Leakage Of Pancreaticojejunostomy Research Articles

Efficacy of Peri Operative Hydrocortisone and Indomethacin Treatment in Reducing Major Complications after Whipple's Pancreaticoduodenectomy, Randomized Controlled Clinical Trial

Introduction: Post Whipple's Pancreatico-duodenectomy (PD) the major concern is pancreaticojejunostomy (PJ) leak which leads to post operative pancreatic fistula (POPF), post pancreatectomy haemorrhage(PPH), delayed gastric emptying (DGE) ,sepsis. sometimes mortality.Hydrocortisone and indomethacin have been postulated to reduce post operative pancreatitis and thus PJ leak. Methods: Between Jan 2018 - April 2019, 146 patients for Whipple's PD were included. Only high risk patient (n= 105)with >40% of acini (marker of soft pancreas) on frozen section of transection margin were randomized to intravenous (iv) hydrocortisone, per rectal (PR) indomethacin or placebo (3 groups ,35 in each group). All patients received total 8 doses of iv treatment (8 hourly) and 6 doses of PR treatment (12 hourly). 100 ml NS and glycerin suppository were the placebo drugs. Primary end-points were overall major complications(Clavien Dindo 2-5). Results: Hydrocortisone group had less major complications compared to placebo(overall 14.3% vs 40.0%; P value = 0.003). POPF (8.6% vs 20%) and DGE (14.3% vs 22.9%) were also lower in hydrocortisone group Indomethacin group did not reduce major complications compared to placebo (overall, 37.2% vs 40%; p value = 1.00). POPF (17.1% vs 20%) and PPH (11.4% vs 14.3%) Although, DGE is significantly less in indomethacin group (14.3% vs 22.9%; p value = 0.001). 30 day mortality was zero in all the groups. Conclusions: Hydrocortisone treatment significantly reduces major postoperative complications in high risk patients after Whipple's PD whereas Indomethacin treatment does not as compared to placebo.

Simultaneous resection for synchronous double primary adenocarcinomas of the head of pancreas and rectum. Challenges and result of an aggressive surgical approach

Introduction: Pancreatic ductal adenocarcinoma is a malignant disease with poor prognosis and high mortality due to its late presentation. Synchronous double primary tumours of the head of pancreas and rectum is a rare occurrence and scarcely reported in the literature. Case presentation: A 67-year-old man presented with fever for 10 days associated with anorexia and weight loss for three weeks. He denied abdominal pain, jaundice or altered bowel habit. His co-morbidities included diabetes mellitus and hypertension. Physical examination was unremarkable. His biochemistry showed obstructive jaundice features and non-reactive viral hepatitis infection. Abdominal sonography and contrasted tomography scan meanwhile revealed grossly dilated intra- and extra-hepatic bile ducts. The endoscopic ultrasound demonstrated distal common bile duct mass and fine needle biopsy was performed. A biliary stent was inserted via ERCP to relieve the biliary obstruction. Subsequently, a colonoscopy was performed following his positive fecal occult blood test which unveiled a polypoidal upper rectal mass. Biopsy of both the ductal and rectal lesions revealed adenocarcinoma. He underwent simultaneous pancreaticoduodenectomy and anterior resection but complicated by pancreaticojejunostomy leak postoperatively, which was treated conservatively. The final histology reaffirmed adenocarcinomas of pancreas and rectum. He recovered well and completed adjuvant chemotherapy with no tumour recurrence detected a year later. Conclusions: Simultaneous resection for synchronous double primary adenocarcinomas of the head of pancreas and rectum is an aggressive approach with considerable perioperative morbidity that necessitates multidisciplinary discussion. We report the surgical management of this rare case, discuss its challenges and present a review of the literature.

Post pancreaticoduodenectomy hemorrhage: A retrospective analysis of incidence, risk factors and outcome.

