Standard Pancreaticoduodenectomy Research Articles

Perioperative and Long-Term Outcome after Standard Pancreaticoduodenectomy, Additional Portal Vein and Multivisceral Resection for Pancreatic Head Cancer

IntroductionThe value of extended resection (portal vein, multivisceral) in patients with pancreatic adenocarcinoma (PDAC) is not well defined. We analyzed the outcome after standard resection (standard pancreaticoduodenectomy (SPR)), additional portal vein (PV) and multivisceral (MV) resection in PDAC patients. MethodsClinicopathologic, perioperative, and survival data of patients undergoing pancreatic head resection (PHR) for PDAC 1994–2014 were reviewed from a prospective database. ResultsThree hundred fifty nine patients had PHR for PDAC: 208 (58 %) underwent SPR, 131 (36 %) additional PV, and 20 (6 %) MV. The postoperative complication rate in MV (65 %) was slightly higher than in PV (56 %) or SPR (50 %; p = 0.32). MV patients had higher in-hospital mortality (10 %) than SPR (3.8 %) and PV (1.5 %) patients (p = 0.12). Nodal status was comparable, whereas more patients in PV and MV had final R0 resection (p = 0.02). Five-year survival was 7 % after MV versus 17 % in patients without MV (p = 0.07). Multivariate survival analysis identified resection margin, nodal disease, blood transfusions, and MV are set as independent risk factors for overall survival. ConclusionMultivisceral pancreatic head resections for PDAC are associated with increased perioperative morbidity and mortality, without improving oncologic outcome. Portal vein resection can be performed safely to reach R0 resection and its survival benefits.

Comparison of Pathological Radicality between Open and Laparoscopic Pancreaticoduodenectomy in a Tertiary Centre.

Laparoscopic pancreaticoduodenectomy (LPD) remained a formidable challenge owing to retroperitoneal location, difficult dissection near great vessels and critical intracorporeal anastomoses. Recent reviews of literature have established the feasibility and comparable short term outcomes of laparoscopic pancreaticoduodenectomy (LPD) with that of open pancreaticoduodenectomy (OPD). This study was undertaken to compare the pathological radicality of LPD with OPD. A prospective database of all patients who underwent standard pancreaticoduodenectomy from Mar 2006 to Feb 2011 was taken up for this study. 45 patients who underwent LPD and 118 patients who underwent OPD for periampullary and pancreatic head malignancy were taken up for analysis. The study groups were comparable in terms of age of presentation, ASA grades, comorbidity, type of surgery and BMI. There was no statistically significant difference with regard to tumor size, lymph node yield, node positivity rates, R1 rates and margin lengths. The pathological radicality of laparoscopic pancreaticoduodenectomy is comparable with that of open approach when performed by experienced minimal-access surgeons. Standardized protocols for evaluation of the resection margins should be mandatory in studies reporting outcomes of pancreaticoduodectomy.

Association of Preoperative Biliary Drainage with Postoperative Morbidity after Pancreaticoduodenectomy.

Background. The advantages or disadvantages of preoperative biliary drainage (PBD) prior to pancreaticoduodenectomy (PD) remain unclear. Methods. A prospectively maintained database was queried for 335 consecutive patients undergoing standard PD surgery between 2009 and 2013. Clinical data and postoperative complications of the 47 patients receiving PBD and 288 patients with early surgery were compared. A matching analysis was also performed between patients receiving or not receiving PBD (no-PBD). Results. The indication for PBD was severe obstructive jaundice (81%) and cholangitis (26%) at the time of PBD. 47 PBD patients had higher bilirubin level than 288 no-PBD patients preoperatively (363.2 μmol/L versus 136.0 μmol/L, p < 0.001). Although no significant difference of any complications could be observed between the two groups, positive intraoperative bile culture and wound infection seemed to be moderately increased in PBD compared to no-PBD patients (p = 0.084 and 0.183, resp.). In the matched-pair comparison, the incidence of wound infection was three times higher in PBD than no-PBD patients (14.9% versus 4.3%, p = 0.080). Conclusions. PBD seems to moderately increase the risk of postoperative wound and bile duct infection. Therefore, PBD should be selectively performed prior to PD.

