Pylorus-preserving Pancreaticoduodenectomy Group Research Articles

The impact of pylorus preservation on the development of nonalcoholic fatty liver disease after pancreaticoduodenectomy: A historical cohort study.

The pathophysiology and associated factors of nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD) remain elusive. We aimed to investigate these factors, including the operation type, for NAFLD development after PD. This historical cohort study included 786 consecutive patients treated with either classic Whipple operation or pylorus-preserving pancreaticoduodenectomy (PPPD) in Korea between 2012 and 2018. De novo NAFLD was determined based on hepatic attenuation in nonenhanced computed tomography during follow-up. Of the 786 patients, 216 (27.5%) had a newly developed NAFLD at 2 years after PD. The incidences of newly developed NAFLD at 0.5, 1, 1.5, and 2 years were 13 (1.7%), 41 (5.2%), 48 (6.1%), and 114 (14.5%), respectively. The Whipple group showed a significantly higher incidence of NAFLD than the PPPD group (40.3% vs 24.5%, P < .001). Seventeen patients (2.2%) had severe fatty liver with abnormal liver enzymes. Multivariable analysis revealed that Whipple operation (vs PPPD; adjusted odds ratio [AOR]: 1.92, P < .001) and high preoperative body mass index (vs normal; AOR: 1.71, P=.001) were independently associated with a higher risk of NAFLD. The incidence of NAFLD was 27.5% at 2 years after PD. Undergoing Whipple operation and high preoperative body mass index were significantly associated with de novo NAFLD development.

Correlation between Fistula Risk Score with Post Operative Pancreatic Fistula - A Single Centre Indian Study

Introduction: Post operative pancreatic fistula (POPF) is a major cause of morbidity and mortality of pancreatic surgeries done for management of malignancy or chronic pancreatitis. This study was undertaken in our centre as an introspective into the rate of POPF and its predictability assessment. Aims and Objectives: To look for the incidence of POPF in Medical College, Kolkata, India and its correlation with the existing Fistula Risk Score (FRS). Methods: This was a retrospective single centre study. All the existing records of patients undergoing Pylorus preserving pancreaticoduodenectomy(PPPD) and pancreatic drainage or resection procedures were evaluated. POPF and FRS were defined as per the latest International Study Group on Pancreatic Fistula (ISGPF) 2016 guideline. Results: From 2016 to 2021, 31 patients underwent PPPD and 45 patients underwent pancreatic drainage or resection procedures. Of these, seven patients developed POPF. Three patients had only biochemical leak and 2 had Grade B and 1 had Grade C leak. All were from PPPD group. The mean FRS was 2. Three patients had soft pancreatic parenchyma. The mean Main Pancreatic Duct(MPD) diameter was 3.5mm. Conclusion: This study reflects an encouraging data carrying cumulative incidence of POPF of 9.21% comparable with the world data (3%-45%). It carries a mortality risk of nearly 1%. In our centre one patient succumbed. No statistically significant correlation found (correlation coefficient 0.022) between rate of POPF and FRS. Post operative hospital stay was found to be significantly prolonged with POPF,17.62 days with POPF vs 13.36 days without POPF(p- value: 0.045 ).

Is delayed gastric emptying associated with pylorus ring preservation in patients undergoing pancreaticoduodenectomy?

Background/objectiveA high incidence of delayed gastric emptying (DGE) is observed in patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). However, DGE incidence after pancreaticoduodenectomy varied because of heterogeneity in surgical techniques, number of surgeons, and DGE definition. This study aimed to evaluate the difference in the incidence of DGE following PpPD and pylorus-resecting pancreaticoduodenectomy (PrPD) and to analyze the risk factor of DGE by a single surgeon to determine whether pylorus preservation was the main factor of DGE. MethodsThis retrospective study included 115 patients who underwent PpPD (with pylorus ring preservation) and PrPD (without pylorus ring preservation) with laparotomy by a single surgeon at a tertiary center. ResultsThe overall incidence of DGE was 23.1%. For comparison, 20 patients (39.2%) in the PpPD group and 5 patients (8.8%) in the PrPD group had DGE, showing a significant difference (p < 0.001). On univariate analysis, hypertension, PpPD, operation time, intraoperative bleeding, packed red blood cell transfusion ≥500 mL, and clinically relevant postoperative pancreatic fistula were associated with DGE. Multivariate analysis identified pylorus preservation and clinically relevant postoperative pancreatic fistula as risk factors for DGE. ConclusionCompared with PpPD, PrPD significantly reduced the incidence of DGE.

