Soft Pancreatic Texture Research Articles

Prediction of Pancreatic Anastomotic Failure After Pancreatoduodenectomy

To determine whether remnant pancreatic volume (RPV), subcutaneous/visceral adipose tissue(SAT/VAT) area, and skeletal muscle (SM) area calculated from preoperative computed tomography (CT) can predict the occurrence of pancreatic anastomotic failure (PAF) after pancreatoduodenectomy (PD). Increased body mass index, small main pancreatic duct, and soft pancreatic texture are well-established predictors of PAF after PD. The impact on PAF of anthropomorphic measurements, such as RPV and body composition, is unknown. In 173 patients undergoing PD from 2004 to 2009, cross sections of SAT/VAT/SM area were quantitated volumetrically, respectively, from preoperative CT. RPV was calculated from the CT as the sum of pancreatic tissue area to the left of the presumed pancreatic transection site. The predictive ability for multiple models using combinations of body mass index, RPV, SAT/VAT area, SM area, main pancreatic duct size, and pancreatic gland texture was described using a concordance index (c-index). Clinically relevant PAF occurred in 22 patients (13%). Multivariate logistic regression analysis identified RPV (P = 0.0012), VAT area (P = 0.0003), and SM area (P = 0.0006) as independent predictors of PAF. Using previously identified risk factors, the best 2-predictor model (body mass index and pancreatic duct size) resulted in a c-index of 0.748. Using anthropomorphic factors, however, the 2-predictor model using VAT and SM areas revealed a superior c-index of 0.959. Our 2-predictor model using VAT area and SM area based on volumetric quantification using preoperative CT may offer clinical benefit as an objective prognostic measure to predict clinically relevant PAF after PD.

Diabetes mellitus does not impact on clinically relevant pancreatic fistula after partial pancreatic resection for ductal adenocarcinoma

The prevalence of diabetes mellitus (DM) in patients with pancreatic ductal adenocarcinoma (PDAC) ranges from 20 to 80%. In patients undergoing resection, it is unclear whether DM impacts on clinically relevant pancreatic fistula (CR-PF). To address this issue, data from 602 consecutive partial pancreatic resections were analyzed using univariate and multivariate models. There were 120 patients with DM; 84 had longstanding DM and 36 a new-onset DM. The incidence of CR-PF was greater among nondiabetics (11.8% vs 5.0%; P = .043), who were also more likely to have a soft pancreatic texture (79.5% vs 46.0%; P = .001) or combined presence of soft texture and small pancreatic duct (high-risk pancreas; P = .001). All these variables did not differ when stratifying by DM type. Univariate analysis showed that gender (P = .005), body mass index (P = .05), DM (P = .043), pancreatic texture (P = .001), pancreatic duct size (P = .012), and the combined presence of soft parenchyma and small duct (P = .001) were associated with CR-PF. On multivariate analysis, DM resulted to be a negative predictor of CR-PF (odds ratio [OR], 0.53; P = .047). Additional variables associated with an increased probability of CR-PF formation were male gender (OR, 3.48; P = .002), soft pancreatic texture (OR, 2.19), pancreatic duct size <3 mm (OR, 1.79), and the combined presence of soft pancreas and small duct (OR, 2.24). DM is not a risk factor for CR-PF after resection of PDAC. The decreased incidence of CR-PF in diabetics is likely to be a consequence of a decreased frequency of high-risk features of the pancreatic gland (soft texture and/or small duct).