Continuous suture of the pancreatic stump and Braun enteroenterostomy in pancreaticoduodenectomy

To investigate a new modification of pancreaticoduodenectomy (PD)-a mesh-like running suturing of the pancreatic remnant and Braun's enteroenterostomy. Two hundred and three patients underwent PD from 2009 to 2014 and were classified into two groups: Group A (98 patients), who received PD with a mesh-like running suturing for the pancreatic remnant, and Braun's enteroenterostomy; and Group B (105 patients), who received standard PD. Demographic data, intraoperative findings, postoperative morbidity and perioperative mortality between the two groups were compared by univariate and multivariate analysis. Demographic characteristics between Group A and Group B were comparable. There were no significant differences between the two groups concerning perioperative mortality, and operative blood loss, as well as the incidence of the postoperative morbidity, including reoperation, bile leakage, intra-abdominal fluid collection or infection, and postoperative bleeding. Clinically relevant postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE) were identified more frequently in Group B than in Group A. Technique A (PD with a mesh-like running suturing of the pancreatic remnant and Braun's enteroenterostomy) was independently associated with decreased clinically relevant POPF and DGE, with an odds ratio of 0.266 (95%CI: 0.109-0.654, P = 0.004) for clinically relevant POPF and 0.073 (95%CI: 0.010-0.578, P = 0.013) for clinically relevant DGE. An additional mesh-like running suturing of the pancreatic remnant and Braun's enteroenterostomy during PD decreases the incidence of postoperative complications and is beneficial for patients.

Combined pancreaticoduodenectomy and colon resection for locally advanced peri-ampullary tumours: analysis of peri-operative morbidity and mortality

BackgroundCombined pancreaticoduodenectomy (PD) and colonic resection may be necessary to achieve an R0 resection of peri-ampullary tumours. The aim of this study was to examine the morbidity and mortality associated with this procedure. MethodsA retrospective cohort study was performed comparing 607 patients who underwent a standard pancreaticoduodenectomy (S-PD) to 28 patients who had a concomitant colon resection and PD (PD-colon) over a 10-year period at an academic centre. ResultsPatients in the PD-colon group were more likely to have received neoadjuvant chemotherapy ± radiation (3/28, 11% versus 14/607, 2%, P = 0.024). Operative time was also longer (530 versus 410min, P < 0.001) and they were more likely to have had portal vein resections (9/28, 32% versus 76/607, 13%, P = 0.007). There was no difference in the intra-operative blood loss, length of stay, or overall complication rates. The PD-colon group had a higher rate of severe post-operative bleeding (4/28, 11% versus 8/607, 1%, P = 0.002). The post-operative mortality rates for the PD-colon and PD groups were 2/28 (7%) and 8/607 (1%), respectively (P = 0.068). ConclusionsPD-colon has an acceptable risk of peri-operative morbidity compared with S-PD in well-selected patients.

Inferior mesenteric vein serves as an alternative guide for transection of the pancreatic body during pancreaticoduodenectomy with concomitant vascular resection: a comparative study evaluating perioperative outcomes.

