Small Pancreatic Duct Research Articles

Characterization of a BAC transgenic mouse expressing Krt19-driven iCre recombinase in its digestive organs.

Cytokeratin 19 (KRT19) protein is highly expressed in the epithelium of the gastrointestinal (GI) tract, hepatobiliary tissues, and pancreas of humans and mice. In the present study, we used an improved Cre (iCre) gene to enhance the efficiency of Cre expression in mammalian cells. We established a new transgenic Krt19-iCre bacterial artificial chromosome (BAC) mouse model using the BAC recombineering strategy. Site-specific iCre expression pattern was examined in embryos, adults, and elderly Krt19-iCre mice crossed with Tomato or LacZ reporter mice. Both iCre and reporter protein expressions in adult Krt19-iCre;Tomatoflox/+ (Krt19-iCre Tomato reporter) mice were observed mainly in the epithelial cells of the GI tract, hepatobiliary tissues, and pancreas. However, the expression in the intrahepatic and small pancreatic duct were lower than those in the common bile and large pancreatic duct. In the Krt19-iCre; LacZ reporter embryos, β-galactosidase for the LacZ reporter was expressed in the glandular epithelial cells of the GI tract in 9.5-day embryos, 12-day embryos, and newborn mice. The reporter protein expression in Krt19-iCre-Tomato reporter mice was consistent with the KRT19 expression in human GI tissues. In conclusion, Krt19-iCre BAC transgenic mice can be used to investigate developmental and pathological conditions using the iCre-loxP system.

The Dilemma of Drains after Pancreatoduodenectomy: Still an Issue?

Routine drainage after pancreatoduodenectomy is a controversial issue. In this article, we present and discuss the current evidence on abdominal drains in pancreatic surgery. Review of the pertinent English-language literature. There is a growing body of evidence showing a lack of benefit of prophylactic drainage after pancreatoduodenectomy. Randomized trials have reported similar outcomes with or without routine drains. If drains were used, early removal was found to be superior to late removal in patients with a low risk of postoperative pancreatic fistula. Consequently, criteria for early drain removal have been developed based on the measurement of drain amylase levels. On the contrary, there exists a subgroup of patients where drains may have a role. In patients with high risk of pancreatic fistula formation, such as those having a soft pancreatic texture, small pancreatic duct and high body mass index, the placement of drains may give sentinel information about future clinical deterioration. The drain may thus help reduce failure-to-rescue rates. Despite much research, there are many unanswered questions regarding drains in pancreatic surgery. It is evident that routine drainage should be abandoned for a more selective strategy. Furthermore, what is needed is a postoperative warning score that early on can identify patients at risk of a pancreatic fistula, without the routine placement of drains.

The effect of bilateral U-sutures in pancreaticojejunostomy in 75 consecutive cases

Background: Various technical interventions have been suggested to decrease the frequency of postoperative pancreatic fistulas but the effect is not particularly satisfactory. We have analyzed our application of bilateral U-sutures in pancreaticojejunostomy.Methods: The pancreatic stump is freed over approximately 2 cm, an appropriate diameter silicone catheter with 2–4 lateral holes was inserted into the remnant pancreatic duct (>2 mm in diameter is required) over 2–3 cm as a stent in 69 patients. In six patients with soft pancreas and very small pancreatic duct (<2 mm in diameter), the silicone catheter was not used. An incision was made on the side of the distal section of the jejunum and end-to-side an invaginated pancreaticojejunostomy was performed using bilateral U-sutures.Results: Only two (2.67%) cases developed pancreatic ‘biochemical leaks’. None of the 75 patients developed grade B and grade C pancreatic leakage. The overall morbidity was 29.33%. The anastomosis time was 14 minutes on average. There were no symptoms such as abdominal discomfort, dyspepsia and diarrhea, and no dilatation of pancreatic duct was found by CT in 75 patients after discharge from hospital.Conclusions: Bilateral U-sutures are a safe, simple, and effective technique in pancreaticojejunostomy, preventing the primary complication of anastomotic leakage, and worthy of wide use.

Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation.