Morphological Features of Pancreatic Stump, Other than Wirsung Diameter and Pancreatic Texture, Influence Pancreatic Fistula Rate After Pancreaticoduodenectomy

Context Pancreaticoduodenectomy (PD) is still characterized by high morbidity rates even in high volume centers, mainly represented by postoperative pancreatic fistula (POPF) and its associated further consequences. Wirsung diameter and pancreatic texture are well known features related to increased POPF risk. However, limited information about the relationship between morphological features of pancreatic stump and POPF onset is available. Objective Aim of the study was to evaluate the relationship between pancreatic stump morphology, intra-operatively assessed, and the occurrence of POPF in patients undergoing PD in an high volume center. Methods Between January 2010 and June 2012 we performed 136 PDs for benign and malignant disease; in a subgroup composed by 72 cases we realized a prospective study recording intra-operative measurements of the remnant pancreatic stump, recording surgeon’s judgment about pancreatic texture, and highlighting the caliber of main pancreatic duct, its position and the whole area. Between March 2011 and June 2012, in a consecutive series of 72 PD, we prospectively recorded the following characteristics of the pancreatic stump: surgeon’s judgment about pancreatic texture, diameter of main pancreatic duct, the whole area of pancreatic section (approximately calculated as elliptic), the distance between Wirsung duct and cranio-caudal and antero-posterior margins. In all patients, post-operative complications were recorded. Results Pancreatic fistula occurred in 19 cases (23.8%), 10 of them clinically significant (grade B and C according to ISGPF classification). In univariate analysis, mean Wirsung diameter resulted significantly smaller in patients with POPF (3.18 vs . 4.48 mm; P=0.007) and in patients with clinically significant POPF (P=0.015); searching for a cut off value, Wirsung diameter smaller than 4 mm demonstrated an association with higher POPF incidence (37.5% vs . 4.35%; P=0.003). Similarly, soft pancreas texture resulted associated with an increasing POPF rate (75% vs . 7%; P<0.001). Analyzing pancreatic stump morphology, we observed a relationship between larger stump areas and POFP development (206 mm 2 in POPF cases vs . 131 mm 2 in patients without fistula; P=0.017); moreover, main pancreatic duct decentralization appeared significantly associated with a lower POPF risk (more evident on antero-posterior axis than on cranio-caudal; P=0.019 and P=0.144, respectively). In multivariate analysis, only pancreatic stump soft texture and Wirsung diameter smaller than 4 mm were associated with POPF. Conclusion This study confirms small Wirsung diameter and soft pancreatic texture as the main determinants for POPF development. Moreover, an higher risk of failure of pancreatic anastomosis is also observed in large pancreatic stumps and when main pancreatic duct is centrally located.

Toward defining grade C pancreatic fistula following pancreaticoduodenectomy: incidence, risk factors, management and outcome

BackgroundIn 2005 the International Study Group for Pancreatic Fistula (ISGPF) created a definition and grading system for pancreatic fistulae (PF) in which grade C denotes the most severe and potentially life-threatening type. Factors and outcomes associated with grade C fistulae have been ill defined. MethodsSystematic searches of PubMed and EMBASE were conducted by two independent reviewers utilizing the keywords ‘pancreaticoduodenectomy’ (PD) and ‘pancreatic fistula’. Inclusion criteria were: (i) a sample of ≥100 patients; (ii) consecutive accrual of all pathologies, and (iii) use of the ISGPF definition and grading system. Quality appraisal and data extraction were performed using pilot-tested templates. ResultsFourteen articles describing a total of 2706 PDs met the study entrance criteria. Pancreatic fistulae occurred in 479 patients (18%) and included 71 grade C PF that were directly responsible for 25 deaths (35% mortality rate). Only two studies analysed risk factors; these found soft pancreatic texture and histology other than adenocarcinoma to be the most common risk factors. Ten studies reported management strategies and indicated that 51% of patients required reoperation. ConclusionsGrade C PF: (i) accounts for 15% of fistulae following PD and has an associated mortality rate of 35%; (ii) occurs most commonly in pathology associated with a soft remnant, and (iii) requires reoperation in approximately one half of patients. The published literature incompletely describes grade C PF.