BackgroundTumors of the pancreatic head often involve the superior mesenteric and portal veins. The purpose of this study was to assess perioperative outcomes after pancreaticoduodenectomy (PD) with concomitant vascular resection using the inferior mesenteric vein (IMV) as a guide for transection of the pancreatic body (Whipple at IMV, WATIMV).MethodsOne hundred thirty-seven patients had segmental vein resection during PD between January 2006 and June 2013. Depending on whether the standard approach of creating a tunnel anterior to the mesenterico-portal vein (MPV) axis was achieved for pancreatic transection, patients were subjected to a standard PD with vein resection procedure (s-PD + VR, n = 75) or a modified procedure (m-PD + VR, n = 62). Within the m-PD + VR group, 28 patients underwent the WATIMV procedure, while 34 patients underwent the usual procedure of transection, or ‘central pancreatectomy’ (c-PD + VR).ResultsThe volume of intraoperative blood loss and the blood transfusion requirements were significantly greater, and the venous wall invasion and neural invasion frequency were significantly higher in the m-PD + VR group compared with the s-PD + VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, and grades of complications between the two groups. Multivariate logistic regression identified intraoperative blood transfusion (P = 0.004) and vascular invasion (P = 0.008) as the predictors of postoperative morbidity. Further stratification of the entire cohort of 62 (45%) patients who underwent m-PD + VR showed a higher rate of negative resection margins (96.4%) in the WATIMV group compared with the c-PD + VR group (76.5%) (P = 0.06). The volume of intraoperative blood loss (P = 0.013), and intraoperative blood transfusion requirements (P = 0.07) were significantly greater in the c-PD + VR group compared with the WATIMV group. Furthermore, high intraoperative blood loss and tumor stage were predictive of a positive resection margin.Conclusions‘Whipple at the IMV (WATIMV)’ has comparable postoperative morbidity with standard PD + VR. If IMV runs into the splenic vein, it could serve as an alternative guide for transection of the pancreatic body during PD + VR.

Continuous versus interrupted suture techniques of pancreaticojejunostomy after pancreaticoduodenectomy

BackgroundPostoperative pancreatic fistula (POPF) has traditionally been a source of significant morbidity and potential mortality after pancreaticoduodenectomy (PD). Both patient-derived and technical factors contribute to pancreatic anastomotic failure. The continuous suture duct-to-mucosa pancreaticojejunostomy (PJ) described previously is associated with a low rate of POPF. The aim of the present study was to observe whether the new technique would effectively reduce the POPF rate in comparison with conventional interrupted suture duct-to-mucosa PJ. MethodsData on 255 consecutive patients, who underwent the two methods of PJ after standard PD by one group of surgeons between 2006 and 2013, were collected retrospectively from a prospective database. The primary end point was the POPF rate. The risk factors of POPF were investigated by using univariate and multivariate analyses. ResultsA total of 120 patients received continuous suture PJ and 135 underwent interrupted suture PJ. Rate of POPF for the entire cohort was 12.5%. There were 9 fistulas (7.5%) in the continuous anastomosis group and 23 fistulas (17%) in the interrupted anastomosis group (P = 0.022). The rates of major complications (Clavien grades 3–5) were less in the continuous anastomosis group (5%) compared with the interrupted anastomosis group (13.3%) (P = 0.023). The greatest risk factor for a POPF was pancreatic duct diameter: POPF developed in only 3 patients (3.6%) with large pancreatic ducts (≥3 mm) and in 29 patients (16.9%) with small pancreatic ducts (<3 mm). There were four postoperative (in-hospital) deaths (both in the interrupted anastomosis group); two of which had POPF as the proximate cause of death, followed by bleeding and sepsis. ConclusionsThe continuous suture duct-to-mucosa PJ effectively reduces the POPF rate after PD in comparison with interrupted anastomosis. The results confirm increased POPF rates in patients with pancreatic duct diameter <3 mm compared with pancreatic duct diameter ≥3 mm.

Meta-analysis of the efficacies of extended and standard pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas.