Clinical outcomes of pancreaticoduodenectomy for pancreatic ductal adenocarcinoma depending on preservation or resection of pylorus.

Backgrounds/AimsThe comparative effectiveness of pylorus-resecting pancreaticoduodenectomy (PRPD) and pylorus-preserving pancreaticoduodenectomy (PPPD) in pancreatic head cancer is still disputed. The aim of this study was to analyze the data obtained from a large, single center with PPPD compared with PRPD in terms of postoperative outcomes, including blood glucose levels and survival in patients with pancreatic head cancer.MethodsBetween January 2007 and December 2016, a total of 556 patients with pancreatic head cancer underwent either PPPD or PRPD. We analyzed the clinicopathologic data to assess short- and long-term outcomes retrospectively.ResultsFor underlying disease, patients with DM in PPPD were fewer than in PRPD (33.0% vs. 46.2%, p=0.002). The median value of CA19-9 was significantly higher in PRPD than in PPPD (129.36 vs. 86.47, p=0.037). The incidence of Clavien-Dindo grade III to V major complications in PPPD was significantly higher than in PRPD (20.4% vs. 13.4%, p=0.032). Resection of pylorus was shown to reduce complications in univariate and multivariate analyses (p=0.032 and = 0.021, respectively). The 5-year survival rates were 27.6% in the PPPD group and 22.4% in the PRPD group (p=0.015).ConclusionsThe results of PPPD and PRPD showed no significant differences from those reported conventionally in previous studies. Although further well-designed studies are needed, it is more important to select the range of surgical resection for the patient’s disease regardless of resection of pylorus.

Delayed gastric emptying after Pancreaticoduodenectomy: a propensity score-matched analysis and clinical Nomogram study

BackgroundDelayed gastric emptying (DGE) is a common and frustrating complication of pancreaticoduodenectomy (PD). Studies suggest that surgical methods and other clinical characteristics may affect the occurrence of DGE. Nevertheless, the results of such studies are conflicting. The objective of this work was to perform a propensity score matching analysis to compare the differences between pylorus-preserving pancreaticoduodenectomy (PPPD) and pylorus-removing pancreaticoduodenectomy (PrPD) and to develop and validate a nomogram to predict the probability of severe DGE (SDGE).MethodsThis retrospective study enrolled patients who underwent PD at our institution from December 2009 to December 2018. Propensity score matching was applied at a ratio of 1:1 to compare PPPD and PrPD groups. We compared incidence of complications, DGE, lengths of hospital stay, hospitalization costs, and mortality. Univariate and multivariate logistic regression analysis were performed to identify potential risk factors of severe DGE. Finally, a nomogram was developed and validated to predict severe DGE.ResultsThe PPPD group had a significantly higher rate of postoperative pancreatic fistula (29.9% versus 17.4%, P < 0.05) and less blood loss (463.7 ml versus 694.9 ml, P < 0.05). After propensity score matching, the PPPD group had a significantly higher rate of postoperative DGE (19.2% versus 3.8%, P < 0.05), especially severe DGE (17.3% versus 0%) than the PrPD group. There were no significant differences in terms of lengths of hospital stay, hospitalization costs or mortality between the groups. Surgical method, biliary leakage, abdominal infection, and diabetes were independent risk factors for SDGE. The nomogram predicted SDGE with a training C - index of 0.798 and a validation C - index of 0.721.ConclusionPPPD increases the risk of DGE than PrPD, especially SDGE. Our prediction nomogram gives good prediction of SDGE after pancreaticoduodenectomy.

Pylorus-preserving pancreaticoduodenectomy versus standard pancreaticoduodenectomy in the treatment of duodenal papilla carcinoma.