Risk factors of pancreatic fistula after pancreaticoduodenectomy

Objective To investigate the risk factors of pancreatic fistula after pancreaticoduodenectomy (PD).Methods The clinical data of 186 patients who received PD at the Second Affiliated Hospital of Kunming Medical College from May 2000 to May 2010 were retrospectively analyzed.All patients were divided into pancreatic fistula group (39 patients) and non-pancreatic fistula group ( 147 patients).Risk factors of pancreatic fistula after PD were screened out from 20 factors by univariate and multivariate analysis.The univariate analysis was carried out by chi-square test or Fisher exact test,and the muhivariate analysis was done by Logistic regression.Results Thirty-nine patients were complicated with pancreatic fistula,including 26 in grade A,10 in grade B and 3 in grade C.The results of univariate analysis showed that duration of preoperative jaundicc,loss of body weight at 6 months before operation,preoperative total bilirubin level,preoperative albumin level,postoperative albumin level,length of pancreas dissected,pancreatic tube diameter,pancreatic texture and time of abdominal drainage tube pull out were high risk factors of pancreatic fistula ( x2 =34.990,20.480,8.212,10.890,13.561,11.505,13.820,4.539,36.590,P ＜ 0.05).The results of multivariate analysis showed that duration of preoperative jaundice ＞ 8 weeks,loss of body weight at 6 months before operation ≥ 10％,pancreatic tube diameter ＜ 3 mm,soft pancreatic texture and time of abdominal drainage tube pull out ＞ 5 days were the independent risk factors of pancreatic fistula ( OR =2.229,3.383,1.437,1.273,11.939,P ＜ 0.05).Conclusion Duration of preoperative jaundice ＞ 8 weeks,unconscious loss of body weight ≥ 10％ within 6 months before operation,pancreatic tube diameter ＜ 3 mm,soft pancreatic texture,time of abdominal drainage tube pull out ＞ 5 days would increase the risk of pancreatic fistula after PD. Key words: Pancreatic diseases ; Pancreaticoduodenectomy ; Pancreatic fistula

Clinical Validation of the ISGPF Classification and the Risk Factors of Pancreatic Fistula Formation Following Duct-to-Mucosa Pancreaticojejunostomy by One Surgeon at a Single Center

BackgroundPostoperative pancreatic fistula remains a troublesome complication after pancreatoduodenectomy (PD), and many authors have suggested factors that affect pancreatic leakage after PD. The International Study Group on Pancreatic Fistula (ISGPF) published a classification, but the new criteria adopted have not been substantially validated. The aims of this study were to validate the ISGPF classification and to analyze the risk factors of pancreatic leakage after duct-to-mucosa pancreatojejunostomy by a single surgeon. MethodsAll patient data were entered prospectively into a database. The risk factors for pancreatic fistula were analyzed retrospectively for 247 consecutive patients who underwent conventional pancreatoduodenectomy or pylorus-preserving pancreatoduodenectomy between June 2005 and March 2009 at the Samsung Medical Center by a single surgeon. Duct-to-mucosa pancreatojejunostomy was performed on all patients. The ISGPF criteria were used to define postoperative pancreatic fistula. ResultsConventional pancreatoduodenectomy was performed in 84 patients and pylorus-preserving pancreatoduodenectomy in 163. Postoperative complications occurred in 144 (58.3%) patients, but there was no postoperative in-hospital mortality. Pancreatic fistula occurred in 105 (42.5%) [grade A, 82 (33.2%); grade B, 9 (3.6%); grade C, 14 (5.7%)]. However, no difference was evident between the no fistula group and the grade A fistula group in terms of clinical findings, including postoperative hospital stays (11 versus 12 days, respectively, p = 0.332). Mean durations of hospital stay in the grade B and C fistula groups were significantly longer than in the no fistula group (21 and 28.5 days, respectively; p < 0.001). Multivariate analysis revealed that a soft pancreas and a long operation time (>300 min) were individually associated with pancreatic fistula formation of grades B and C. ConclusionsAlthough the new ISGPF classification appears to be sound in terms of postoperative pancreatic leakage, grade A fistulas lack clinical implications; thus, we are of the opinion that only grade B and C fistulas should be considered in practice. A soft pancreatic texture and an operation time exceeding 300 min were found to be risk factors of grade B and C pancreatic fistulas.