The aim of this study was to develop an alternative fistula risk score (a-FRS) for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, without blood loss as a predictor. Blood loss, one of the predictors of the original-FRS, was not a significant factor during 2 recent external validations. The a-FRS was developed in 2 databases: the Dutch Pancreatic Cancer Audit (18 centers) and the University Hospital Southampton NHS. Primary outcome was grade B/C POPF according to the 2005 International Study Group on Pancreatic Surgery (ISGPS) definition. The score was externally validated in 2 independent databases (University Hospital of Verona and University Hospital of Pennsylvania), using both 2005 and 2016 ISGPS definitions. The a-FRS was also compared with the original-FRS. For model design, 1924 patients were included of whom 12% developed POPF. Three predictors were strongly associated with POPF: soft pancreatic texture [odds ratio (OR) 2.58, 95% confidence interval (95% CI) 1.80-3.69], small pancreatic duct diameter (per mm increase, OR: 0.68, 95% CI: 0.61-0.76), and high body mass index (BMI) (per kg/m increase, OR: 1.07, 95% CI: 1.04-1.11). Discrimination was adequate with an area under curve (AUC) of 0.75 (95% CI: 0.71-0.78) after internal validation, and 0.78 (0.74-0.82) after external validation. The predictive capacity of a-FRS was comparable with the original-FRS, both for the 2005 definition (AUC 0.78 vs 0.75, P = 0.03), and 2016 definition (AUC 0.72 vs 0.70, P = 0.05). The a-FRS predicts POPF after pancreatoduodenectomy based on 3 easily available variables (pancreatic texture, duct diameter, BMI) without blood loss and pathology, and was successfully validated for both the 2005 and 2016 POPF definition. The online calculator is available at www.pancreascalculator.com.

Pancreatic fistula after pancreaticoduodenectomy: Risk factors and preventive strategies.

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. This study aimed to investigate the risk factors and preventive strategies for POPF after PD. We retrospectively reviewed 301 consecutive patients who underwent PD at our hospitals between January 2011 and December 2017. We analyzed the pancreatic fistula rate according to the clinical characteristics, pathologic and laboratory findings, and the anastomotic methods and summarized the prevention measures. Postoperative morbidities included pancreatic leakage in 10.30% (31/301), delayed gastric emptying in 22.92% (69/301), abdominal infection in 6.98% (21/301), post-PD hemorrhage in 4.65% (14/301), and bile leakage in 4.98% (15/301), and the mortality rate was 2.33% (7/301). POPF was the most prominent factor for preoperative morbidity. Significant risk factors for pancreatic fistula were a soft pancreas, small pancreatic duct, tumor location, and interrupted anastomosis. Of these, soft texture, pancreatic duct <4 mm, and end-to-end anastomosis through hand suture closure were independent risk factors on multivariate analysis, while interrupted anastomosis, internal stent, and somatostatin use were risk factors in the high-risk pancreas subgroup. Our study demonstrated that pancreatic fistula is related to a soft texture and small pancreatic duct. The surgeon must consider these risk factors when performing PD. Thus, we propose a risk- and indication-adapted choice of anastomosis or an individualized approach for the pancreatic remnant to reduce the pancreatic fistula rate.

Chen’s continuous suture technique for invaginated pancreaticojejunostomy following pancreaticoduodenectomy with no grade B/C POPF and zero motality in 644 patients with soft pancrease and small pancreatic duct

Introduction: Internationally, postoperative pancreatic fistula (POPF) remains a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). In order to reduce the POPF incidence, a number of technical modifications for pancreato-enteric anastomosis after PD has been proposed. In 1995, we established a new suture technique for end-to-end or end-to-side invaginated pancreaticojejunostomy (PJ) following PD, and the preliminary results were quite encouraging. This study aims to review this new surgical approach, the Chen’s continuous suture technique for invaginated PJ, to evaluate the effectiveness of this approach in reducing the incidence of POPF. Method: To evaluate this new approach, 1852 patients from 8 medical center in China receiving the Chen’s continuous suture technique after a open PD from Jan. 2016 to Jan. 2019 were reviewed. Among them, 644 (34.8%) patients were with soft pancrease and small duct (small than 3 mm in diameter) and were included in this study. The postoperative morbidity and mortality including the POPE incidence were analyzed. Result: The postoperative morbidity was 27% (174/644) and mortality was 0% (0/644). The POPF rate was 8.8% (57/644) for Grade A, and no Grade B and Grade C POPF occurred. Conclusion: Chen’s continuous suture technique is a simple method and provides excellent outcomes in lowering POPF incidence following PD in the patients with the soft pancrease and a small pancreatic duct.