Background:The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence and outcomes of patients with PPH after PD to determine the associated risk factors and effect on hospital stay.Methods:We retrospectively analyzed from a prospectively collected data of patients developing PPH following PD between January 2007 and May 2018. ISGPS definition and grading system were used. By using univariate and multivariate analyses, independent predictors of PPH were identified.Results:Of the 340 patients undergoing PD, PPH occurred in 39 patients (11.5%), of whom 5 (12.8%) had Grade A, 22 (56.4%) had Grade B and 12 (30.8%) had Grade C PPH. Six (15.4%) of the 39 patients with PPH died against an overall mortality in the study population of 16 out of 340 patients (4.7%), reflecting higher mortality (P = 0.019) in patients with PPH . The independent risk factors for PPH were a high pre-operative bilirubin (mean 4.7 vs. 7.4 mg/dl, P = 0.01) and INR (mean 1.2 vs. 1.72, P = 0.024), whereas it was closely followed by but, but not significantly associated with pre-operative biliary stent placement (P = 0.09). Pancreatico-jejunostomy (PJ) leak was seen in 20.7% in non-hemorrhage group vs. 41% in hemorrhage group (P = 0.008) and was an independent risk factor for PPH.Conclusion:PPH occurred in 11.5% of patients and resulted in a mortality four times greater than those without a PPH. It occurred more frequently in patents with a high pre-operative serum bilirubin, INR, biliary stenting or those with a PJ leak.

Towards universal no pancreaticojejunostomy leak

Introduction: In a quest to decrease the incidence of pancreatic fistula after a pancreaticojejunostomy (PJ) for Whipple procedure, we used a modification of the Blumgart technique (seromuscular transpancreatic U stitch PJ) in which the U sutures were extended along the superior and inferior edges of the pancreas to completely invaginate the PJ. This was compared with 2 other conventional methods. Method: Patients who had a Whipple procedure between 2010 and 2018 in were included and divided into three groups. Group 1: (19 patients, 2010-2013) either invagination or duct to mucosa; Group 2 ( 26 patients, 2014-2015) Blumgart technique; and Group 3 (30 patients) 2016-2017, modified Blumgart Result: 3 surgeons, who work as a team, did the operations. The results were not influenced by surgeon identity. There were 75 patients, divided into 3 groups. Group I: 19 patients of whom 5 (26%) had pancreatic leaks. Group 2: 26 patients 1 (4%) leak. Group 3: 30 patients, no leaks. Thus the Blumgart technique resulted in fewer leaks compared with older techniques (P= 0.003 group 1 vs. 2 and 3). The improvement was even more pronounced in those with the modified PJ (P=0.005 groups 1 vs.3; P= 0.07 groups 1 vs. 2). Conclusion: The Blumgart technique reduced the PJ leak rate compared with older methods, and extending the U sutures along the superior and inferior borders of the pancreas was even better.

Three Steps for a Safe Pancreaticoduodenectomy: Neither Pancreatic Texture nor Duct Size Matters

Background: I have designed a Q-shape biliary diversion pancreaticoduodenectomy (PD) to prevent delayedhemorrhage in case of pancreaticojejunostomy (PJ) leakage. However, eliminating PJ leakage is the ultimate goal. A PJ anastomosis technique, irrespective of soft pancreatic texture or duct-size, has been found. Methods: Nine PDs were included. An end-to-side anastomosed proximal jejunal loop (30 cm), divided by a GIA stapler at its top and reapproximated using serosal sutures, was used for a choledochojejunostomy and PJs (4 fistulation, 2 duct-to-mucosa, 1 conventional and 2 whole-thickness mattress end-to-side sutures) at each divided loop. Finally, a gastro/duodenojejunostomy was made 30 cm distal to this looped jejunojejunostomy. Results: There was no mortality. One minor PJ leakage healed spontaneously. One major PJ leakage had a delayed-hemorrhage crisis salvaged by continuous normal saline irrigation to neutralize the pH condition for bile and pancreatic juice interaction. The clinical courses were surprisingly uneventful and without fear of leakage in two PJs using whole-thickness mattress sutures. Secure ties without tearing were possible in the soft pancreatic texture. Conclusion: Current evolutional strategies of biliary diversion reconstruction with whole-thickness-mattress PJ sutures plus normal saline irrigation can increase the safety of a pancreaticoduodenectomy by reducing PJ leakage and preventing the activation of pancreatic juice to eliminate a lethal delayed-hemorrhage.