It is not known whether pylorus-preserving pancreaticoduodenectomy (PPPD) is as effective as the standard pancreaticoduodenectomy (SPD) in the treatment of duodenal papilla carcinoma (DPC). A retrospective cohort trial was undertaken to compare the results of these two procedures. Clinical data, histological findings, short-term results, survival and quality of life of all patients who had undergone surgery for primary DPC between January 2003 and February 2010 were analyzed. According to the inclusion criteria and the surgical methods, 116 patients were divided into the PPPD group (n=43) and the SPD group (n=73). There were no significant differences in various indices, including surgery duration, extent of intraoperative hemorrhage and postoperative pathological indexes. The incidence of postoperative complications, including pancreatic fistula and delayed gastric emptying, were also similar between the two groups (20.9 vs. 21.9%; P=0.900 and 11.6 vs. 5.4%; P=0.402). Long-term survival and quality of life were identical following a median follow-up of 45.6 months (range, 4–144 months). Within 6 months, there was a decreased loss of appetite following the pylorus-preserving procedure (26.9 vs. 49.3; P=0.003). The procedures were equally effective for the treatment of DPC. PPPD offers minor advantages in the early postoperative period but not in the long term.

Efficacy comparison between pylorus-preserving pancreaticoduodenectomy and standard pancreaticoduodenectomy for periampullary carcinoma

Objective To compare the short-term efficacy of pylorus-preserving pancreaticoduodenectomy (PPPD) and standard pancreaticoduodenectomy (SPD) for the treatment of periampullary carcinoma. Methods The clinical data of 85 patients with periampullary carcinoma who were admitted to the Zhongshan Hospital of Fudan University from October 2010 to October 2012 were retrospectively analyzed. Forty-four patients who underwent PPPD were divided into the PPPD group and 41 patients who underwent SPD were divided into the SPD group. The pancreatic fistula(Grade B and above), biliary fistula, blood loss, intra-abdominal infection, delayed gastric emptying (DGE) and prognosis were analyzed. Patients were followed up by telephone interview and outpatient examination once every 3 months within postoperative 1 year and once every 6 months within postoperative 2-3 years till October 2014. Count data were analyzed using the chi-square test, measurement data with normal distribution were presented as M(Qn) and comparison was analyzed using the Mann-Whitney U test. The survival curve was drawn by the Kaplan-Meier method, and survival rate was analyzed using the Log rank test. Results The operation time was 195 minutes (180 minutes, 240 minutes) in the PPPD group and 210 minutes (180 minutes, 300 minutes) in the SPD group, with a significant difference (Z=-2.090, P 0.05). There was no perioperative death and incidence of overall complication was 42.4%(36/85) with pancreatic fistula, intra-abdominal infection and DGE as the top 3 common postoperative complications. The incidence of DGE was 20.5%(9/44) in the PPPD group, which was significantly different from 4.9%(2/41) in the SPD group (χ2=4.571, P 0.05). Eighty-five patients were followed up for 6-47 months with a median time of 31 months, and postoperative overall 1- and 3-year survival rates were 95.3% and 75.5%, respectively. The 1- and 3-year survival rates were 97.7% and 78.9% in the PPPD group, and 92.7% and 71.7% in the SPD group, respectively, with no significant difference in 3-year survival rate (χ2=0.690, P>0.05). The 3-year overall survival rate was 80.5% in patients without lymph node involvement (LNI) compared with 54.9% in patients with LNI, showing a significant difference (χ2=4.290, P<0.05). Conclusions Both PPPD and SPD have good short-term efficacy for periampullary carcinoma. There is no significant difference between PPPD and SPD concerning short-term survival rate of periampullary carcinoma. PPPD has shorter operation time, but has a higher postoperative DGE incidence. LNI is a significant prognostic factor for short-term survival of periampullary carcinoma. PPPD is not recommended while the lymph nodes are involved. Key words: Periampullary neoplasms; Pancreaticoduodenectomy; Delayed gastric emptying; Pancreatic fistula

A case-matched comparison and meta-analysis comparing pylorus-resecting pancreaticoduodenectomy with pylorus-preserving pancreaticoduodenectomy for the incidence of postoperative delayed gastric emptying