High Risk Pancreatic Anastomosis: Does External Pancreatic Stent Help?

Introduction: The role of external pancreatic stent in pancreatic anastomosis has not been clearly defined In- Hitherto. Method: Patients undergoing high risk pancreatico-jejunostomy after pancreatico-duodenectomy (as defined by small size duct (<3mm) and soft pancreas) were divided into two groups based on the type of trans-anastomotic stent used into External or Internal stent group and the outcomes were evaluated. Result: 99 of the 275 patients had small pancreatic duct. 19 underwent external stenting and 80 had internal stent. Both the groups were comparable in terms of demographic data, presence of jaundice, comorbidity, diabetes mellitus, need for biliary drainage, mean duct diameter, duration of surgery, blood loss. The overall incidence of pancreatic fistula was similar between the two groups (21% vs 20%). The incidence of clinically relevant fistula (grade B & C) was higher in patients with external stent (10.5% vs 5%). Overall Incidence of DGE (42% vs 51%) and post pancreatectomy haemorrhage (0 vs 6.25%) were comparable between the groups. However, patients with external pancreatic stent had a higher incidence of Grade C DGE (10.5% vs 3.75%, p = 0.063). There were three stent related complications, slippage of external stent in one and stent related pancreatitis in two (both with internal stent). The incidence of intra-abdominal collection (31.5% vs 15%, p = 0.09), SSI (47.5% vs 25%) and deep space infections (60% vs 36%, p = 0.08) were higher with external stent. Grade IIIb or more complications were (6.25% vs 3.25%) . Mean in- hospital stay was comparable between the two groups (18.9 vs 14.3 days). There was no difference in mortality (5.2% vs 3.75%). Conclusion: External pancreatic stent neither decreased the incidence nor the severity of pancreatic fistula in patients with high risk anastomosis. instead external stent was associated with a higher incidence of intra-abdominal infective complications.

How to perform laparoscopic duct-to-mucosa pancreatojejunostomy in high-risk score patients

Background: According to prospective validated study score for pancreatic fistula, the main risk factors are gland texture, pathology, duct diameter and blood loss. While major blood loss usually is not an issue in laparoscopic surgery, we present our technique to safely perform pancreatojejunostomy in patients with soft gland and extremely small pancreatic ducts. Methods: This video presents laparoscopic duct-to-mucosa pancreato-jejunostomy in different scenarios. Small and extremely small pancreatic ducts, odd position of the pancreatic duct (position from posterior edge <3 mm) in patients with soft texture of pancreas are shown. Results: In most cases there is a difficulty in finding the main duct. The duct located near to the posterior edge needs pancreatic stump posterior face dissection in order to allow duct-to-mucosa anastomosis without compromise external layer. Internal stents are used for extremely small ducts (1 mm). Sometimes even pediatric feeding tubes are not small enough to be introduced and venous catheter may be used. Interrupted sutures are usually necessary. Forty-seven patients with high-risk score submitted to laparoscopic duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy or central pancreatectomy were studied. Pancreatic fistula occurred in 15 patients (35%) but only two patients with grades B and C. Conclusion: Laparoscopic duct-to-mucosa pancreatojejunostomy is feasible and safe even in patients with high-risk score for developing postoperative pancreatic fistula.