Extended pancreatic transection for secure pancreatic reconstruction during pancreaticoduodenectomy.

Backgrounds/AimsPancreaticoduodenectomy (PD) is associated with various surgical complications including healing failure of the pancreaticojejunostomy (PJ). This study intended to ensure blood supply to the pancreatic stump through extended pancreatic transection (EPT).MethodsThis study assessed whether EPT reduces PJ-associated complications and whether EPT is harmful on the remnant pancreatic function. The EPT group included 19 patients undergoing PD, pylorus-preserving PD (PPPD) or hepatopancreaticoduodenectomy. The propensity score matched control group included 45 patients who had undergone PPPD. Pancreatic transection was performed at the level of the celiac axis in the EPT group, by which the pancreatic body was additionally removed by 3 cm in length comparing with the conventional pancreatic transection.ResultsA small invagination fissure suspected as the embryonic fusion site was identified at the ventro-caudal edge of the pancreatic body in all patients undergoing EPT. A sizable fissure permitting easy separation of the pancreatic parenchyma was identified in 15 of 19 patients (78.9%). The incidence of significant postoperative pancreatic fistula was significantly lower in the EPT group than in the control group (p=0.047). There was no significant increase in the postoperative de novo diabetes mellitus in EPT group (p=0.60).ConclusionsThe EPT technique contributes to the prevention of major pancreatic fistula without impairing remnant pancreatic function. EPT is feasible for routine clinical application or at least in patients with any known risk of PJ leak.

Shifting role of operative and nonoperative interventions in managing complications after pancreatoduodenectomy: What is the preferred intervention?

Operative complications after pancreatoduodenectomy can be managed by nonoperative or operative interventions. The aim of this study was to analyze the shift in management of five major complications and their success rates. An algorithm was developed according to predictors for type of intervention and failure of management. From 1992-2012, patients with pancreaticojejunostomy, hepaticojejunostomy or gastroenterostomy leakage, postpancreatectomy hemorrhage, or primary abscess after pancreatoduodenectomy were selected from a prospectively maintained database. Complications were treated by nonoperative or operative intervention Two cohorts were created according to period of index operation. Pre- and postoperative characteristics were analyzed. Of 1,037 patients, 263 (25%) experienced operative complications. The incidence of pancreatic fistula increased from 11 to 18%, accompanied by a shift from operative toward nonoperative management. This was also seen in the management of late hemorrhage. Success rates of interventions remained similar for all complications. The incidence of primary abscesses decreased. Early sepsis (odds ratio [OR] 17.8, 95% confidence interval [CI] 4.9-64.4) was associated with failure of nonoperative interventions in patients with pancreatic fistula. Hemodynamic instability (OR 17.2, 95% CI 1.8-160.1) and sepsis (OR 6.7, 95% CI 2.7-16.3) were predictive for operative intervention. Failure ofnonoperative intervention (HR 3.95% CI 1.3-7.1) and operative intervention (HR 6.4 95% CI3.2-12.8) were predictors for poor survival. The shift towards nonoperative interventions was notable in patients suffering from pancreaticojejunostomy leakage and late hemorrhage. Anastomotic leakage, late hemorrhage, and primary abscesses can be managed nonoperatively however; hemodynamic instability and early sepsis are strong arguments to perform surgery.