ObjectivesThis study was conducted to compare the incidences of delayed gastric emptying (DGE) following pylorus-resecting pancreaticoduodenectomy (PrPD) and pylorus-preserving pancreaticoduodenectomy (PpPD), respectively. MethodsData for 37 patients submitted to PrPD were compared with data for a matched number of patients submitted to PpPD during the same period. A meta-analysis of comparative studies of the two techniques was also carried out. The primary endpoint was the rate of DGE (grades A–C) defined according to the International Study Group of Pancreatic Surgery criteria. ResultsIn the case-matched comparison, both overall DGE (six PrPD patients and 17 PpPD patients; P = 0.006) and clinically relevant DGE (one PrPD and eight PpPD patients; P = 0.013) occurred significantly less often in the PrPD group than in the PpPD group. Based on eight non-randomized clinical trials and two randomized clinical trials involving 804 subjects, the meta-analysis further confirmed a significant reduction in DGE with pooled odds ratios of 0.33 [95% confidence interval (CI) 0.17–0.63; P < 0.001] and 0.13 (95% CI 0.05–0.40; P < 0.001) for overall DGE and clinically relevant DGE, respectively. Other complications and mortality were similar in both groups. ConclusionsPylorus-resecting pancreaticoduodenectomy is a safe procedure associated with less severe and less frequent postoperative DGE than PpPD.

Meta-analysis of pylorus-preserving pancreaticoduodenectomy in the treatment of periampullary adenocarcinoma

To evaluate the efficacy and safety of pylorus-preserving pancreatico-duodenectomy(PPPD) in the treatment of periampullary adenocarcinoma by using Meta-analysis. From January 1, 1980 to November 8, 2013, the articles of randomized controlled trials (RCTs) about PPPD versus PD in the treatment of periampullary adenocarcinoma were collected from Cochrane Libriary, Embase, PubMed, Ovid, Web of science and CBM etc. The methodological quality of the included studies was evaluated according to Cochrane system review valuator handbook of risk of bias standards. Meta-analysis was performed by RevMan 5.2 software. Seven RCTs were enrolled in the meta-analysis. Compared to PD group, PPPD group was associated with significantly less intraoperative blood loss (MD=-200.10, 95% CI:-400.66 to 0.46, P=0.05), shorter operation time (MD=-46.55, 95% CI:-91.02 to -2.07, P=0.04), and less postoperative blood transfusion (MD=-0.89, 95% CI:-1.59 to -0.19, P=0.01). There were no significant differences between the PPPD and PD group in pancreatic fistula, biliary fistula, intestinal fistula, abdominal abscess, postoperative bleeding, wound infection, relaparotomy, mortality and survival rate(all P>0.05). PPPD in the treatment of the periampullary adenocarcinoma is safe and effective with similar survival of PD surgery. PPPD can reduce operative time, intraoperative blood loss, transfusion and does not increase the surgery complications as compared to PD.

Prevalence Analysis of de novo Hepatic Steatosis Following Pylorus-Preserving Pancreaticoduodenectomy

Background: Prevalence of hepatic steatosis following pylorus-preserving pancreaticoduodenectomy (PPPD) is high. This study intended to reveal the prevalence and patterns of de novo hepatic steatosis following PPPD. Methods: We investigated postoperative de novo hepatic steatosis following PPPD (n = 101) with a control group of bile duct resection (BDR) (n = 54). Results: At postoperative 1 year, hepatic steatosis occurred in 21 of 82 patients (25.6%) of PPPD group and in 2 of 47 patients (4.3%) of BDR group (p = 0.001). Thereafter, at 2 to 5 years, a high prevalence of hepatic steatosis persisted in the PPPD group, but no further occurrence developed in BDR group. Once steatosis developed, it persisted until the end of the study period or patient death. Five-year cumulative incidence of hepatic steatosis was 26.7% in the PPPD group and 3.7% in BDR group (p < 0.001). Univariate analyses showed that patient sex, age, body mass index, blood lipid profile, recurrence of tumor, and diabetes did not have significant influence on the development of hepatic steatosis following PPPD. Conclusions: De novo hepatic steatosis may develop in a not negligible proportion of patients undergone PPPD. Multicenter studies with a high number of patients are needed to elucidate its pathogenesis and to find effective treatment for pancreaticoduodenectomy-associated hepatic steatosis. i 2014 S. Karger AG, Basel

Comparison of results between pylorus-preserving pancreaticoduodenectomy and subtotal stomach-preserving pancreaticoduodenectomy: report at a single cancer institute.