How to perform laparoscopic duct-to-mucosa pancreatojejunostomy in high-risk score patients

Background: According to prospective validated study score for pancreatic fistula, the main risk factors are gland texture, pathology, duct diameter and blood loss. While major blood loss usually is not an issue in laparoscopic surgery, we present our technique to safely perform pancreatojejunostomy in patients with soft gland and extremely small pancreatic ducts. Methods: This video presents laparoscopic duct-to-mucosa pancreato-jejunostomy in different scenarios. Small and extremely small pancreatic ducts, odd position of the pancreatic duct (position from posterior edge <3 mm) in patients with soft texture of pancreas are shown. Results: In most cases there is a difficulty in finding the main duct. The duct located near to the posterior edge needs pancreatic stump posterior face dissection in order to allow duct-to-mucosa anastomosis without compromise external layer. Internal stents are used for extremely small ducts (1 mm). Sometimes even pediatric feeding tubes are not small enough to be introduced and venous catheter may be used. Interrupted sutures are usually necessary. Forty-seven patients with high-risk score submitted to laparoscopic duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy or central pancreatectomy were studied. Pancreatic fistula occurred in 15 patients (35%) but only two patients with grades B and C. Conclusion: Laparoscopic duct-to-mucosa pancreatojejunostomy is feasible and safe even in patients with high-risk score for developing postoperative pancreatic fistula.

Evaluation of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy

Background: Pancreatic fistula (PF) remains the most common and challenging complication following pancreaticoduodenectomy (PD), with an incidence of 2%–28%. The primary objective of this study was to assess the correlation of fatty infiltration and fibrosis of the pancreas with postoperative pancreatic fistula (POPF). Secondary objectives were to investigate the correlations of POPF with the main pancreatic duct size and subjective intraoperative assessment of pancreatic texture and to determine if diabetes mellitus (DM), body mass index, or increased serum bilirubin correlate with POPF. Materials and Methods: This prospective study was performed at Sudhamayi Hospital, Kochi, India. Forty-six patients were included and divided into either the fatty infiltration group (n = 20) or fibrosis group (n = 17); nine patients had neither fatty nor fibrotic glands. Data were analyzed using analysis of variance and Chi-square test, utilizing SPSS software version 20 (IBM Inc., Armonk, NY, USA). Results: Patients with fatty pancreas had a ten times higher incidence of PF than those with fibrotic pancreas (odds ratio, 10.8; 95% confidence interval [CI], 2.2–52.4; P = 0.003). POPF was 7.9 times higher in patients with a nondilated duct compared to patients with a dilated duct (95% CI, 2.118–29.5; P = 0.003). Preoperative elevated serum bilirubin, body mass index, and DM were not found to be significant risk factors for POPF. Conclusion: We demonstrated that fatty pancreas and small pancreatic duct size (≤3 mm) are risk factors for POPF. Preoperative elevated serum bilirubin, body mass index, and DM were not found to be significant risk factors.

Outcome of 150 Consecutive Blumgart's Pancreaticojejunostomy After Pancreaticoduodenectomy.

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

Is pancreaticogastrostomy a safer alternative to restore pancreatico-digestive continuity than pancreaticojejunostomy

Background: Pancreatic anastomotic leakage poses one of the biggest challenges to a pancreatic surgeon. Many techniques have been described for restoring pancreatico-digestive continuity, none of which is proven to be the best till date. Objective: To assess the outcomes following pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) after pancreaticoduodenectomy (PD). Methods: It is a retrospective analysis of 41 Whipple procedures done between June 2014 and September 2017. PJ was performed in duct to mucosa fashion in patients with dilated ducts (>3.3 mm, the size of 10Fr feeding tube). PG was performed in a dunking manner through the posterior stomach wall in patients with small ducts (<3.3 mm). The primary outcome measure was rate of pancreatic fistula. Secondary outcomes measured were, overall morbidity, postoperative length of hospital stay and rates of reintervention. Results: PJ was performed in 21 and PG in 20 patients. Age, gender, preoperative bilirubin, incidence of preoperative biliary drainage, pancreatic texture, operating time, blood loss and blood transfusions were identical in both the study groups. The rate of pancreatic fistula (p = 0.01) and the overall morbidity (p = 0.017) were significantly higher in the PJ group. Rates of delayed gastric emtying did not attain statistical significance (p = 0.099). Rates of re-intervention and mortality did not attain statistical significance. The length of postoperative hospital stay was significantly lower in the PG group (p = 0.041). Conclusions: Pancreaticogastrostomy appears to be a safe procedure for pancreatico-digestive continuity following pancreaticoduodenectomy in patients with small pancreatic ducts. The choice may be extended to those with dilated ducts too.