The purpose of the present study was to evaluate the efficacy of extended pancreatoduodenectomy (EPD) and standard pancreatoduodenectomy (SPD) for ductal adenocarcinoma of the head of the pancreas via meta-analysis. Relevant articles (published between 1995 and 2012) were compiled from online data sources. A total of nine studies satisfied the selection criteria, including a total of 973 patients (478 in the SPD group and 495 in the EPD group). Evaluation parameters included 1-, 3-, and 5-year survival, as well as mortality, morbidity, and specific morbidity outcomes. Meta-analysis revealed (1) differences in morbidity (Odds ratio [OR] = 1.740; 95 % confidence interval [CI], 0.840-3.600; P = 0.140), mortality (OR = 0.890; 95 % CI, 0.560-1.400; P = 0.620), 1-year overall survival (OS) rate (OR = 1.20; 95 % CI, 0.490-2.930; P = 0.69), 3-year OS rate (OR = 0.770; 95 % CI, 0.460-1.280; P = 0.190), and 5-year OS rate (OR = 1.12; 95 % CI, 0.690-1.810; P = 0.560) were not significant between EPD and SPD. (2) For bile leak (OR = 2.640; 95 % CI, 1.040-6.700; P = 0.040), pancreatic leak (OR = 1.740; 95 % CI, 1.040-2.91; P = 0.030), delayed gastric emptying (OR = 2.090; 95 % CI, 1.240-3.520; P = 0.006), and lymphatic fistula (OR = 6.120; 95 % CI, 1.06-35.320; P = 0.040) differences between EPD and SPD were significant, whereas other specific morbidities were not significantly different. Extended pancreatoduodenectomy does not improve 1-, 3-, 5-year OS rates compared to SPD and there is a trend toward increased bile leak, pancreatic leak, delayed gastric emptying, and lymphatic fistula after EPD.

Reduced Dissemination of Circulating Tumor Cells With No-Touch Isolation Surgical Technique in Patients With Pancreatic Cancer

Circulating tumor cells (CTCs) disseminate from the primary tumor and travel through the bloodstream and lymphatic system. The detection of and/or increase in the number of CTCs during a patient’s clinical course may be a harbinger of forthcoming overt metastasis. We aimed to examine the impact of 2 different surgical techniques, standard (ST) pancreaticoduodenectomy (PD) and no-touch isolation (NT) PD, on tumor behavior and outcome in patients with pancreatic cancer by using CTCs as biomarkers. In this pilot study, patients were randomized to either ST-PD (n = 6) or NT-PD (n = 6). Intraoperatively, blood samples were taken from the portal vein for measurement of CTCs before and immediately after removal of the tumor. An increase in CTCs was seen in 5 of 6 patients (83%) with ST-PD but no patients with NT-PD (P = .003). In the ST-PD and NT-PD groups, median overall survival was 13.0 and 16.7 months, respectively (P = .33); there was no difference in disease-free survival (P = .42). The use of NT-PD significantly reduced the number of CTCs in the portal vein with no benefit in survival outcomes compared with ST-PD, although more extensive studies are required.

Diagnosis and treatment of delayed postoperative hemorrhage after pancreaticoduodenectomy