Protection of Major Vessels and Pancreaticogastrostomy using the Falciform Ligament and Greater Omentum for Preventing Pancreatic Fistula in Soft Pancreatic Texture after Pancreaticoduodenectomy

Pancreatic fistula is one of the major causes of morbidity in patients undergoing pancreaticoduodenectomy. Protection of the skeletonized vessels and the anastomotic site of pancreaticoenterostomy is one of the surgical options to prevent the development of a pancreatic fistula. The aim of this study was to describe an operative technique to protect the vessels and anastomotic site by wrapping them with the falciform ligament and the greater omentum. After a modified subtotal stomach-preserving pancreaticoduodenectomy reconstruction with pancreaticogastrostomy was performed, the falciform ligament and greater omentum was used on the skeletonized major vessels and wrapped around the anastomotic site of pancreaticogastrostomy. Twenty consecutive patients were enrolled in this prospective study. The entire procedure did not result in any operative complications. Postoperative pancreatic fistula developed in 2 cases (10%). According to the international postoperative pancreatic fistula criteria, grade A and grade B was observed in 1 case each. No intra-abdominal hemorrhage and late intra-abdominal abscess were observed. This procedure is a convenient and safe technique, and may be helpful in preventing major complications caused by pancreatic fistula.

Pancreatic Stump-Closed Pancreaticojejunostomy can be Performed Safely in Normal Soft Pancreas Cases

Pancreatic anastomotic failure remains the main reason for morbidity and mortality after pancreaticoduodenectomy, and there is no existing flawless pancreaticojejunal reconstruction approach to this date, especially for the normal soft pancreas cases. We compared a pancreatic stump-closed pancreaticojejunostomy technique (group B; n = 33) with conventional duct-to-mucosa fashion (group A; n= 30) retrospectively in 63 normal soft pancreatic texture cases. Some operative related data including postoperative complications, anastomosis time, hospital stay days, mortality rate, and relaparotomy rate were analyzed. There was no difference concerning the incidences of postoperative morbidity, including pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, intra-abdominal abscess, and remnant pancreatitis between two groups. The differences of anastomosis time, hospitalization days, relaparotomy rate, and mortality rate were also not significant. However, group B patients had a shorter duration (d) for healing of postoperative pancreatic fistula than group A (15.3 ± 8.5 versus 33.0 ± 14.1 d, P < 0.05). For the normal soft pancreas cases, pancreatic stump-closed pancreaticojejunostomy technique is quite safe and convenient according to our experience; ideal clinical results could be achieved with its application in the future.

Combined invagination and duct-to-mucosa techniques with modifications: a new method of pancreaticojejunal anastomosis

Soft pancreatic texture and a small main pancreatic duct are thought to be the most significant risk factors for the occurrence of pancreatic fistula (PF), a common and serious complication after pancreaticoduodenectomy (PD). This is in part due to the technical difficulties of pancreaticojejunostomy (PJ) posed by a soft gland with a normal-sized duct. To deal with this problem, we developed a new anastomotic technique which combines the two most widely used techniques, namely, the invagination technique and the duct-to-mucosa technique, with a modification of the suture route and insertion of a temporary stent tube. Between January 2003 and December 2009, ninety-two consecutive patients underwent PD in which the new PJ technique was used. Charts and follow-up data of these patients were reviewed for operative details, early postoperative events, and outcomes at 6 months after the operation. PF was defined by the International Study Group on Pancreatic Fistula (ISGPF) guidelines and graded (A, B or C) according to the clinical procedures and outcome. In this group of 92 patients, there was only 1 early death from acute renal failure. PF was observed in 11 patients (12.0%), 8 in grade A, 1 in grade B, and 2 in grade C. For the 2 patients in grade C, PF was surgically managed. There were no early or late deaths attributable to PF. Six months after the operation, all of the patients were free of PJ-related symptoms except for 2, who were found to have steatorrhea. Our modified technique is simple and safe in PD. Present data suggest that this technique produces excellent early and medium-term results.