Pancreatic Atrophy Relative to External Versus Internal Drainage of the Pancreatic Duct After Pylorus-Preserving Pancreaticoduodenectomy

BackgroundAtrophy of the pancreatic parenchyma, which occurs frequently after pylorus-preserving pancreaticoduodenectomy (PPPD), is often associated with pancreatic exocrine insufficiency. Many surgeons prefer to insert a drainage tube into the remnant pancreatic duct primarily to prevent pancreatic leakage at the pancreaticojejunostomy (PJ) after PPPD. Drainage methods vary widely but can be roughly classified as internal or external drainage. This study intended to evaluate their effects on pancreatic parenchymal atrophy following PPPD. MethodsFifty-seven patients who underwent PPPD were retrospectively divided into two groups, 28 who underwent external and 29 who underwent internal pancreatic drainage. External drainage tubes were removed 4 weeks after PPPD. The volume of the pancreatic parenchyma was serially measured on abdominal computed tomography (CT) scans before PPPD, as well as 7 days and 3, 6, and 12 months after surgery. Degree of pancreatic parenchymal atrophy was determined by calculating pancreatic volume relative to that on day 7. ResultsUnivariate analysis showed that patient sex, age, body mass index, concurrent pancreatitis, pathology, and types of PJ did not significantly affect changes in pancreatic volume following PPPD. The degree of pancreatic volume atrophy did not differ significantly in the external and internal drainage groups. No patient in the external drainage group experienced drainage-related surgical complications. The incidence of PJ leak was comparable in the two groups. Postoperative pancreatic atrophy did not induce new-onset diabetes mellitus at 1 year. ConclusionsBoth external and internal pancreatic drainage methods showed similar atrophy rate of the pancreatic parenchyma following PPPD.

Pure pancreaticocutaneous fistula shunted into the urinary bladder. Lesson learned by an incomplete, original attempt.

Because pancreaticocystostomy is a method of exocrine secretion management in pancreas transplantation, a legitimate question is whether a pure pancreatic fistula could be shunted into the bladder. After duodenopancreatectomy for cancer, a pancreaticojejunostomy leakage was treated by pancreas-saving anastomosis disconnection. The resulting pure pancreaticocutaneous fistula was later diverted into the bladder using a Denver valved-pump device. Technical problems necessitated redoing the shunt using a modified technique and device. Although the system did work, catheter displacement outside the bladder finally caused device takedown and external fistula restoration. Our attempt did not succeed mostly because of our inexperience in dealing with an altogether novel issue without appropriate technology. Supposing its feasibility, a pancreatic-bladder shunt might have a role in treating pure pancreatic fistulas or creating an external fistula whenever the pancreatic remnant is unreliable for an anastomosis, or when a leaked anastomosis' disconnection is preferable to completion pancreatectomy.

Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy on the rate and severity of pancreatic fistula after pancreaticoduodenectomy

Anastomotic leakage of pancreaticojejunostomy (PJ) remains the single most important source of morbidity after pancreaticoduodenectomy (PD). The primary aim of this randomized clinical trial comparing PG with PJ after PD was to test the hypothesis that invaginated PG would result in a lower rate and severity of pancreatic fistula. Patients undergoing PD were randomized to receive either a duct-to-duct PJ or a double-layer invaginated PG. The primary endpoint was the rate of pancreatic fistula, using the definition of the International Study Group on Pancreatic Fistula. Secondary endpoints were the evaluation of severe abdominal complications (Clavien-Dindo grade IIIa or above), endocrine and exocrine function. Of 123 patients randomized, 58 underwent PJ and 65 had PG. The incidence of pancreatic fistula was significantly higher following PJ than for PG (20 of 58 versus 10 of 65 respectively; P = 0.014), as was the severity of pancreatic fistula (grade A: 2 versus 5 per cent; grade B-C: 33 versus 11 per cent; P = 0.006). The hospital readmission rate for complications was significantly lower after PG (6 versus 24 per cent; P = 0.005), weight loss was lower (P = 0.025) and exocrine function better (P = 0.022). The rate and severity of pancreatic fistula was significantly lower with this PG technique compared with that following PJ. ISRCTN58328599 (http://www.controlled-trials.com).

