Small Pancreatic Duct Research Articles

Peri-operative outcomes of pancreaticoduodenectomy comparing an isolated Roux loop or single loop for reconstruction: An ambispective observational study

BackgroundA post-operative pancreatic fistula is a major cause of morbidity and mortality in patients undergoing pancreaticoduodenectomy. We compared two methods of reconstruction of pancreaticojejunal anastomosis, an isolated loop with a single loop, to assess their effects on the incidence and severity of fistula. MethodsThe data was collected in an ambispective manner. The drain fluid was sent for amylase measurement on post-operative day 3 and a fistula was defined and classified according to the 2016 modification of the International Study Group for Pancreatic Surgery definition. The patients were divided into the isolated (Group I) and single (Group II) loop groups and compared for the incidence and severity of clinically relevant fistula along with other parameters. ResultsA total of 349 (Group I: 201, Group II: 148) patients were included in the study. The incidence of clinically relevant fistula was comparable (p = 0.206). Grade C fistula was found to be lower in the group I (7 % vs 11.6 %, p = 0.137), in patients with a soft pancreas (8.5 % vs 18.3 %, p = 0.049) and pancreatic duct diameter less than 5 mm (9.8 % vs 17.2 %, p = 0.036). The operative time was lower in Group I than in Group II (438 min vs 478, p < 0.001). ConclusionWe found that the incidence of clinically relevant fistula was similar in both the groups but the isolated reconstruction method reduced the incidence of severe fistula. In patients with a smaller pancreatic duct, soft pancreas echotexture and obesity, it provides a safer alternative and can be performed in less time than a single loop reconstruction.

Buttressed pancreaticogastrostomy for a soft pancreas and/or small pancreatic duct in pancreaticoduodenectomy: A retrospective cohort study

AbstractObjectivePost‐operative pancreatic fistula (POPF) has a major impact on the post‐operative outcomes after pancreaticoduodenectomy (PD). Soft pancreas and small pancreatic duct diameter are major risk factors for POPF. In this study, we aimed to evaluate the short‐term outcomes of our technique of buttressed pancreaticogastrostomy (PG) as a method of pancreatic anastomosis.Patients and MethodsA retrospective cohort study was conducted on patients who underwent PD with a soft pancreas and/or small pancreatic duct diameter ≤5 mm. The study period spanned from January 2018 to December 2022.ResultsA total of 69 patients were included in the study, comprising 30 females and 39 males. The mean age of the patients was 57 ± 14.3 years. The mean operative time of the whole procedure was 335 ± 43.7 min and that of buttressed PG was 22 ± 4.6 min. Two patients had early post‐operative bleeding. Only 5 (7.24%) patients developed a grade A POPF. Eight (11.8%) patients had delayed gastric emptying.ConclusionButtressing PG represents a simple and safe reconstruction technique following PD, particularly for patients with a soft pancreas and/or small pancreatic duct. This approach is associated with a low incidence of POPF. However, prospective randomised trials with large sample sizes are required to confirm these results.

A novel technique of managing undilated small pancreatic duct(SPD) during pancreatojejunal anastomosis (PJA) in Whipple’s pancreatoduodenectomy (WPD) for malignancy-Comparative retrospective analysis

A novel technique of managing undilated small pancreatic duct(SPD) during pancreatojejunal anastomosis (PJA) in Whipple’s pancreatoduodenectomy (WPD) for malignancy-Comparative retrospective analysis

Serum amylase on postoperative day 1 is superior to serum lipase in predicting clinically relevant pancreatic fistula after partial pancreaticoduodenectomy.