The modified duct-to-mucosa pancreaticojejunostomy for small pancreatic duct during pancreaticoduodenectomy

Purpose: Postoperative pancreatic fistulas(POPFs) due to anastomotic leak are closely related to significant morbidity and mortality following pancreaticoduodenectomy(PD).The aim of this study is to introduce modification of the conventional duct-to-mucosa (DM) pancreaticojenunostomy(PJ) and the improved outcomes of this modified PJ technique for small main pancreatic duct. Methods: The modified DM anastomosis is characterized that matching internal stent was inserted into the pancreatic duct remnant and secured with suture at the opening of the pancreatic duct to enhance sealing, prior to the anastomosis. From January 2012 to October 2017, 102 patients underwent PD for small main pancreatic duct (≤ 3mm). In total, 33 cases received conventional DM pancreaticojejunal anastomosis and 69 cases received modified DM pancreaticojejunal anastomosis. Results: The postoperative stay time, diet resumption time and timing of drain removal in the modified DM group were lower than those in conventional DM group. The overall incidence of POPFs was not significantly different between two groups. But, the clinical POPFs (grade B/C) in the modified DM group occurred less frequently than those in the conventional DM group. (4.3 % vs. 24.2 %, p=0.002). Moreover, neither grade C POPF nor in-hospital mortality occurred in the modified DM group. In addition, multivariate analysis showed a significant difference between both groups on significant POPFs (OR 0.211, 95% CI 0.09 to 0.51, P=0.001). Conclusion: The modified DM anastomosis technique in our study is a safer anastomotic method than the traditional DM pancreaticojejunostomy technique. This new technique could effectively reduce the incidence of POPF.

Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy

ImportanceTechnical proficiency at robotic pancreaticoduodenectomy (RPD) and video assessment are promising tools for understanding postoperative outcomes. Delayed gastric emptying (DGE) remains a major driver of cost and morbidity after pancreaticoduodenectomy.ObjectiveTo determine if technical variables during RPD are associated with postoperative DGE.Design, Setting, and ParticipantsA retrospective study was conducted of technical assessment performed in all available videos (n = 192) of consecutive RPDs performed at a single academic institution from October 3, 2008, through September 27, 2016.ExposuresVideo review of gastrojejunal anastomosis during RPD.Main Outcomes and MeasuresDelayed gastric emptying was classified according to International Study Group of Pancreatic Surgery criteria. Video analysis reviewed technical variables specific in the construction of the gastrojejunal anastomosis. Using multivariate analysis, DGE was correlated with known patient variables and technical variables, individually and combined.ResultsOf 410 RPDs performed, video was available for 192 RPDs (80 women and 112 men; mean [SD] age, 65.7 [11.1] years). Delayed gastric emptying occurred in 41 patients (21.4%; grade A, 15; grade B, 14; and grade C, 12). Patient variables contributing to DGE on multivariate analysis were advanced age (odds ratio [OR] 1.11; 95% CI, 1.05-1.16; P < .001), small pancreatic duct size (OR, 0.84; 95% CI, 0.72-0.98; P = .03), and postoperative pseudoaneurysm (OR, 17.29; 95% CI, 2.34-127.78; P = .005). However, technical variables contributing to decreased DGE on multivariate analysis included the flow angle (within 30° of vertical) between the stomach and efferent jejunal limb (OR, 0.25; 95% CI, 0.08-0.79; P = .02), greater length of the gastrojejunal anastomosis (OR, 0.40; 95% CI, 0.20-0.77; P = .006), and a robotic-sewn anastomosis (robotic suture vs stapler: OR, 0.30; 95% CI, 0.09-0.95; P = .04).Conclusions and RelevanceThis study examines modifiable technical factors through the use of review of video obtained at the time of operation and suggests ways by which the surgical construction of the gastrojejunal anastomosis during RPD may reduce the incidence of DGE as a framework for prospective quality improvement.

Ductal Mucus Obstruction and Reduced Fluid Secretion Are Early Defects in Chronic Pancreatitis.