Pancreatic Anastomotic Failure Rate after Pancreaticoduodenectomy Decreases with Microsurgery

We have observed that leakage from pancreaticojejunostomy is reduced when a surgical microscope is used to construct the pancreaticojejunostomy during pancreaticoduodenectomy. To validate our hypothesis that better vision improves the technical performance of pancreaticojejunostomy, we limited inclusion criteria to those patients at high risk for leak, performed more cases, and used the grading system of the International Study Group of Pancreatic Surgery. From 1988 through 2008, 507 consecutive pancreaticoduodenectomies were performed with pancreaticojejunostomy. A subset of 283 patients at risk for leak had a main pancreatic duct (MPD) ≤3 mm at the surgical margin. Pancreaticojejunostomy was completed with surgical loupes (n = 135) or surgical microscope (n = 148). Incidence of pancreaticojejunostomy leak and delayed gastric emptying was determined using a Web-based calculator for the severity grading scale of the International Study Group of Pancreatic Surgery. Within the 507 pancreaticoduodenectomies, the clinically relevant pancreaticojejunostomy leak for those with an MPD >3 mm (n = 224) was 4%, and with an MPD ≤3 mm (n = 283) it was 16% (p < 0.0001). For these 283 high-risk patients, outcomes were worse in the loupes versus microscope group, ie, clinically relevant pancreaticojejunostomy leak (21% versus 11%; p = 0.021), pancreas-related complications (31% versus 19%; p = 0.018), clinically relevant delayed gastric emptying (19% versus 9%; p = 0.016), and hospital length of stay (12.9 versus 9.5 days; p < 0.0001). In a subset of pancreaticoduodenectomy patients at high risk for pancreaticojejunostomy leak, the increased visual acuity of the surgical microscope reduced clinically relevant pancreatic anastomotic failure, delayed gastric emptying, and hospital length of stay.

A new technique of polypropylene mesh-reinforced pancreaticojejunostomy

Anastomotic leakage of pancreaticojejunostomy is a common problem and a significant cause of morbidity and mortality after pancreatic resection. An appropriate technique to minimize pancreatic leakage is very important. Recently we have performed a safe and simple mesh-reinforced pancreaticojejunostomy, by which a strip of polypropylene mesh is wrapped around the pancreatic stump in order to secure the end-to-end pancreaticojejunal anastomosis. No leakage developed in all 10 patients who received this procedure.

Hepatobiliary and pancreatic tuberculosis: a two decade experience.

BackgroundIsolated hepatobiliary or pancreatic tuberculosis (TB) is rare and preoperative diagnosis is difficult. We reviewed our experience over a period two decades with this rare site of abdominal tuberculosis.MethodsThe records of 18 patients with proven histological diagnosis of hepatobiliary and pancreatic tuberculosis were reviewed retrospectively. The demographic features, sign and symptoms, imaging, cytology/histopathology, procedures performed, outcome and follow up data were obtained from the departmental records. The diagnosis of tuberculosis was based on granuloma with caseation necrosis on histopathology or presence of acid fast bacilli.ResultsOf 18 patients (11 men), 11 had hepatobiliary TB while 7 had pancreatic TB. Two-thirds of the patients were < 40 years (mean: 42 yrs; range 19–70 yrs). The duration of the symptoms varied between 2 weeks to 104 weeks (mean: 20 weeks). The most common symptom was pain in the abdomen (n = 13), followed by jaundice (n = 10), fever, anorexia and weight loss (n = 9). Five patients (28%) had associated extra-abdominal TB which helped in preoperative diagnosis in 3 patients. Imaging demonstrated extrahepatic bile duct obstruction in the patients with jaundice and in addition picked up liver, gallbladder and pancreatic masses with or without lymphadenopathy (peripancreatic/periportal). Preoperative diagnosis was made in 4 patients and the other 14 were diagnosed after surgery. Two patients developed significant postoperative complications (pancreaticojejunostomy leak [1] intraabdominal abscess [1]) and 3 developed ATT induced hepatotoxicity. No patient died. The median follow up period was 12 months (9 – 96 months).ConclusionTuberculosis should be considered as a differential diagnosis, particularly in young patients, with atypical signs and symptoms coming from areas where tuberculosis is endemic and preoperative tissue and/or cytological diagnosis should be attempted before labeling them as hepatobiliary and pancreatic malignancy.

Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial.

This study compared the postoperative pancreatic anastomosis leakage rate of a new binding technique with the conventional technique of pancreaticojejunostomy after pancreaticoduodenectomy. Leakage from pancreatic anastomoses remains the single most important morbidity after pancreaticoduodenectomy and contributes to prolonged hospitalization and mortality. The reported incidence after conventional pancreaticojejunostomy ranged from 10% to 29%. We previously reported a new binding pancreaticojejunostomy technique with a leakage of 0%. We conducted a prospective randomized study on 217 patients who underwent pancreaticoduodenectomy for benign and malignant diseases of the pancreatic head and the periampullary region comparing the 2 techniques of pancreaticojejunostomy. Of the 111 patients randomized to the conventional group, pancreaticojejunostomy leakage occurred in 8 patients, while no patient in the 106 patients randomized to the binding group developed leakage (chi test, P = 0.014). The overall postoperative complications developed in 41 patients (36.9%) in the conventional group compared with 26 patients (24.5%) in the binding group (chi test, P = 0.048). Seven patients (6.3%) died in the perioperative period in the conventional group compared with 3 patients (2.8%) in the binding group (chi test, P = 0.37). The postoperative hospital stay (mean +/- SD) for the conventional group was 22.4 +/- 10.9 days, which was significantly longer than the binding group (18.4 +/- 4.7 days) (Mann-Whitney U test, P < 0.001). Binding pancreaticojejunostomy after panceaticoduodenectomy significantly decreased postoperative complication and pancreaticojejunostomy leakage rates and shortened hospital stay when compared with conventional pancreaticojejunostomy.

Pancreaticojejunostomy using duct-to-mucosa anastomosis without a stenting tube

There is a high risk of anastomotic leakage after pancreaticojejunostomy following pancreaticoduodenectomy in patients with a normal soft pancreas because of the high degree of exocrine function. Therefore, pancreaticojejunostomy is generally performed using a stenting tube (stented method). However, pancreaticojejunostomy with a certain duct-to-mucosa anastomosis does not always require a stenting tube, even in patients with a normal soft pancreas. Recently, we have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stenting tube (nonstented method) and obtained good results. The point of this technique is to maintain adequate patency of the anastomosis using a fine atraumatic needle and monofilament thread. The results of end-to-side pancreaticojejunostomy of the normal soft pancreas using the nonstented method (n = 123) were compared with those using the stented method (n = 45). There were no differences in background characteristics between the groups, including age, gender, and disease. The mean times to complete pancreaticojejunostomy were around 30 min in the two groups and the rates of morbidity and leakage of pancreaticojejunostomy were 26.8% and 5.7% in the nonstented group and 22.2% and 6.7% in the stented group, respectively. These differences were not statistically significant. One patient in the stented group died of sepsis following leakage of pancreaticojejunostomy. There were also no significant differences in the mean time to initiation of solid food intake or postoperative hospital stay. In conclusion, complete pancreaticojejunostomy using duct-to-mucosa anastomosis for a normal soft pancreas does not require a stenting tube. This nonstented method can be considered one of the basic procedures for pancreaticojejunostomy because of its safety and certainty.