External Pancreatic Duct Stent Decreases Pancreatic Fistula Rate After Pancreaticoduodenectomy

Pancreatic fistula (PF) is a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). The aim of this multicenter prospective randomized trial was to compare the results of PD with an external drainage stent versus no stent. Between 2006 and 2009, 158 patients who underwent PD were randomized intraoperatively to either receive an external stent inserted across the anastomosis to drain the pancreatic duct (n = 77) or no stent (n = 81). The criteria of inclusion were soft pancreas and a diameter of wirsung <3 mm. The primary study end point was PF rate defined as amylase-rich fluid (amylase concentration >3 times the upper limit of normal serum amylase level) collected from the peripancreatic drains after postoperative day 3. CT scan was routinely done on day 7. The 2 groups were comparable concerning demographic data, underlying pathologies, presenting symptoms, presence of comorbid illness, and proportion of patients with preoperative biliary drainage. Mortality, morbidity, and PF rates were 3.8%, 51.8%, and 34.2%, respectively. Stented group had a significantly lower overall PF (26% vs. 42%; P = 0.034), morbidity (41.5% vs. 61.7%; P = 0.01), and delayed gastric emptying (7.8% vs. 27.2%; P = 0.001) rates compared with nonstented group. Radiologic or surgical intervention for PF was required in 9 patients in the stented group and 12 patients in the nonstented group. There were no significant differences in mortality rate (3.7% vs. 3.9%; P = 0.37) and in hospital stay (22 days vs. 26 days; P = 0.11). External drainage of pancreatic duct with a stent reduced. PF and overall morbidity rates after PD in high risk patients (soft pancreatic texture and a nondilated pancreatic duct).

A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively

BackgroundPostoperative pancreatic fistula (POPF) is regarded as the most serious complication of pancreatic surgery. The preoperative risk stratification of patients by simple means is of interest in perioperative clinical management. MethodsBased on prospective data, we performed a risk factor analysis for POPF after pancreatoduodenectomy in 62 patients operated between 2006 and 2008 with special focus on clinical parameters that might serve to predict POPF. A predictive score was developed and validated in an independent second dataset of 279 patients operated between 2001 and 2010. ResultsSeveral pre- and intraoperative factors, as well as underlying pathology, showed significant univariate correlation with rate of POPF. Multivariate analysis (binary logistic regression) disclosed soft pancreatic texture (odds ratio [OR] 10.80, 95% confidence interval [CI] 1.80–62.20) and history of weight loss (OR 0.15, 95% CI 0.04–0.66) to be the only independent preoperative clinical factors influencing POPF rate. The subjective assessment of pancreatic hardness by the surgeon correlated highly with objective assessment of pancreatic fibrosis by the pathologist (r=−0.68, P<0.001, two-tailed Spearman's rank correlation). A simple risk score based on preoperatively available clinical parameters was able to stratify patients correctly into three risk groups and was independently validated. ConclusionsPreoperative stratification of patients regarding risk for POPF by simple clinical parameters is feasible. Pancreatic texture, as evaluated intraoperatively by the surgeon, is the strongest single predictive factor of POPF. The findings of the study may have important implications for perioperative risk assessment and patient care, as well as for the choice of anastomotic techniques.