To compare the predictive value of serum amylase and lipase regarding the occurrence of clinically relevant postoperative pancreatic fistula (cr-POPF) after partial pancreaticoduodenectomy (PD). Data from 228 consecutive patients undergoing PD were obtained from a prospective database. Serum amylase and lipase were measured on postoperative days (PODs) 0-2. Receiver-operating characteristics analysis was performed and cutoff values were tested using logistic regression. Serum amylase had a larger area under the curve (AUC) on POD1 (AUC 0.89, p <0.001) than serum lipase. For serum amylase POD 1, a cutoff value of 70 U/l showed sensitivity and specificity of 100% and 70% for the diagnosis of cr-POPF. Serum amylase POD 1 > 70 U/l (OR 9.815, 95% CI 3.683-26.152, p < 0.001), drain amylase POD 1 > 300 U/l (OR 2.777, 95% CI 1.071-7.197, p= 0.036), and a small (≤ 3mm) pancreatic duct diameter (OR 3.705, 95% CI 1.426-9.627, p= 0.007) were significant predictors of cr-POPF in the multivariable analysis. Patients were divided into three risk groups based on serum amylase POD 1 and pancreatic duct diameter. This model had a good performance in discriminating cr-POPF (AUC 0.846, 95% CI 0.793-0.898). The sensitivity, specificity, and negative predictive value for the combination of serum amylase POD 1 <70 U/l and pancreatic duct diameter >3 mm were 100%, 70%, and 100%. Serum amylase POD 1 was superior to serum lipase in predicting cr-POPF after PD. The proposed risk prediction model had a sensitivity and negative predictive value of 100%, allowing for early identification of cr-POPF.

Comparison of the modified Blumgart mattress vs. interrupted suture pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy

Aim: The modified Blumgart mattress (BM) and conventional interrupted suture (IS) methods are currently the most widely adopted pancreaticojejunostomy (PJ) techniques utilized during minimally invasive pancreaticoduodenectomy (MIPD). This study aimed to evaluate the postoperative outcomes between the two PJ techniques using robotic and laparoscopic approaches. Methods: This was a retrospective study involving patients who underwent robotic or laparoscopic pancreaticoduodenectomy (PD) performed by two surgeons from two institutions. Surgical outcomes of the patients were compared according to the PJ techniques of robotic BM (Rob-BM), robotic IS (Rob-IS), and laparoscopic IS (Lap-IS), which were further analyzed among patients who had a soft pancreas and small pancreatic duct, while those with pancreatic ductal adenocarcinoma were excluded from the study. Results: A total of 230 patients underwent MIPD with 63 Rob-BM, 48 Rob-IS, and 119 Lap-IS for PJ. Within the study population, clinically relevant-postoperative pancreatic fistula (CR-POPF) rates were comparable between Rob-BM and Rob-IS (6.3% vs. 10.4%, P = 0.283) and between Rob-IS and Lap-IS (10.4% vs. 7.6%, P = 0.661). Comparing patients with soft pancreas and small pancreatic duct, CR-POPF rates were not statistically different among the groups [16.0% (Rob-BM) vs. 10.5% (Rob-IS), P = 0.055, and 10.5% (Rob-IS) vs. 10.1% (Lap-IS), P = 0.543]. In the multivariable analysis for risk factors of POPF, soft pancreatic textures and periampullary pathology other than pancreatic cancer were found to be risk factors. Conclusion: POPF rates after MIPD were not different according to the PJ methods of BM and IS when performed by skilled surgeons.

Which pancreaticoduodenectomy dunking conduit is optimal for very small pancreatic ducts?

BackgroundPancreaticoduodenectomy data regarding the optimal technique for reconstruction of small pancreatic ducts, where duct-to-mucosa is technically difficult, are lacking. We sought to retrospectively evaluate outcomes of dunking pancreaticojejunostomy (DPJ) compared to dunking pancreaticogastrostomy (DPG) after pancreaticoduodenectomy. MethodsUsing NSQIP-targeted pancreatectomy data (2014–2019), we retrospectively identified patients undergoing elective pancreaticoduodenectomy with small pancreatic ducts (<3 ​mm) who underwent DPJ or DPG. Outcomes between patients undergoing DPJ versus DPG were compared using multivariable regression. ResultsAmong 780 patients, 79.8% underwent DPJ and 20.1% DPG. Patient comorbidities were similar. More patients who underwent DPG were Black, underwent vascular reconstruction (29.0% v. 10.5%; p ​< ​0.001), and had shorter operative time (324 v. 377 ​min; p ​< ​0.001). After adjustment, DPJ reconstruction was associated with higher likelihood of clinically-relevant postoperative pancreatic fistula (CR-POPF) (OR 2.1; p ​= ​0.024), deep abscess (OR 1.9; p ​= ​0.041), and postoperative percutaneous drainage (OR 2.2; p ​= ​0.027). There was no difference in delayed gastric emptying, postoperative sepsis, transfusions, reoperation, length of stay, or 30-day readmission. ConclusionAmong patients with small pancreatic ducts where a dunking pancreaticoenteric anastomosis is performed, DPG was associated with decreased CR-POPF incidence compared to DPJ. Future clinical trials are needed to confirm the generalizability of this result across centers with varying DPG expertise.