Objective: Defective mucus production in the pancreas may be an important factor in the initiation and progression of chronic pancreatitis (CP), therefore we aimed to (i) investigate the qualitative and quantitative changes of mucus both in human CP and in an experimental pancreatitis model and (ii) to correlate the mucus phenotype with epithelial ion transport function.Design: Utilizing human tissue samples and a murine model of cerulein induced CP we measured pancreatic ductal mucus content by morphometric analysis and the relative expression of different mucins in health and disease. Pancreatic fluid secretion in CP model was measured in vivo by magnetic resonance cholangiopancreatography (MRCP) and in vitro on cultured pancreatic ducts. Time-changes of ductal secretory function were correlated to those of the mucin production.Results: We demonstrate increased mucus content in the small pancreatic ducts in CP. Secretory mucins MUC6 and MUC5B were upregulated in human, Muc6 in mouse CP. In vivo and in vitro fluid secretion was decreased in cerulein-induced CP. Analysis of time-course changes showed that impaired ductal ion transport is paralleled by increased Muc6 expression.Conclusion: Mucus accumulation in the small ducts is a combined effect of mucus hypersecretion and epithelial fluid secretion defect, which may lead to ductal obstruction. These results suggest that imbalance of mucus homeostasis may have an important role in the early-phase development of CP, which may have novel diagnostic and therapeutic implications.

AB047. P018. A technical refinement of the pancreaticojejunostomy after pancreatoduodenectomy (PD): the pancreas encompassing jejunal anastomosis (PEJA)

Background: Postoperative pancreatic fistula (POPF) is the factor most strongly implicated in life-threating complications and death in most pancreatoduodenectomy (PD) series. It’s well demonstrated that the incidence of pancreatic leak following PD depends from surgeon’s and center experience as well as from certain predisposing factors. In particular, the fistula is most likely to occur when anastomosis involve a normal and soft pancreas and a small pancreatic duct, with no significant difference in the different techniques. Nevertheless, the knowledge of these predisposing factors can lead to possible technical refinements to mitigate the risk of POPF.

Analysis of risk factors and outcomes for delayed gastric emptying following pancreaticoduodenectomy: a single center experience of 492 cases

Objective: To evaluate risk factors for delayed gastric emptying(DGE)following pancreaticoduodenectomy(PD). Methods: There were 492 consecutive patients who underwent PD in Pancreas Center, the First Affiliated Hospital with Nanjing Medical University between January 2012 and December 2014 were identified from a prospective database.There were 315 male and 177 female patients with a median age of 60.5 years.Univariate and multivariate analyses were performed to investigate the independent risk factors for clinically relevant DGE(CR-DGE). Results: The overall incidence of DGE was 29.5%, with Grade B and C occurring at 4.3% and 5.9%, respectively.In multivariate analysis, pancreatic duct diameter less than 3 mm(OR=1.888, P=0.042), pylorus-preserving pancreaticoduodenectomy(OR=2.627, P=0.005) and clinically relevant postoperative pancreatic fistula(OR=2.740, P=0.007) were independently associated with CR-DGE.Other main complications such as postoperative pancreatic fistula, pyoperitoneum, intraabdominal infection were also associated with the severity of DGE(χ(2)=21.360, 14.422, 14.378; P=0.011, 0.002, 0.002). DGE patients had a significantly prolonged postoperative length of stay(31(24-41)d vs. 13(11-17)d) and increased medical cost((122 367.5±66 068.3)yuan vs. (78 200.7±27 043.9)yuan)(both P<0.01). Conclusions: Small pancreatic duct, underwent pylorus-preserving pancreaticoduodenectomy and suffered postoperative pancreatic fistula might indicate a high risk of CR-DGE.