Pylorus-preserving pancreaticoduodenectomy (PPPD) has the advantage of achieving good nutritional status postoperatively, but delayed gastric empty (DGE) is a frequent complication leading to a longer fasting period. Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) is an alternative option to preserve nutritional status and shorten the fasting period. We retrospectively compared clinical results between PPPD and SSPPD. PPPD was performed in 28 patients and SSPPD in 27, between 2000 and 2009. Pancreatic carcinoma was more frequent in the SSPPD group (p = 0.041). Operating time was longer in the SSPPD group (610 min) than in the PPPD group (540 min; p = 0.031). Blood loss was greater in the SSPPD group (1810 mL) than in the PPPD group (1306 mL; p = 0.048). Period of NG intubation and fasting period were shorter in the SSPPD group (6 days and 9 days, respectively) compared to the PPPD group (15 days and 19 days, respectively; p <0.01 each). Severe DGE was 7% in the SSPPD group and 46% in the PPPD group (p <0.01). Postoperative complications and nutritional status in the early period did not differ between groups, although incidence of fatty liver was higher in the SSPPD group (78%) than in the PPPD group (25%; p <0.01). SSPPD is a useful alternative for pancreaticoduodenectomy. Further prospective studies with longer follow-up are warranted to clarify the superiority and problems associated with this procedure.

BMPR2 deletion increases susceptibility to chronic pancreatitis

Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China Background: Delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) or pylorus-preserving PD (PPPD) remains a debatable problem. The superiority of either procedure in terms of DGE incidence was still unclear. Aim: To compare the incidence of DGE and other perioperative outcomes after PPPD or PD by one surgeon in a certain period. Methods: From January 2009 to December 2010, we started to substitute PPPD for PD in surgical treatment for periampullary lesions. During these two years, 37 cases of PPPD and 59 PD were performed by one surgeon (Y. Miao) in the setting of a tertiary hospital in southern China. Definition and grading of DGE were according to ISGPS recommendation. Data were reviewed and analyzed in retrospective way. Results: Two groups were comparable in terms of age and male/female ratio (59.0 12.2 for PD vs. 58.4 12.0 for PPPD, p1⁄40.834; 24/13 vs. 38/21, p1⁄40.964; respectively). Due to a different clinical pathway in our country, our practice tends to keep nasogastric tube for a longer time. This lead to high incidence rates of DGE in our patients, 78.4% in PD group, and slightly higher in PPPD group (79.9%), but not reaching statistical difference (p1⁄40.880). However, severe DGE (grade B+C) happenedmore in PPPD group compared with PD group (21/59 vs. 3/37, p1⁄40.002). Other complications, including pancreatic fistula, hemorrhage, chyle fistula and intraabdominal infectionswere distributed equally in these two groups. Both groups had no mortality. Patients had a longer length of hospital stay after PPPD compared with those after PD (19.3 11.3 days vs. 17.4 7.5 days, p1⁄40.363). Conclusion: Pylorus-preserving in PD will lead to more severe DGE in southern Chinese population. To our knowledge, this is the first related report on DGE after PPPD in this large population.

Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy versus pancreaticoduodenectomy in southern Chinese population

Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China Background: Delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) or pylorus-preserving PD (PPPD) remains a debatable problem. The superiority of either procedure in terms of DGE incidence was still unclear. Aim: To compare the incidence of DGE and other perioperative outcomes after PPPD or PD by one surgeon in a certain period. Methods: From January 2009 to December 2010, we started to substitute PPPD for PD in surgical treatment for periampullary lesions. During these two years, 37 cases of PPPD and 59 PD were performed by one surgeon (Y. Miao) in the setting of a tertiary hospital in southern China. Definition and grading of DGE were according to ISGPS recommendation. Data were reviewed and analyzed in retrospective way. Results: Two groups were comparable in terms of age and male/female ratio (59.0 12.2 for PD vs. 58.4 12.0 for PPPD, p1⁄40.834; 24/13 vs. 38/21, p1⁄40.964; respectively). Due to a different clinical pathway in our country, our practice tends to keep nasogastric tube for a longer time. This lead to high incidence rates of DGE in our patients, 78.4% in PD group, and slightly higher in PPPD group (79.9%), but not reaching statistical difference (p1⁄40.880). However, severe DGE (grade B+C) happenedmore in PPPD group compared with PD group (21/59 vs. 3/37, p1⁄40.002). Other complications, including pancreatic fistula, hemorrhage, chyle fistula and intraabdominal infectionswere distributed equally in these two groups. Both groups had no mortality. Patients had a longer length of hospital stay after PPPD compared with those after PD (19.3 11.3 days vs. 17.4 7.5 days, p1⁄40.363). Conclusion: Pylorus-preserving in PD will lead to more severe DGE in southern Chinese population. To our knowledge, this is the first related report on DGE after PPPD in this large population.