Pancreatico-jejunostomy versus pancreatico-gasrostomy after pancreatico-duodenectomy in decreasing postoperative pancreatic fistula

Background Pancreatico-duodenectomy is still the cornerstone in curating pancreatic and periampullary cancers. Many techniques for pancreatic anastomosis were described. Pancreatico-gastrostomy (PG) may be a suitable technique, especially in small pancreatic ducts where the stitching of duct to mucosa may be difficult. Still, the results of pancreatico-gastrostomy compared to pancreatico-jejunostomy (PJ) in terms of morbidity are not well studied; hence, this study was designed to investigate. Objective To compare pancreatico-gastrostomy versus pancreatico-jejunostomy post pancreatico-duodenectomy from points of operative techniques and characteristics, and postoperative morbidity and mortality. Patients and methods The Cohort study included all cases diagnosed with either pancreatic head or periampullary cancers and underwent pancreatico-duodenectomy at National Cancer Institute (NCI), Cairo University, between January 2021 and February 2023. Cases were enrolled into one of the two groups, group 1: underwent pancreatico-gastrostomy, while group 2 underwent pancreatico-jejunostomy. The two groups were compared by: Demographic characteristics, preoperative investigations results, operative, postoperative data and histopathological results of the specimens resected. Results Incidence of the pancreatic leak was not significantly different in both groups (17.6% versus 15.8% for PG and PJ respectively, P=0.833), operative time was shorter in a pancreatico-gastrostomy group (310, 355 min, P=0.001), Delayed gastric emptying (DGE) was less occurred in cases of pancreatico-gastrostomy (5.9%, 31.6%, P=0.006). Postoperative mortality was not different in both groups (8.8%, 2.6% for PG and PJ respectively, P=0.338). Conclusion Regarding the incidence of postoperative pancreatic fistula, both reconstruction methods produce comparable postoperative results. Pancreatico-gastrostomy is a good alternative technique to the standard pancreatico-jejunostomy.

Risk Models for Developing Pancreatic Fistula After Pancreatoduodenectomy: Validation in a Nationwide Prospective Cohort.

To evaluate the performance of published fistula risk models by external validation, and to identify independent risk factors for postoperative pancreatic fistula (POPF). Multiple risk models have been developed to predict POPF after pancreatoduodenectomy. External validation in high-quality prospective cohorts is, however, lacking or only performed for individual models. A post hoc analysis of data from the stepped-wedge cluster cluster-randomized Care After Pancreatic Resection According to an Algorithm for Early Detection and Minimally Invasive Management of Pancreatic Fistula versus Current Practice (PORSCH) trial was performed. Included were all patients undergoing pancreatoduodenectomy in the Netherlands (January 2018-November 2019). Risk models on POPF were identified by a systematic literature search. Model performance was evaluated by calculating the area under the receiver operating curves (AUC) and calibration plots. Multivariable logistic regression was performed to identify independent risk factors associated with clinically relevant POPF. Overall, 1358 patients undergoing pancreatoduodenectomy were included, of whom 341 patients (25%) developed clinically relevant POPF. Fourteen risk models for POPF were evaluated, with AUCs ranging from 0.62 to 0.70. The updated alternative fistula risk score had an AUC of 0.70 (95% confidence intervals [CI]: 0.69-0.72). The alternative fistula risk score demonstrated an AUC of 0.70 (95% CI: 0.689-0.71), whilst an AUC of 0.70 (95% CI: 0.699-0.71) was also found for the model by Petrova and colleagues. Soft pancreatic texture, pathology other than pancreatic ductal adenocarcinoma or chronic pancreatitis, small pancreatic duct diameter, higher body mass index, minimally invasive resection and male sex were identified as independent predictors of POPF. Published risk models predicting clinically relevant POPF after pancreatoduodenectomy have a moderate predictive accuracy. Their clinical applicability to identify high-risk patients and guide treatment strategies is therefore questionable.