Surgical Treatment of Pancreatic Head Carcinoma in Elderly Patients

The treatment of cancer in elderly patients has become a global clinical issue, considering the increasingly longer life expectancy. Three quarters of patients with pancreatic adenocarcinoma are older than 60 years. Surgical resection is the only chance of cure, and early outcome of pancreaticoduodenectomy in elderly patients is comparable with that obtained in a younger population. During an 11-year period, 166 patients underwent curative pancreaticoduodenectomy for pancreatic adenocarcinoma. Clinical and demographic factors were evaluated by univariate and multivariate analyses to test their effect on early outcome. State university medical school tertiary care center. One hundred sixty-six patients underwent curative pancreaticoduodenectomy for pancreatic adenocarcinoma. They were divided into 2 groups according to age (group A for patients older than 70 years, group B for patients younger than 70 years). Pancreaticoduodenectomy was performed using a Whipple procedure. An end-to-end pancreaticojejunostomy was constructed. Lymphadenectomy was carried out along the hepatoduodenal ligament, common hepatic artery, vena cava, superior mesenteric vein, and along the right side of the superior mesenteric artery. Four abdominal drainage sites were routinely used. The postoperative hospital stay was calculated and morbidity and mortality were assessed. Significantly higher operative morbidity and mortality were observed in group A (group A, 49.1% vs group B, 45.8% and 10.5% vs 3.7%, respectively). Underlying comorbid conditions in group B patients influenced postoperative morbidity but not mortality. Rate and nature of surgical complications were indicated as causes of significant higher mortality in group B patients. An aggressive surgical approach is justified for elderly patients with pancreatic adenocarcinoma. However, surgical complications that lead to reoperation are responsible for a high mortality in elderly patients. In addition to general causes, such as concomitant disorders, reduced functional reserve, poor tolerance to stress, and the texture of the pancreatic remnant, there are specific prognostic factors affecting pancreaticojejunostomy leakage and related mortality.

Haemorrhagic complications of pancreaticoduodenectomy

Haemorrhagic complication occurs in 5-16% of patients following pancreaticoduodenectomy (PD). We report an analysis of patients with post-PD bleed, to identify predictors of bleed, predictors of survival following bleed and the management of post-PD bleed. Two hundred and eighteen patients with periampullary cancers underwent PD from 1989 to 2002. Forty-four (20.2%) patients had a bleeding complication. Of these, 25 patients had an intra-abdominal (IA) bleed and 21 had gastrointestinal (GI) bleed (two had both IA and GI bleed). Clinical, biochemical and tumour characteristics were analysed to identify factors influencing bleeding complications. The median time to presentation was 4.5 days (0-21 days). Serum bilirubin (P = 0.000, OR: 1.090) and pancreaticojejunostomy (PJ) leak (P = 0.009, OR: 3.174) were significant independent factors predicting bleeding complications. Forty-three per cent of patients each had early bleed (<48 h after PD) or delayed bleed (7 days after PD). Comparison of early and late bleeds showed that IA bleed (P = 0.02) presented as early bleeds. Male sex (P = 0.00) longer duration of jaundice (P = 0.02), PJ leak (P = 0.001), HJ leak (P = 0.001), duct to mucosa type of PJ anastomosis (P = 0.03) and IA abscess (P = 0.00) were associated with a significantly higher incidence of late bleeds. Overall mortality after PD was 9.6% with 34% and 3% in bleeders and non-bleeders, respectively. Septicaemia (P = 0.01, OR: 5.49), and acute renal failure (P = 0.01) were associated with increased mortality. Bleeding complications following PD were seen in one-fifth of patients and were associated with high mortality. Serum bilirubin levels and PJ leak were significant factors associated with bleeding complications. Septicaemia and acute renal failure were significant factors associated with mortality in the bleeders.