Objective To summarize the clinical experience in the diagnosis and treatment of delayed postoperative hemorrhage after pancreaticoduodenectomy.Methods The clinical data of 246 patients who received pancreaticoduodenectomy at the First Affiliated Hospital of Xinjiang Medical University from January 2002 to February 2013 were retrospectively analyzed.Patients with pancreatic head carcinoma and ampullary malignancies received standard pancreaticoduodenectomy or combined organ resection,and patients with benign and duodenal tumor received pylorus-preserving pancreaticoduodenectomy.Pancreatic anastomosis was done using pancreaticogastrostomy or pancreaticojejunostomy.Delayed hemorrhage was defined as bleeding at the operation site after 5 or more postoperative days.Patients were divided into the gastrointestinal hemorrhage group and the abdominal hemorrhage group according to the bleeding site,and the treatment methods included conservative treatment or surgical treatment (including interventional therapy and laparotomy).The Measurement data were expressed as mean ± standard deviation,and the enumeration data were compared using the Fisher exact probability.Results There were 224 patients received pancreaticoduodenectomy,10 received pylorus-preserving pancreaticoduodenectomy,9 received pancreatieoduodenectomy + portal vein resection or replacement,1 received pancreaticoduodenectomy + superior mesenteric vein replacement,1 received pancreaticoduodenectomy + resection of quadrate lobe of liver and 1 received pancreaticoduodenectomy + resection of left semihepatectomy.There were 127 patients received improved end-to-side pancreaticojejunostomy,53 received pancreaticogastrostomy,39 received end-to-end pancreaticojejunostomy and 27 received mucosa-to-mucosa pancreaticojejunostomy.Fifteen patients died perioperatively,with the mortality rate of 6.10％ (15/246).Twenty-nine patients were complicated with delayed hemorrhage with the rate of 11.79％ (29/246),including 14 with gastrointestinal hemorrhage and 15 with abdominal hemorrhage.There were 9 patients with mild hemorrhage (5 with gastrointestinal hemorrhage and 4 with abdominal hemorrhage) and 20 with severe hemorrhage (9 with gastrointestinal hemorrhage and 11 with abdominal hemorrhage).Seventeen patients had sentinel bleeding,including 5 with abdominal hemorrhage and 12 with gastrointestinal hemorrhage.Twenty-nine patients received conservative treatment,and the success rates of conservative treatment were 8/14 in the gastrointestinal hemorrhage group,which was significantly higher than 2/15 of the abdominal hemorrhage group (P ＜ 0.05).Patients who failed in conservative treatment received surgical treatment.Of the 20 patients with severe hemorrhage,19 were cured by surgical treatment and I was cured by conservative treatment.Nine patients with mild hemorrhage received conservative treatment,8 were cured and 1 died of pulmonary infection.Of the 29 patients with delayed postoperative hemorrhage,10 died with the mortality rate of 34.5％ (10/29).The morality rate of the gastrointestinal hemorrhage group was 2/14,which was lower than 8/15 of the abdominal hemorrhage group,with no significant difference between the 2 groups (P ＞ 0.05).Conclusions Most of the delayed postoperative hemorrhage after pancreaticoduodenectomy severe and combined with sentinel bleeding.Gastrointestinal hemorrhage can be cured through conservative treatment,but abdominal hemorrhage need surgical treatment. Key words: Pancreaticoduodenectomy ; Postoperative hemorrhage ; Diagnosis ; Treatment

Decoy receptor 3 (DcR3) overexpression predicts the prognosis and pN2 in pancreatic head carcinoma

BackgroundThis study was carried out to examine decoy receptor 3 (DcR3) expression and investigate its clinical and prognostic significance in patients with pancreatic head carcinoma.MethodsTissue samples were obtained from 50 patients with pancreatic head carcinoma. DcR3 protein expression in tissues and sera was assessed by immunohistochemistry and ELISA. Correlations between DcR3 and clinicopathologic features and prognoses were analyzed statistically.ResultsSerum DcR3 levels were significantly elevated in patients with pancreatic head carcinoma compared with patients with cystadenoma and healthy individuals (P < 0.01 and P < 0.01, respectively). DcR3 overexpression correlated with lymph node metastases and TNM stages (P < 0.05 and P < 0.05, respectively). Median overall survival for the high DcR3 group was 16.3 months, compared to 21.6 months for the low DcR3 group (P < 0.05). In the low DcR3 group, no significant difference was found in the overall survival between patients who underwent standard pancreatoduodenectomy (SPD) and those who had radical pancreatoduodenectomy (RPD) (P > 0.05). In the high DcR3 group, the median overall survival rates were 16.8 months in the RPD group and 13.5 months in the SPD group (P < 0.05).ConclusionsWe found that DcR3 was overexpressed in pancreatic head carcinoma. The patients with high DcR3 levels had higher pN2 stages than those with low DcR3 levels. Detecting serum DcR3 level preoperatively might be an additional approach for evaluating pN2 stage and guiding the range of lymphadenectomy.