Long-term Outcomes after Frey's Procedure for Chronic Pancreatitis with an Inflammatory Mass of the Pancreatic Head, with Special Reference to Locoregional Complications

Frey's procedure might be a good alternative to pylorus-preserving pancreaticoduodenectomy (PPPD) for patients with an inflammatory mass of the head of the pancreas, because it is technically easy and associated with low morbidity and good pain relief. To analyze the short-term and long-term outcomes of Frey's procedure in comparison with PPPD and to evaluate the efficacy of Frey's procedure against preoperative locoregional complications. From August 1997 through December 2007, 6 patients underwent Frey's procedure (as described by Frey and Smith), and 10 patients underwent PPPD. The mean follow-up times were 70.8 months (Frey's procedure) and 119.8 months (PPPD). Preoperative biliary stricture and duodenal stenosis were observed in 4 and 3 patients, respectively, of patients undergoing Frey's procedure. Pain intensity was assessed with a pain scoring system. Quality of life (QOL) was assessed with the European Organization for Research and Treatment of Cancer Quality of-Life Questionnaire-Core 30. Exocrine and endocrine pancreatic function was measured during follow-up. Significant reductions in total pain scores and all QOL scale scores were observed immediately after surgery in all patients (P<0.05). Frey's procedure was superior to PPPD with regard to physical status 7 years after surgery (P<0.05). One patient in the Frey group had a grade B pancreatic fistula, and 2 patients in the PPPD group had intra-abdominal bleeding and delayed gastric emptying. There were no re-operations or surgery-related deaths in either group. Diabetes developed postoperatively in 2 patients in the PPPD group. No patients with preoperative duodenal or biliary stricture or both had a relapse. Three patients in the PPPD group died during follow-up of diseases unrelated to chronic pancreatitis. Frey's procedure is safe and effective with regard to pain relief, preservation of pancreatic function, and improvement of QOL over the long term. Moreover, this procedure can also be used to treat preoperative biliary stricture and duodenal stenosis associated with an inflammatory mass of the pancreatic head.

Delayed gastric emptying improved by straight stomach reconstruction with twisted anastomosis to the jejunum after pylorus-preserving pancreaticoduodenectomy (PPPD) in 118 consecutive patients at a single institution

Delayed gastric emptying (DGE) is a leading cause of complication after pylorus-preserving pancreaticoduodenectomy (PPPD). Its incidence has been reported to range from 5 to 57%. We describe a modified reconstruction method, which resulted in a low rate of DGE. Between April 2003 and March 2008, we performed PPPD and reconstruction using an antecolic method in 118 consecutive patients. After PPPD, reconstruction was done using conventional Child procedure in 12 patients (PPPD group) and with the following modifications in the remaining 106 patients (PPPDR group): duodenojejunostomy was performed using the straight method and the jejunum was anastomosed with a 30° counterclockwise twist. We evaluated the incidence of DGE based on the grading system defined by the International Study Group of Pancreatic Surgery (ISGPS). The PPPDR group had a lower incidence of DGE than the PPPD group (PPPD), occurring in 7 patients (7%) versus 4 patients (33%), respectively. However, the overall morbidity rates and postoperative hospital stays of the two groups did not differ significantly. Straight stomach reconstruction with a twisted anastomosis could reduce the incidence of DGE after PPPD reconstruction.

Effect of Pyloric Dilatation on Gastric Emptying after Pylorus-Preserving Pancreaticoduodenectomy

Pylorus-preserving pancreaticoduodenectomy (PPPD) is the standard treatment for periampullary and pancreatic head tumors. Delayed gastric emptying (DGE) is the most common (ranging from 15-45%) but not life threatening complication and impairs patient recovery and prolongs the hospital stay after PPPD. The precise pathomechanism of DGE is still unclear. The aim of this study was to evaluate whether the method of pyloric dilatation performed at the time of PPPD could improve gastric emptying. Forty patients underwent PPPD for pancreatic or periampullary lesions from January 1999 to July 2004 were included in this study. In twenty patients mechanical dilatation of the pylorus after duodenal transaction was performed (PPPD+PD group) while in other twenty PPPD was not followed with pyloric dilatation (PPPD group). The incidence of DGE as well as other complications was analyzed. Delayed gastric emptying was defined as gastric stasis requiring nasogastric intubation for more than 4 postoperative days (POD), or the inability to tolerate a regular diet on the 8th POD. Delayed gastric emptying occurred in seven (35%) out of the 20 patients in the PPPD group, while none of the 20 patients in the PPPD+PD group developed DGE. Pyloric dilatation reduces DGE after PPPD enabling patients to return sooner to a normal diet.