Localization and Laparoscopic Excision of Gastric Heterotopic Pancreas in a Child by Endoscopic SPOT® Tattooing

Heterotopic pancreas (HP) is defined as pancreatic tissue lacking vascular or anatomic connection with the normal pancreas. Surgical resection is often indicated for symptomatic gastric HP. However, intraoperative identification of gastric HP is often difficult during laparoscopic surgery. Herein, we describe a patient with gastric HP, which was marked with SPOT® dye (GI Supply, Camp Hill, PA, USA). The dye was seen clearly laparoscopically facilitating total excision of the lesion. The final pathology report confirmed the presence of heterotopic pancreatic tissue including pancreatic acini, small pancreatic ducts tissue with islets of Langerhans in the deep gastric submucosal area. There were no postoperative complications, and the patient was symptom-free. To the best of our knowledge, this was the first case report in the literature in which endoscopic tattooing of gastric HP before laparoscopic resection was performed. This method of localization was simple and reliable in children.

Selective use of pancreatic duct occlusion during pancreaticoduodenectomy in patients with a small-size duct and atrophic parenchyma in the distal pancreas: A retrospective study.

Despite the advancements in surgical techniques, postoperative pancreatic fistula (POPF) remains a potentially life-threatening complication of pancreaticoduodenectomy (PD). Pancreatic duct occlusion (PDO) without anastomosis has also been proposed to alleviate the clinical consequences of POPF in selected patients after PD. To assess the safety and effectiveness of PDO with mechanical closure after PD in patients with an atrophic pancreatic body-tail and a small pancreatic duct. We retrospectively identified two female and two male patients from April 2019 to October 2020 through preoperative computed tomography of the abdomen. Among them, three patients underwent PDO with mechanical closure after PD, and one underwent PDO after pylorus-preserving PD. In addition, patients' medical records and medium-and long-term follow-up data were analyzed. Postoperative histological examination revealed a solid pseudopapillary tumor in two patients, pancreatic ductal adenocarcinoma in one patient, and chronic pancreatitis with pancreatic duct stones in one patient. However, none of the patients developed biochemical or clinically relevant POPF, with no postpancreatectomy hemorrhage, biliary leakage, delayed gastric emptying, intra-abdominal abscess, or chyle leakage. Among the four patients, three developed new-onset diabetes mellitus, and one had impaired glucose tolerance. Furthermore, three patients received pancreatic enzyme supplementation at a dose of 90,000 Ph. Eur. units/d, and one was prescribed a higher dose of 120,000 Ph. Eur. units/d. PDO with mechanical closure is an alternative approach for patients with an atrophic pancreatic body-tail and a small pancreatic duct after PD. Therefore, further evidence should evaluate the potential benefits of selective PDO in these patients.

Pancreaticogastrostomy as a fistula mitigating strategy for a high-risk pancreatic anastomosis following pancreaticoduodenectomy

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) has been associated with soft gland texture and/or small pancreatic duct. We hypothesized that selective use of pancreaticogastrostomy (PG) over pancreaticojejunostomy (PJ) in those scenarios would decrease the rate of CR-POPF. MethodsReview of prospective database of all PD’s performed at a single institution between 2009 and 2019 was performed. The pancreatic remnant was deemed “high risk” if soft gland and/or small duct were present. ResultsPJ was performed in 199 (147 “low-risk” and 52 “high-risk”) cases, and 110 patients (all “high-risk”) had a PG. Overall CR-POPF rate was 11.9% with no difference between the groups. Risk-stratified analysis within PJ group showed CR-POPF rate of 5.4% versus 36% in “low-risk” versus “high risk” scenarios, respectively; the use of PG significantly decreased CR-POPF rate (9.1%, p < 0.0001). Gastrointestinal bleeding was more likely to occur following PG than PJ. Soft gland texture and gastrointestinal bleeding were the strongest predictors of CR-POPF in PJ and PG groups, respectively. ConclusionSelective use of PG after PD in “high-risk” scenarios mitigates the risk of CR-POPF. Increased rate of gastrointestinal bleeding calls for further refinement of the technique and heightened postoperative vigilance.

Pancreaticoduodenectomy for benign and premalignant pancreatic and ampullary disease: is robotic surgery the better approach?