Aberrant right hepatic artery in pancreaticoduodenectomy for adenocarcinoma: impact on resectability and postoperative outcomes

ObjectivesAn aberrant right hepatic artery (aRHA) may pose technical and oncologic challenges during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA) as a result of its proximity to the head of the pancreas. The aim of this study was to assess the impact of an aRHA on resectability, and perioperative and oncologic outcomes after PD for PA. MethodsAn 11-year retrospective cohort study was conducted. A total of 289 patients with PA scheduled for PD with intent for resection were included in the study. ResultsOf 289 patients, 249 underwent PD and 40 were found to have unresectable tumours. Incidences of aRHA in the resectable (14.9%) and unresectable (7.5%) groups were similar (P = 0.2); the main reasons for aborting PD were not directly related to the presence of an aRHA. In patients who underwent resection, complications occurred more frequently in the standard PD group (41.5% versus 24.3%; P = 0.04), but there was no difference in rates of positive margin (R1) resection (10.8% versus 16.0%; P = 0.4) or median overall survival (17 months versus 23 months; P = 0.1) between patients with and without an aRHA. ConclusionsThe presence of an aRHA in patients with PA does not affect resectability. In patients with resectable tumours, the presence of an aRHA does not increase morbidity or R1 resection rates and does not impact on overall survival.

Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy

BackgroundThe incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma. Materials and methodsAll 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up). ResultsPatients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced. ConclusionsIn patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.

Portal Vein Resection in Borderline Resectable Pancreatic Cancer: A United Kingdom Multicenter Study

Until recently, in the United Kingdom, borderline resectable pancreatic cancer with invasion into the portomesenteric veins often resulted in surgical bypass because of the presumed high risk for complications and the uncertainty of a survival benefit associated with a vascular resection. Portomesenteric vein resection has therefore remained controversial. We present the second largest published cohort of patients undergoing portal vein resection for borderline resectable (T3) adenocarcinoma of the head of the pancreas. This is a UK multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection (PDVR), standard pancreaticoduodenectomy (PD), and surgical bypass (SB). Nine high-volume UK centers contributed. All consecutive patients with T3 (stage IIA to III) adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. The primary outcomes measures are overall survival and in-hospital mortality. Secondary outcomes measure is operative morbidity. One thousand five hundred and eighty-eight patients underwent surgery for borderline resectable pancreatic cancer; 840 PD, 230 PDVR, and 518 SB. Of 230 PDVR patients, 129 had primary closure (56%), 65 had end to end anastomosis (28%), and 36 had interposition grafts (16%). Both resection groups had greater complication rates than the bypass group, but with no difference between PD and PDVR. In-hospital mortality was similar across all 3 surgical groups. Median survival was 18 months for PD, 18.2 months for PDVR, and 8 months for SB (p = 0.0001). This study, the second largest to date on borderline resectable pancreatic cancer, demonstrates no significant difference in perioperative mortality in the 3 groups and a similar overall survival between PD and PDVR; significantly better compared with SB.

Gastric conduit-preserving, radical pancreaticoduodenectomy with microvascular reconstruction for pancreatic head cancer after esophagectomy: report of a case

Pancreaticoduodenectomy is a radical treatment for pancreatic head cancer. However, it is sometimes difficult to perform pancreaticoduodenectomy, particularly in patients who have previously undergone esophagectomy with gastric conduit reconstruction. We herein describe a surgical technique for radical pancreaticoduodenectomy with microvascular reconstruction that preserves the gastric conduit. A 72-year-old male with a previous history of esophagectomy and gastric conduit reconstruction for esophageal cancer was referred to our hospital for surgical treatment of advanced pancreatic head cancer. After considering both the cancer curability and preservation of the gastric conduit, we performed a standard pancreaticoduodenectomy, and added a microvascular anastomosis of the gastroduodenal artery to the right gastroepiploic artery. In addition, we also performed reconstruction of the right gastroepiploic vein. This radical pancreaticoduodenectomy with microvascular reconstruction was safely and successfully performed, and it preserved the gastric conduit. The 6-month follow-up showed recurrence-free survival and a good quality of life.