Measurement of Pancreatic Fat by Magnetic Resonance Imaging

The purpose of this study was to determine whether patients who develop a pancreatic fistula after pancreatoduodenectomy are more likely to have higher pancreatic fat levels than matched controls and if so, to investigate whether preoperative dual gradient-echo magnetic resonance (MR) imaging can be used to measure pancreatic fat and predict the development of postoperative pancreatic fistula. Pancreatic fistula is a major complication and its most frequently reported risk factors tend to be anatomic features of the pancreatic remnant, such as a soft pancreatic texture. Between January 2007 and September 2007, a total of 96 cases of pancreatoduodenectomy were performed at Seoul National University Hospital. Of total, 20 patients (20.8%) who developed a pancreatic fistula were carefully matched for multiple parameters including age, gender, pancreatic pathology, surgeon, and type of operation with 20 control patients who did not develop a pancreatic fistula. In the pancreatic fistula group, 9 patients (45%) had a grade A fistula and 11 (55%) grade B fistula. Degrees of pancreatic fatty infiltration and fibrosis were assessed quantitatively. In-phase and opposed-phase images were obtained by dual-gradient-echo MR imaging. Percentage decreases in pancreatic signal intensity on opposed-phase images relative to those on in-phase images were calculated and defined as relative signal intensity decreases (RSID). More patients in the pancreatic fistula group had a soft pancreatic texture or a smaller pancreatic duct and total fat and RSID were significantly higher. In soft pancreatic texture group, intralobular, interlobular, and total fat were significantly elevated. Furthermore, pancreatic fat levels were found to be correlated positively with RSID (P=0.013). RSID was correlated with total pancreatic fat and when an RSID criterion more than 7.032 was used, pancreatic fistula could be predicted as 72.7% sensitivity and 75.9% specificity. Our findings suggest that increased pancreatic fat is a risk factor of postoperative pancreatic fistula. Preoperative measurements of pancreatic fat by MRI offer a noninvasive predicting the occurrence of pancreatic fistula.

Pancreatic fistula: definition and current problems

Postoperative pancreatic fistula (POPF) is the most common major complication after pancreatoduodenectomy (PD) and it can lead to prolonged hospital stay, increased costs, and mortality. The POPF rate is strictly correlated to the definition applied, but there are so many different definitions in the literature that comparison between published series of patients is difficult. The International Study Group of Pancreatic Fistula (IGSPF) has developed a new definition, with a grading system able to stratify complicated patients into three groups, based upon the clinical implications and costs of their postoperative course. The most important risk factors identified are a soft pancreatic texture and a main pancreatic duct diameter of 3 mm or less. Several surgical techniques have been studied in order to prevent anastomotic leakage, but none has been demonstrated to be superior to others. The use of somatostatin analogues is still matter of controversy. Conservative management of POPF is usually effective, but in patients with deteriorating clinical status with evidence of sepsis, surgical management is needed.

A Soft Pancreatic Remnant is Associated with Increased Drain Fluid Pancreatic Amylase and Serum CRP Levels Following Pancreatoduodenectomy

The aim of this prospective study was to clarify differences in postoperative changes of serum or drainage fluid pancreatic amylase levels and serum C-reactive protein (CRP) levels between patients with a soft pancreatic texture and those with a hard pancreatic texture undergoing pancreatoduodenectomy (PD) with pancreaticogastrostomy. A total of 61 consecutive patients with resectable periampullary tumors undergoing PD were recruited. This population was divided into 27 patients with a hard pancreatic texture and 34 patients with a soft pancreatic texture. Drainage fluid total amylase or pancreatic amylase levels, serum total amylase or pancreatic amylase levels, and serum CRP levels were measured postoperatively. Clinicopathological data were also compared between two groups. Postoperative complications more frequently occurred in patients with a soft pancreatic texture compared with those with a hard pancreatic texture (P = 0.029). Serum or drainage fluid pancreatic amylase levels and serum CRP levels of patients with a soft pancreatic texture were significantly higher than those of patients with a hard pancreatic texture after PD on postoperative days 1 and 2 (P < 0.05). A soft pancreatic texture was identified as an only independent predictive factor of increased drainage fluid pancreatic amylase levels (P = 0.006) and serum CRP levels (P = 0.047). A soft pancreatic texture is closely associated with increased drainage fluid pancreatic amylase and serum CRP levels after PD. More careful post-PD management is needed for patients with a soft pancreatic texture.