Impact of obesity on short and long term results following a pancreatico-duodenectomy

BackgroundThe impact of obesity on short and long term outcomes following a pancreatico-duodenectomy (PD) is still unclear and needs further clarification. MethodsDemographic, operative and outcomes data in 524 patients undergoing PD were analysed. ResultsNinety-seven patients (18.5%) had BMI greater than or equal to 30 kg/m2 (group A) and 427 patients (81.5%) had BMI less than 30 kg/m2 (group B). Group A had a significantly greater operative duration, (375 vs 360 min, p = 0.024) and a higher intra-operative blood loss, (660 vs 500 ml, p = 0.005). Post-operative pancreatic fistula (POPF) were more common in Group A (28.9% vs 16.2%, p = 0.006), this difference was also observed when considering only major POPF (Grade B and C) (16.5% vs 8.0%, p = 0.020). Intra-abdominal collections were higher in Group A, 28.9% compared to 19.0% in Group B (p = 0.037). On multivariate analysis BMI (OR 2.006; 95% CI 1.147–4.985, p = 0.040), small pancreatic duct (OR 2.755; 95% CI 1.589–2.968, p = 0.026) and soft pancreas (OR 2.289; 95% CI 1.126–3.665, p = 0.040) were found to be independent factors for POPF. The median survival for adenocarcinomas was 20 months in Group A and 22 months in Group B, (p = 0.109). ConclusionPatients with BMI ≥ 30 are at an increased risk of developing pancreatic fistula following PD. Obesity does not appear to have an impact on long term outcomes in patients undergoing a PD for adenocarcinomas.

Circumferential pedicled omental flap for protection of portomesenteric venous reconstruction and gastroduodenal artery stump following pancreatoduodenectomy

Abstract This video demonstrates a technique for creation of an omental tissue barrier to protect a portomesenteric vein reconstruction or gastroduodenal artery (GDA) stump. Following routine pancreatoduodenectomy reconstruction, a generous tongue of omentum is mobilized off the transverse colon ensuring to preserve the feeding branches from the left gastroepiploic artery. The omentum is then passed behind the pancreatojejunostomy above the vein repair site. It is grasped superiorly and passed anterior to the pancreatojejunostomy to exclude the GDA stump. The flap is then secured to the blind end of the jejunum with suture thereby completing the circumferential wrap. Care must be taken in obese patients to trim the flap so it can fit behind the pancreas without devascularizing it or causing tension on the pancreatojejunostomy. If a closed suction drain is desired, it can be passed from the patient's right either in front of or behind the hepaticojejunostomy and placed around the flap. This technique is most applicable to patients with moderate to high risk of pancreatic fistula (small pancreatic duct and/or soft gland) after undergoing PD with an intact omentum. This circumferential, pedicled omental flap is an easy, reproducible, and durable method to protect vascular structures and repairs from pancreatic fistulas.

Predictors of delayed gastric emptying after robotic pancreatoduodenectomy: analysis of intraoperative techniques using video review

Objective: Delayed gastric emptying (DGE) remains a major driver of prolonged length of stay and morbidity following the pancreatoduodenectomy. The objective of this study was to evaluate whether technical factors observed during video review of DGE during robotic pancreatoduodenectomy (RPD) could add to predictive models of DGE. Methods: Two blinded surgeons analyzed RPD videos with 90-day postoperative clinical data. DGE was classified according to ISGPS criteria. Clinical and technical variables were analyzed using multivariate analysis (MVA). Specific variables reviewed were: 1) type of anastomosis 2) angle of efferent limb 3) OSATS score of performing surgeon, 4) length of time to complete anastomosis, and 5) if performed by trainee. Results: Video was available for 172 RPD, 56% percent of all performed during time period. DGE was observed in 38 (21.1%): A=15 (40%), B=12 (32%), and C=11 (29%). Clinical variables (prior to inclusion of technical variables) that predicted DGE on MVA were age, duct size and non-pancreatic adenocarcinoma malignancies (p=0.0003; R2=0.112). As a group, trainees took longer to complete the anastomosis than attendings (p=0.029). On MVA, the best model of independent predictors of DGE included (p=0.0002; R2=0.1651): advanced age, small pancreatic duct, short [1st Interquartile Range] gastrotomy (<4.5 cm) length, stapled (compared to sutured) anastomosis, extreme efferent GJ angle from midline (>30°; middle figure best), and performance of anastomosis by trainee. Conclusion: Technical components of the gastrojejunostomy added to predictive models of DGE. This study establishes the framework for innovative prospective quality improvement projects targeting surgical micro-techniques available only through review of video databases.