Stenting Is Unnecessary in Duct-to-Mucosa Pancreaticojejunostomy Even in the Normal Pancreas

Background: There is a high risk of anastomotic leakage after pancreaticojejunostomy after pancreaticoduodenectomy (PD) in patients with a normal pancreas because of the high degree of exocrine function. These PD are therefore generally performed using a stenting tube (stented method). In recent years, we have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stenting tube (nonstented method) and obtained good results. Methods: The point of this technique is to preserve adequate patency of the pancreatic duct by carefully picking up the pancreatic duct wall with a fine atraumatic needle and monofilament thread. The results of end-to-side pancreaticojejunostomy of the normal pancreas were compared between the nonstented method (n = 109) and the stented method (n = 39). Results: There were no differences in background characteristics between the groups, including age, gender and disease. The mean duration to complete pancreaticojejunostomy was 26.6 min in the nonstented group and 29.2 min in the stented group. The mean durations of surgical procedure and intraoperative blood loss were also similar in the groups. Morbidity rates due to early postoperative complications were 20.2 and 23.1%, with pancreatic leakage occurring in 7.3 and 7.7% of patients, respectively. These differences were not statistically significant. One patient in the stented group died of sepsis following leakage of pancreaticojejunostomy. There were also no significant differences in the mean time to initiation of solid food intake or postoperative hospital stay. Conclusion: We conclude that a stenting tube is unnecessary if the duct-to-mucosa anastomosis is completely performed. This operative technique can be considered a basic procedure for pancreaticojejunostomy because of the low risk.

Use of fibrin glue in the prevention of leakage in pancreatico-jejunal anastomoses

The aim of this study was to test the protective effects of fibrin sealing on the pancreatico-jejunostomy (PJA), the high-risk anastomosis following pancreas head resection. Experimental study was performed on the mongrel dogs, divided in two groups (20 animals each): Experimental group-with end to end "dunking" PJA, protected by temporary occlusion of the pancreatic duct with fibrin sealant/Tissucol/Immuno Ag/, while control group was without any protective procedure. The animals were followed 5 months in order to study: protective effects of such procedure on the PJA quantified with the percent of anastomotic leakage, effects of the exocrine secretion and effects the endocrine function Results: PJA leakage occurred in 13.33% in control group. No leakage was registered in experimental group. Biochemical, histological and electron microscopic study showed slight transitory elevation of amylase levels. Fibrin glue plug was dissolved and pancreatic juice output was reestablished 12th days postoperatively. Long term follow-up showed no damages of the endocrine and exocrine pancreas. Pancreatic duct occlusion with fibrin glue appeared to be an useful method in the prevention of pancreatico-jejunostomy leakage, without negative effects on the exocrine and endocrine pancreas.

Preoperative exocrine pancreatic function predicts risk of leakage of pancreaticojejunostomy

Background: The objective of this study was to clarify the relationship between preoperative exocrine pancreatic function and pancreatic anastomotic leakage after pancreatectomy. Methods: Fifty-five patients who underwent proximal pancreatectomy with pancreaticojejunostomy were reviewed with regard to preoperative exocrine pancreatic function, size of the main pancreatic duct, postoperative pancreatic juice output, and pancreaticojejunostomy leakage. Results: There were 32 patients with a normal value at the preoperative N-benzoyl-L -tyrosyl-p-aminobenzoic acid (BT-PABA) excretion test (>70%) and 23 with a low BT-PABA value (≤70%). The greatest diameter of the main pancreatic duct in the group with normal BT-PABA results was significantly smaller than that in the group with low BT-PABA results (4.6 ± 2.7 mm vs 7.1 ± 4.2 mm; P < .05). The output of pancreatic juice during a 10-day period (from postoperative days 5 through 14) in the group with normal BT-PABA results was significantly higher than that in the group with low BT-PABA results (1738 ± 898 mL vs 1072 ± 1174 mL; P < .05). Pancreatic leakage occurred in 8 (25%) of the 32 patients in the group with normal BT-PABA results and in none of the 23 patients in the group with low BT-PABA results (P < .01). Conclusions: Patients with normal exocrine pancreatic function produce a larger amount of pancreatic juice than those with low exocrine pancreatic function and have a potential risk of anastomotic leakage after pancreatectomy. (Surgery 1998;124:871-6.)