Emprego da anastomose pancreatojejunal tipo ducto-mucosa sem cateter transanastomótico em pâncreas de consistência mole e ducto fino: experiência inicial do Instituto Nacional de Câncer

OBJETIVO: O objetivo deste trabalho foi relatar a morbimortalidade associada à técnica de reconstrução pancreática utilizando anastomose pancreato-jejunal tipo ducto-mucosa, sem cateter transanastomótico, em pâncreas de consistência mole e ducto de Wirsung menor que três mm. MÉTODOS: Analisamos consecutivamente os resultados de 16 pacientes submetidos à GDP com técnica de anastomose pancreato-jejunal tipo ducto-mucosa no Serviço de Cirurgia Abdômino-pélvica do INCA. Todos pacientes eram portadores de pâncreas de consistência mole e ducto pancreático fino (&lt; 3mm). RESULTADOS: Dos 16 pacientes analisados, oito eram do sexo masculino e com mediana de idade de 55 anos. No período pós-operatório um paciente apresentou fístula pancreática e houve um caso que evoluiu para óbito. CONCLUSÃO: Acreditamos que é possível a realização de anastomose pancreática tipo ducto-mucosa, sem cateter transanastomótico, em pacientes com ducto pancreático menor que três mm sem aumento da morbimortalidade.

Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy

The aim of this study was to prospectively analyze the possible association of delayed gastric emptying and postoperative pancreatic complications after pancreaticoduodenectomy. Although hospital mortality after pancreaticoduodenectomy is minimal, morbidity is still high; delayed gastric emptying is one of the most frequent complications. Thirty-nine consecutive patients undergoing pancreaticoduodenectomy were included in this study: 14 females and 25 males (median age 65 years; range, 7-82). Delayed gastric emptying was defined as the need for a nasogastric tube or recurrent vomiting that prevented normal feeding on the 10th postoperative day. Blood analysis was performed on postoperative days 4, 6, and 10; Gastrografin examination on day 6; CT scan on days 2 and 5; and drain amylases were measured on day 5. Pancreatitis was defined as pancreatitis changes in CT scan interpreted by an experienced radiologist without knowing other data. Pancreatic fistula was defined according to the recent international recommendations. We had no mortality. Twelve patients (31%) developed delayed gastric emptying. Surgical (9/12 vs. 5/27; P = 0.001) but not medical complications occurred more often in the delayed gastric emptying group. Of the single complications, postoperative CT-detected pancreatitis (6/12 vs. 4/27; P = 0.03) and postoperative pancreatic fistula (5/12 vs. 1/27; P = 0.0007) were significantly associated with delayed gastric emptying compared with the patients without delayed gastric emptying. This pancreatitis was already detected in CT scan on day 2 in most patients (6/10, 60%). In delayed gastric emptying patients, the only parameters in blood analysis that differed significantly from patients without this complication were serum amylase activity (mean +/- SEM, 715 +/- 205 vs. 152 +/- 70 IU/L; P = 0.02), blood leukocyte count (16 +/- 2 vs. 9 +/- 0.6 x 10(9)/L; P = 0.007) and serum C-reactive protein (CRP) concentration (144 +/- 28 vs. 51 +/- 14 mg/L, P = 0.01). Postoperative pancreatic (subclinical) fistula was also associated with postoperative pancreatitis (6/10 vs. 0/29; P = 0.003). Preoperative coronary artery disease (OR = 16; 95% CI, 1.0-241; P = 0.05) and soft pancreatic texture at operation (OR = 9; 95% CI, 1.4-52; P = 0.02) were significant risk factors for the development of postoperative pancreatitis. The diagnosis of delayed gastric emptying after pancreaticoduodenectomy often follows postoperative pancreatitis. Delayed gastric emptying is also associated with postoperative pancreatic fistula, for which this pancreatitis seems to be a risk factor. Preoperative coronary artery disease and soft texture of the pancreas are significant risk factors for postoperative CT-detected pancreatitis.