Role of extended lymphadenectomy in the treatment of pancreatic head adenocarcinoma: review and meta‐analysis

Extended lymph node dissection has been established as the method of choice in the treatment of many digestive malignancies, but its role in the treatment of adenocarcinoma of the pancreas remains controversial. The goal is to evaluate the role of extended lymph node dissection in pancreatic head adenocarcinoma and to review how it affects survival, morbidity, mortality and post-operative quality of life. A computerized search was made of the Medline database from January 1973 to October 2012. Fifteen non-duplicated studies, four randomized and 11 non-randomized, comparing extended radical pancreaticoduodenectomy (ERP) and standard pancreaticoduodenectomy were reviewed. Five-year overall survivals were compared using the MetaXL software in eight of these studies, where the necessary data were available. The 5-year survival after ERP ranged from 6 to 33.4% and the local recurrence incidence from 8 to 36.1%, while the incidence of severe diarrhoea, one of the main complications, ranged from 10.8 to 42.4%. Meta-analysis showed that there was no significant difference in the 5-year overall survival (95% confidence interval (CI): -0.21-0.20, Z=0.07, P=0.94) for randomized control trials, (95% CI: -0.51-0.02, Z=1.85, P=0.07) for non-randomized control trials and (95% CI: -0.26-0.06, Z=1.20, P=0.23) for all the studies. Although ERP is a safe procedure, it did not offer a significant improvement in survival, while at the same time leading to an increased incidence of severe diarrhoea for at least 1 year, thus leaving the standard pancreaticoduodenectomy as the surgical method of choice for the treatment of pancreatic head adenocarcinoma.

Outcomes of Vascular Resection in Pancreaticoduodenectomy: Single-surgeon Experience

Extension of pancreatic adenocarcinoma into adjacent vasculature often necessitates resection of the portal vein (PV) and/or superior mesenteric vein (SMV) during pancreaticoduodenectomy (PD). The vein is reconstructed primarily by end-to-end anastomosis of vein remnants or venoplasty or by use of autologous or synthetic vein grafts. The objective of this study was to review outcomes in patients undergoing PD for pancreatic adenocarcinoma, specifically comparing the short- and long-term outcomes between the patients undergoing vascular resection and those undergoing standard PD. All patients undergoing PD for pancreatic adenocarcinoma by a single surgeon between 2007 and 2012 were reviewed. Of the 61 patients identified, 18 patients underwent vascular resection of the PV (four patients), SMV (10 patients), or both (four patients). The remaining 43 patients had standard PD. Demographic, perioperative, pathological, and long-term outcomes data were collected and both vascular and standard groups were compared. Both groups had similar demographics. The vascular group had significantly longer operative times (529 vs 406 minutes; P < 0.01) with a trend to greater estimated blood loss (0.64 vs 0.53 L; P = 0.06). Pathological analysis showed no difference between the two groups with regard to lymph node status/ratio and rate of R0 resection (94 vs 91%; P = 0.57); however, the size of the tumor was significantly greater in the vascular group (4.2 vs 3 cm; P < 0.01). Short-term outcomes were similar in the vascular group and standard group, respectively, with no difference in pancreatic fistula rate (6 vs 7%; P = 1.0), transfusion rate (44 vs 35%; P = 0.57), and median length of stay (8 vs 7 days; P = 0.10), and there was no 30-day mortality in either group. Based on Kaplan-Meier methods, the median recurrence-free survival was 18 versus 23 months (P = 0.37) in the vascular and standard groups, respectively, and the overall survival was almost identical in both groups, each with a median of 31 months (P = 0.91). In our experience, mesenteric and PV resection during PD was performed safely and without compromise of short- or longer-term outcomes. It can be performed safely and patients have no significant difference in perioperative outcomes or overall survival.

Triple-layer duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa decreased pancreatic fistula after pancreaticoduodenectomy

BackgroundPancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy (PD). We described a new method of pancreaticojejunostomy (PJ) developed by combining triple-layer duct-to-mucosa PJ with resection of jejunal serosa, which was named as modified layer-to-layer PJ (MLLPJ). The aim of the present study was to observe whether the new technique would effectively reduce the PF rate in comparison with two-layer duct-to-mucosa PJ (TLPJ). MethodsData on 184 consecutive patients who underwent the two methods of PJ after standard PD between January 1, 2010 and January 31, 2013 were collected retrospectively from a prospective database. The primary endpoint was the PF rate. The risk factors of PF were investigated by using univariate and multivariate analyses. ResultsA total of 88 patients received TLPJ and 96 underwent MLLPJ. Rate of PF for the entire cohort was 8.2%. There were 11 fistulas (12.5%) in the TLPJ group and four fistulas (4.2%) in the MLLPJ group (P = 0.039). Body mass index, pancreatic texture, pancreatic duct diameter, and methods of PJ anastomosis had significant effects on the formation of PF on univariate analysis. Multivariate analysis showed that pancreatic duct diameter ≤3 mm and TLPJ were the significant risk factors of PF. ConclusionsMLLPJ effectively reduces the PF rate after PD in comparison with TLPJ. Results confirm increased PF rates in patients with pancreatic duct diameter ≤3 mm compared with pancreatic duct diameter >3 mm.

Does Modified Braun Enteroenterostomy Improve Alkaline Reflux Gastritis and Marginal Ulcer After Pancreaticoduodenectomy?

The safety of pancreaticoduodenectomy has improved significantly. However, alkaline reflux gastritis and marginal ulcer are two substantial problems after pancreaticoduodenectomy. To identify whether Child reconstruction with a modified Braun enteroenterostomy decreases the incidence of alkaline reflux gastritis and marginal ulcer after pancreaticoduodenectomy better than Roux-en-Y reconstruction. Data on 57 consecutive patients who underwent standard pancreaticoduodenectomy between January 1, 2008 and January 31, 2012 were collected prospectively. Data on early and late complications of the Child reconstruction with a modified Braun enteroenterostomy and Roux-en-Y were gathered. The risk factors of alkaline reflux gastritis and marginal ulcer were also investigated by using univariate and multivariate analyses. Twenty-five patients received Roux-en-Y and 32 underwent Child reconstruction with a modified Braun enteroenterostomy. Early complications after the two reconstruction methods were insignificant. Significant differences in terms of later postoperative morbidity (P = 0.01) and change in body mass index (P = 0.03) were found 12 months after pancreaticoduodenectomy. No significant difference for alkaline reflux gastritis was observed between the two methods (14.8 vs. 28.6 %, P = 0.24). Marginal ulcer occurred significantly lower in patients with the modified reconstruction than in those with Roux-en-Y reconstruction (11.1 vs. 47.6 %, P = 0.01). Peptic ulcer history, diabetes mellitus, and reconstruction type had a significant effect on marginal ulcer formation. Child reconstruction with a modified Braun enteroenterostomy offers an advantage with respect to marginal ulcer after standard pancreaticoduodenectomy, potentially decreasing the incidence of alkaline reflux gastritis as effectively as Roux-en-Y reconstruction.

Standard Versus Extended Pancreaticoduodenectomy in Treating Adenocarcinoma of the Head of the Pancreas

To compare the postoperative complications and survival of standard pancreatoduodenectomy (SPD) and extended pancreatoduodenectomy (EPD) in patients with resectable adenocarcinoma of the head of the pancreas. Between January 1994 and December 2011, 165 patients with biopsy-proven adenocarcinoma of the pancreatic head were treated in West China Hospital, among whom 93 underwent SPD and 72 had EPD. Complications and survival after the surgery were analyzed retrospectively. The median operation time of the EPD group was longer compared with the SPD group (375 minutes vs.310 minutes, P<0.01), the volume of blood transfusion was larger (700 mL vs.400 mL, P<0.05), while the median hospital stay (13.5 days vs.12 days, P=0.79) and the total complication rates were comparable (34.7% vs.32.4%, P=0.93). The total recurrence rates of the SPD and EPD groups were not significantly different (52.7% vs. 43.1%, P=0.83). No significant differences were found between the SPD and EPD groups in 1-year (81.7% vs. 86.1%), 3-year (38.7% vs. 43.1%), 5-year (16.7% vs. 19.4%), and median survivals (19.8 months vs. 23.2 months, P= 0.52). The postoperative complications and survival donot differ significantly between SPD and EPD.