The robotic platform is increasingly being utilized in pancreatic surgery, yet its overall merits and putative advantages remain to be adjudicated. We hypothesize that the benefits of minimally invasive pancreatic surgery are maximized in pancreatic benign and premalignant disease, in the setting of friable pancreatic tissue and small pancreatic duct. Retrospective analysis of our prospectively maintained pancreatic database of all consecutive patients who underwent pancreaticoduodenectomy (PD) for benign or premalignant conditions between 2010 and 2020. Peri-operative outcomes and long-term complications were compared between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD). One hundred and eighty eight (n = 188) patients met our inclusion criteria, of which 68 were OPD and 120 RPD. Malignant histologies were excluded. There were only minor differences in baseline characteristics between the two groups. Post-operative merits of the RPD included lower clinically relevant post-operative pancreatic fistula 10 (8.3%) vs 24 (35.3%), p < 0.001, fewer surgical site infections; 9 (7.5%) vs 11 (16.2%), p = 0.024, shorter operative time, greater lymph node yield; 29 (IQR 21, 38) vs 21 (IQR 13, 34), p = 0.001, and lower 90days mortality; 1 (0.8%) vs 4 (5.9%), p = 0.039. Rates of long-term complications were similar, exception made for a higher occurrence of small bowel obstruction (SBO) 2 (1.7%) vs 4 (5.9%), p = 0.031 and need for surgical intervention for SBO 0 (0.0%) vs 2 (2.9%), p = 0.019 in the OPD group. Our study suggests that RPD benefits include lower 90-day mortality, shorter LOS, and lower rates of selected complications compared to open pancreaticoduodenectomy.

Risk factors predicting the development of a pancreatic fistula following pancreaticoduodenectomy: A retrospective cohort study

BackgroundA postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy is considered a life-threatening complication. This study was designed to analyze the risk factors for the development of a POPF in a tertiary care center (Al-Rajhi Liver Hospital/Assiut University). Patients and methodsWe retrospectively analyzed 96 patients who underwent pancreaticoduodenectomy at our hospital from January 2017 to December 2020. A pancreatic fistula was defined according to the 2016 update of the International Study Group of Pancreatic Fistula. The risk factors for a pancreatic fistula were analyzed via a univariate analysis and multivariate logistic regression analysis. ResultsA clinically relevant pancreatic fistula was detected in 26/96 patients (27.1%) who underwent pancreaticoduodenectomy. The perioperative mortality rate was 8.3% (8/96 patients). Univariate analysis showed a significant association between the incidence of a POPF and the following factors: body mass index (BMI) (<28 vs. >28: 12% vs. 43.5%, respectively, p = 0.014), pancreatic consistency (firm vs. soft: 16.7% vs. 44.4%, respectively, p = 0.036), pancreatic duct diameter (>3 mm vs. <3 mm: 12.5% vs. 56.3%, respectively, p = 0.001), and drain amylase level POD 3 (p = 0.000). Multivariate logistic regression analysis identified BMI (p = 0.020), pancreatic consistency (p = 0.042), pancreatic duct diameter (p = 0.003), and drain amylase level (p = 0.003) as significant independent factors for a POPF. Using a ROC curve, the drain amylase level at POD 3 had the best sensitivity (92.3%) and specificity (82.9%) when using a cutoff value of 644 IU. ConclusionOur study demonstrated that a BMI of >28, soft pancreatic texture, small pancreatic duct diameter of ≤3 mm, and drain amylase level at POD 3 (cutoff point = 644 IU) were the most significant risk factors for the development of a POPF following pancreaticoduodenectomy.

Minimally Invasive vs Open Pancreatectomy for Pancreatic Neuroendocrine Tumors: Multi-Institutional 10-Year Experience of 1,023 Patients.