Binding pancreaticojejunostomy – a safe and reliable anastomosis procedure

Over the past one hundred years, the development of pancreaticoduodenectomy (PD) has always involved the struggle against pancreatic leakage. Until now, leakage of the pancreatic anastomosis has remained a common and serious complication after PD. Various methods of dealing with the pancreatic stump for prevention of pancreatic anastomotic leakage have been described. No matter which method is used, however, pancreatic anastomotic leakage is still most likely to occur when anastomosis involves a normal and soft pancreas. To perform a safe and reliable pancreaticoenteric anastomosis, we investigated the risk factors and potential mechanisms of occurrence of pancreatic leakage, including leakage from the needle hole and from the seam between two anastomosed structures, blood supply to the anastomosis and tension at the anastomosis. Based on these findings, we established a new pancreaticoenteric anastomosis procedure - binding pancreaticojejunostomy. The unique aspects of this procedure are as follows. The sero-muscular sheath of jejunum is bound to the invaginated pancreatic stump, so as to seal the gap between them; mucosa of the segment of jejunum that would eventually be in contact with the pancreatic stump is destroyed either chemically or by electric coagulation to promote healing. There is no needle hole on the jejunal surface of the anastomotic site. From 1996 to 2003, a total of 227 consecutive patients were treated with this type of pancreaticojejunostomy in this institution. None of the patients developed a pancreatic anastomotic leak. Binding pancreaticojejunostomy is a safe and reliable anastomotic procedure to effectively minimize leakage even when the texture of the pancreas is soft and normal.

Jejunum or stomach for the pancreatic anastomosis after pancreaticoduodenectomy.

Objective: The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula. Summary Background Data: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications. Methods: Between May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rich fluid on or after postoperative day 10. Results: The pancreaticogastrostomy (n=73) and pancreaticojejunostomy (n=72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (171145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatisc fistula was associated with a significant prolongation of postoperative hospital stay (36±5 vs. 15±1 days) (p<0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p<0.05). A multivariate logistic regression analysis revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the resected specimen. Conclusions: Pancreatic fistula is a common complication after pancreaticoduodenectomy, with an incidence most strongly associated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than pancreaticojejunostomy or is associated with a lower incidence of pancreatic fistula.

Pancreaticoduodenal resection

Postoperative pancreatic fistula (POPF) is regarded as the most serious complication of pancreatic surgery. The preoperative risk stratification of patients by simple means is of interest in perioperative clinical management.Based on prospective data, we performed a risk factor analysis for POPF after pancreatoduodenectomy in 62 patients operated between 2006 and 2008 with special focus on clinical parameters that might serve to predict POPF. A predictive score was developed and validated in an independent second dataset of 279 patients operated between 2001 and 2010.Several pre- and intraoperative factors, as well as underlying pathology, showed significant univariate correlation with rate of POPF. Multivariate analysis (binary logistic regression) disclosed soft pancreatic texture (odds ratio [OR] 10.80, 95% confidence interval [CI] 1.80–62.20) and history of weight loss (OR 0.15, 95% CI 0.04–0.66) to be the only independent preoperative clinical factors influencing POPF rate. The subjective assessment of pancreatic hardness by the surgeon correlated highly with objective assessment of pancreatic fibrosis by the pathologist (r = −0.68, P < 0.001, two-tailed Spearman's rank correlation). A simple risk score based on preoperatively available clinical parameters was able to stratify patients correctly into three risk groups and was independently validated.Preoperative stratification of patients regarding risk for POPF by simple clinical parameters is feasible. Pancreatic texture, as evaluated intraoperatively by the surgeon, is the strongest single predictive factor of POPF. The findings of the study may have important implications for perioperative risk assessment and patient care, as well as for the choice of anastomotic techniques.