Preventing Delayed Gastric Emptying in Pancreaticogastrostomy by a Modified Subtotal-Stomach-Preserving Pancreaticoduodenectomy: Oida Modification

Delayed gastric emptying (DGE) is one of the most troublesome complications of pylorus-preserving pancreaticoduodenectomy (PPPD). In Japan, since the 1990s, subtotalstomach- preserving pancreaticoduodenectomy (SSPPD) has been performed as an alternative to PPPD. Here, we evaluated the efficacy of our modification of the original SSPPD technique as compared to PPPD with an aim to decrease the incidence of DGE. We retrospectively analyzed 67 patients who underwent PD with pancreaticogastrostomy (PG). They were divided into 2 groups on their basis of the surgical treatment: the PPPD group and the modified SSPPPD (MSSPPD) group. The incidence of DGE was determined and compared between the 2 groups. In the MSSPPD group, 98%, 2%, and 0% of the cases developed class A, class B, and class C DGE, respectively; the corresponding values in the PPPD group were 4%, 52%, and 44%, respectively. The incidence of DGE differed significantly between the 2 groups (p<0.0001). We consider that our reconstruction procedure is useful for preventing DGE in patients who have undergone SSPPD with PG.

Duodenum‐preserving versus pylorus‐preserving pancreatic head resection for benign and premalignant lesions

Pylorus-preserving pancreaticoduodenectomy (PPPD) is the treatment of choice for benign or premalignant pancreatic head lesions. Duodenum-preserving pancreatic head resection (DPPHR) has been reported in only 132 patients. This study aimed to compare the long-term results of DPPHR and PPPD. Patients who underwent DPPHR or PPPD for benign or borderline disease between 1991 and 2008 were followed up until December 2009 or their death. Endocrine and exocrine pancreatic functions were evaluated at their last follow-up. Twenty-seven patients underwent DPPHR (Group 1) and 37 PPPD (Group 2). They were followed for a mean of 100 and 135 months, respectively. Group 1 had a higher complication rate (81.5 vs. 40.5%) and pancreatic fistula rate (40.1 vs. 18.9%). Hospital mortality was 0 and 2.7%, respectively. Two patients died 3.3 and 97 months after DPPHR. Significantly more Group 2 patients needed medical treatment for benign cholangitis (P < 0.0001). Insulin-dependent diabetes mellitus was observed in six Group 1 and 15 Group 2 patients (P = 0.077). Ten Group 1 and 21 Group 2 patients are taking pancreatic enzymes (P = 0.003). DPPHR for benign or premalignant lesions is a difficult procedure with a higher complication rate than PPPD, but was without mortality. Preserving the entire duodenum and a normal biliary tree allows better long-term results.

A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: A meta-analysis of 2822 patients

Background The gold-standard for surgical excision of peri-ampullary tumours has not been established despite numerous studies, due to conflicting outcomes. Aim To consolidate the published evidence and compare outcomes between pancreaticoduodenectomy (PD) and pylorus preserving pancreaticoduodenectomy (PPPD) across all published comparative studies. Methods Using meta-analytical techniques the study compared: operative details, post-operative adverse events and survival following PD and PPPD. Comparative studies published between 1986 and 2005 of PD versus PPPD were included. A random effect model was employed, with significance reported at the 5% level. Results 32 studies comprising 2822 patients (1335 PD and 1487 PPPD), including 5 randomized controlled trials with 421 patients (215 PD and 206 PPPD) were included. Patients undergoing PPPD were found to have smaller tumours (weighted mean difference (WMD) −0.54 cm, p = 0.030), although no significant difference in the number of patients with stage III or IV disease existed between the groups (odds ratio, OR 1.55, p = 0.320). Decreased operating times (WMD −41.3 min, p = 0.010) and fewer blood transfusions (WMD −0.9 units, p < 0.001) were observed in the PPPD group. There was no difference in post-operative complications, including pancreatic and biliary leaks or fistulae, between the two groups. It was suggested that peri-operative mortality was decreased in the PPPD group (OR 1.7, p = 0.040), and overall survival was better (hazard ratio (HR) 0.66, p = 0.02), although this did not remain significant on subgroup analysis. Conclusions Both PD and PPPD had similar peri-operative adverse events, however, in overall analysis PPPD has lower mortality and improved long-term patient survival, although this was not reflected in the sub-group analysis.