Resection of pancreatic neuroendocrine tumors (PNETs) may be associated with adverse perioperative outcomes compared with pancreatic adenocarcinoma given the high-risk nature of soft glands with small pancreatic ducts. The effect of minimally invasive surgery (MIS) pancreatectomy on outcomes of PNETs remains to be examined, which is the aim of this study. Between 2009 and 2019, 1,023 patients underwent pancreatectomy for PNETs at 4 institutions. Clinicopathologic data and perioperative outcomes of patients who underwent MIS (n = 447) and open resections (n = 576) were compared. Of the 1,023 patients, 51% were male, the mean age was 58, the median tumor size was 2.1 cm, and 73% were grade 1 PNETs. There were 318 (31%) pancreatoduodenectomies (PDs), 541 (53%) distal pancreatectomies (DPs), 80 (7.8%) enucleation (ENs), 72 (7%) central pancreatectomies (CPs), and 12 (1.2%) total pancreatectomies. Almost half of the patients (N = 447, 44%) had MIS operations, of which 230 (51%) were robotic and 217 (49%) were laparoscopic. Compared with open operations, MIS PDs had significantly lower operative blood loss (150 vs 400 mL, p < 0.001) and rate of clinically relevant postoperative pancreatic fistulas (CR-POPFs; 13% vs 27%, p = 0.030), and MIS DPs had a shorter length of stay (5 vs 6 days, p < 0.001). Although MIS DPs and ENs had CR-POPFs comparable with open operations, MIS CPs had a higher CR-POPF rate (45% vs 15%, p = 0.013). After adjusting for pathological differences, MIS pancreatectomy was associated with recurrence-free survival and overall survival comparable with open pancreatectomy. MIS pancreatectomy for PNETs is associated with improved outcomes or outcomes comparable with open resection.

Pancreatico-Jejunostomy On Isolated Loop After Pancreatico-Duodenectomy: Is It Worthwhile?

BackgroundPostoperative morbidity remains a significant problem after pancreatico-duodenectomy. The management of pancreatic stump continues to be a challenge, and many technical solutions have been developed over the years. In this study, we report the results obtained with the use of an isolated loop for pancreatico-jejunostomy in patients with soft pancreas and small pancreatic duct diameter. MethodsClinical data of patients submitted to pancreatico-duodenectomy in a period of sixteen years (2005–2020) were extracted from a prospective database. Patients with soft pancreas, main duct diameter < 2 mm and reconstruction by pancreatico-jejunostomy on single loop or isolated loop were selected. Primary end-point was the incidence of clinically relevant fistulas in the two groups of patients. Secondary endpoint was the length of postoperative hospital stay. A propensity score matching analysis was used for the statistics. ResultsTwo hundred and twenty-one patients with the above characteristics were found in the database. One hundred and twelve of these received a single-loop reconstruction and 109 an isolated loop reconstruction. Incidence of clinically relevant fistulas was higher in the first group (41% vs 27%; p = 0.023). Postoperative hospital stay was significantly shorter in the second group (21 days vs 15; p < 0.001). These results were confirmed at the propensity score matching. ConclusionIn patients with soft pancreatic texture and small main duct diameter, pancreatico-jejunostomy on isolated loop is associated with a lower incidence of clinically relevant fistulas than after classic reconstruction. The duration of postoperative hospital stay was significantly reduced, with consequent reduction of cost.

Comparison of Postoperative Pancreatic Fistula Rates of Laparoscopic Versus Robotic Pancreaticojejunostomy after Pancreaticoduodenectomy in Soft Pancreas with Small Pancreatic Duct; a Multi-Center Study with a Propensity Score Matching Analysis

Introduction: Soft pancreatic texture and small pancreatic duct were well known risk factors of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). This study aims to compare the POPF rates and other surgical outcomes of laparoscopic versus robotic pancreaticojejunostomy(PJ) in risky pancreas. Method: Between October 2012 to June 2020, total of 429 cases of minimally invasive PD were performed by three surgeons in three different institutions. Among those patients, 201 patients with soft pancreas and small pancreatic duct less than 3 mm were included based on preoperative image study and the operative record. Propensity score matching analysis was performed. Results: 118 totally laparoscopic PD, 49 totally robotic PD, and 34 hybrid PD (laparoscopic resection and robotic anastomosis) were performed. 69 patients underwent laparoscopic PJ and 69 patients underwent robotic PJ were selected after propensity score matching. Demographics of the patients were comparable. Pancreatic duct diameter was similar in both groups (1.8±0.4 mm vs 1.8±0.5 mm, p=1.00). Operative time was shorter in RPJ group (456.1±83.2 vs 405.1±75.4, p=<0.01). Incidence of clinically relevant POPF greater than grade B was comparable in laparoscopic and robotic PJ group (14.5 % vs 11.6 %, p=0.80). Biochemical leakage, grade B, and grade C pancreatic fistulas were 46.4%, 14.5% and 0.0% in laparoscopic PJ group, respectively, and 31.9%, 11.6% and 0.0% in robotic PJ group. Conclusions: Risk of POPF of laparoscopic or robotic PJ in soft texture and small duct was comparable by experienced surgeons. Robotic approach may be beneficial saving operative time.

