection that required anastomosis as independent factors of postoperative complication (P = .02 and P = .002, respectively). The 3 patients operated on for pancreatic malignancies were still alive at follow-up (median, 23 months); all patients with benign disease were alive at long-term follow-up. This series demonstrates that laparoscopic pancreatic resection is not only feasible but also safe. Our study suggests that the best indications for a laparoscopic approach are presumably benign pancreatic tumors not requiring pancreaticoenteric reconstruction.

PANCREATICODUODENECTOMY: DOES PREOPERATIVE BILIARY DRAINAGE, METHOD OF PANCREATIC RECONSTRUCTION OR AGE INFLUENCE PERIOPERATIVE OUTCOME? A RETROSPECTIVE STUDY OF 104 CONSECUTIVE CASES

Whether preoperative biliary drainage (PBD) is beneficial in reducing complications after pancreaticoduodenectomy is controversial. There remains a reluctance to consider pancreaticoduodenectomy in older patients. The major source of morbidity and potential mortality after pancreaticoduodenectomy is pancreatic fistula, which is caused by difficulties associated with the pancreatic anastomosis. The purpose of this study was to examine the effect of PBD, patient age and method of pancreatico-enteric reconstruction on postoperative morbidity and mortality. A total of 104 consecutive patients undergoing pancreaticoduodenectomy between November 1992 and November 2004 were identified from a prospectively collected database. Multiple preoperative and intraoperative variables were examined and their relationship to postoperative outcome was analysed. Postoperative mortality was <1%. Forty-three patients (43%) suffered a total of 85 complications. Median length of stay was 12.5 days (range, 1-88 days). The group undergoing PBD did not have higher rates of infectious complication (12 vs 19%; P = 0.34) or overall complication (41 vs 42%; P = 0.88) compared with the undrained group. Rate of anastomotic leak (18 vs 4%; P = 0.045) and anaemia requiring transfusion (41 vs 9%; P = 0.001) were significantly higher in the pancreaticojejunostomy group compared with the pancreaticogastrostomy group. Patients over the age of 70 years did not have higher rates of complication (44 vs 41%, P = 0.5) or postoperative length of stay. Preoperative biliary drainage was not associated with increased postoperative complications. Pancreaticogastrostomy after pancreaticoduodenectomy is a safe and reliable method of reconstruction. Finally, pancreaticoduodenectomy can be carried out with acceptable rates of postoperative morbidity and mortality in selected patients over 70 years of age.