Pancreatic Head Resection With Segmental Duodenectomy

To evaluate the usefulness and long-term results with pancreatic head resection with segmental duodenectomy (PHRSD; Nakao's technique) in patients with branch-duct type intraductal papillary mucinous neoplasms (IPMNs). A prospective study from Nagoya (Japan) and Barcelona (Spain). Surgery should be the first choice of treatment of IPMNs. An aggressive surgery (eg, pancreatoduodenectomy) should be questioned in patients with an indolent disease or with noninvasive tumors. Recently, organ-preserving pancreatic resections for benign and noninvasive IPMN located in the head of the pancreas have been described. We have PHRSD in which the pancreatic head can be completely resected and the major portion of the duodenum can be preserved by this procedure. There have been only 4 reports concerning PHRSD with <8 patients (each one) in the English literature. Thirty-five patients underwent PHRSD (20 men, 15 women), mean age 65.1 +/- 9.0 (range, 55-75). Mean maximal diameter of the cystic lesion was 26.4 +/- 5.3 mm (range, 20-33 mm) and mean diameter of the main pancreatic duct was 3.3 +/- 0.5 mm (range, 3.0-4.0 mm). Alimentary tract reconstruction was performed in 20 patients by pancreatogastrostomy, duodenoduodenostomy, and choledochoduodenostomy (type A) and 15 patients by pancreaticojejunostomy, duodenoduodenostomy and choledochojejunostomy (Roux-en-Y; type B). Surgical parameters, postoperative complications, endocrine function, exocrine function, and long-term outcomes were evaluated. To compare the perioperative factors, a matched-pairs analysis between PHRSD patients and patients with pylorus preserving pancreaticoduodenectomy (PPPD) was performed. In the latter group were included 32 patients with branch-duct type of IPMN operated during the same time period that patients with PHRSD. The mean follow-up period was 48.8 months. Mean operative time after PHRSD was 365 +/- 50 and mean surgical blood loss was 615 +/- 251 mL. There was no mortality. Pancreatic fistula occurred in 10% and 13% with types (alimentary tract reconstruction) A and B, respectively. Noninvasive IPMN was found in 31 patients and invasive IPMN in 4 patients (11.4%). In the matched-pairs analysis between PHRSD and PPPD, the 2 procedures were comparable in regard to operation time and intraoperative blood loss. The overall incidence of pancreatic fistula was higher after PPPD than after PHRSD; the difference was not statistically significant. When fistulas occurred after PHRSD they were grade A (biochemical). In contrast, pancreatic fistulas after PPPD were grade A in 78% of cases and grade B in 22% (clinically relevant fistula). The incidence of delayed gastric emptying was significantly higher in the PPPD group compared with the PHRSD group (P < 0.01). Endocrine pancreatic function, measured by fasting blood glucose levels and HbA1, levels was unchanged in 94.28% of patients, in the PHRSD group, and in 87.87% in the PPPD group. Body weight was unchanged in 80% after PHRSD and in 59% after PPPD. Postoperative enzyme substitution was needed in 20% of patients after PHRSD and in 40% patients after PPPD. The 5-year survival rate was 100% in patients with benign IPMN and 42% in patients with invasive IPMN. PHRSD is a safe and reasonable technique appropriate for selected patients with branch-duct IPMN. The major advantages of PHRSD are promising long-term results in terms of pancreatic function (exocrine and endocrine) with important consequences in elderly patients. Long-term outcome was satisfactory without tumor recurrence in noninvasive carcinoma. PHRSD should therefore be considered as an adequate operation as an organ-preserving pancreatic resection for branch-duct type of IPMN located at the head of the pancreas.