Clinical Feasibility of Duct-To-Mucosa Pancreaticojejunostomy in Laparoscopic Pancreaticoduodenectomy : Comparison with the Same Technique in Open Pancreaticoduodenectomy

Introduction: Duct-to-mucosa pancreaticojejunostomy (DM-PJ) is one of the most commonly used technique in pancreaticoduodenectomy (PD). However, DM-PJ can be considered technically a challenge procedure in laparoscopic PD (L-PD), especially in cases with small pancreatic duct. Therefore, we will present the clinical feasibility and technical tips for DM-PJ in L-PD. Methods: Between January 2016 and December 2019, we performed 120 cases of PD. Among them, 60 patients underwent totally L-PD. We retrospectively reviewed the medical records to ascertain the safety and the reproducibility of DM-PJ and compared with open DM-PJs. Results: Significant pancreatic fistula [International Study Group on Pancreatic Fistula (ISGPF) grade B or C] in L-PD was less than 10%, and this complication was even more higher than open DM-PJ group. The postoperative mortality in L-PD was nil and this result was also lower than open DM-PJ. The postoperative complication than Clavien-Dindo classification III was identified in 4 patients in L-PD, but recovered by interventional management. The conversion to open PD was required in one patient with tumor invasion to the superior mesenteric vein, but there was no open conversion because of technical difficulty of DM-PJ. Conclusion: We believe that DM-PJ in L-PD can be the standard method as in open PD, because of the magnification of laparoscope and advancement of laparoscopic techniques. And, further development of laparoscopic instruments is essential.

Minimally Invasive versus Open Pancreatectomy for Pancreatic Neuroendocrine Tumors: A Multi-Institutional Ten-Year Experience on 1023 Patients

Introduction: Pancreatectomy for pancreatic neuroendocrine tumors (PNETs) may be associated with worse perioperative outcomes compared to pancreatic adenocarcinoma given the high-risk nature of soft glands with small pancreatic ducts. We aimed to investigate the outcomes of minimally invasive (MIS) vs open pancreatectomy in four high-volume institutions.

Comparative Morphohistological Study of Pancreatic Ducts in Rabbits and Guinea Pigs

The study aims to determine the morphology and histology of the duct system in pancreases ofrabbits and guinea pigs as two important experimental models in diverse medical investigations. To perform this aim, eight adult animals of each species have been collected and used. Animals were euthanized and subsequent dissection was implemented to cut and collect the pancreases. Samples from these organs were fixed by using 10% neutral buffered formalin which then processed routinely to prepare sections stained by either hematoxylin-eosin or Masson’s trichrome stains. Gross findings of the rabbit pancreas revealed an absence of major pancreatic duct and the persistence of only minor pancreatic duct as well as an accessory small pancreatic duct, whereas, in guinea pigs, the only minor pancreatic duct was detected. Microscopically, similar branched ducts were found but with some differences between the two species. In both, it was started with centroacinar cells, then connected to intercalated ducts that were lined with cuboidal cells (in the guinea pig, ducts were surrounded with myoepithelial cells). The latter converged to form interlobular ducts lined with columnar cells (in guinea pig, ducts showed goblet cells and subepithelial mucous glands). The larger interlobular ducts were converged to form a minor pancreatic duct that was lined with tall columnar epithelium with goblet cells surrounded by connective tissue (in guinea pigs, also mucous glands were found invested in the surrounding fibrous tissue with the presence of circularly arranged smooth muscle fibers).

Simplified technique for invaginating pancreaticogastrostomy

Failure of pancreaticoenteric anastomos is a major cause of morbidity after pancreaticoduodenectomy. Factors that contribute to the poor outcome of this anastomosis are soft glandular texture, and small pancreatic duct diameter. Invaginating pancreatogastrostomy has been deemed superior to pancreaticojejuostomy when those risk factors are present. Nevertheless, the suture between gastric mucosa and pancreas is often a bothersome step and has a potential contaminating load to the surgical field. Herein, a simplified method for suturing the pancreatic stump into the stomach is shown, avoiding the complexity of the suture and minimizing the manipulation into the gastric lumen.