Total Pancreatectomy In Patients Research Articles

Partial pancreatoduodenectomy versus total pancreatectomy in patients with preoperative diabetes mellitus: Comparison of surgical outcomes and quality of life.

To reduce perioperative risks among patients with a preoperative diabetes mellitus (DM) a total pancreatectomy (TP) might be a alternative to pancreatoduodenectomy (PD). This study aimed to compare the postoperative quality of life (QoL) of patients with preoperative DM undergoing PD or TP. A single-centre retrospective study was conducted, all consecutive patients with preoperative DM undergoing PD or TP between 2011 and 2023 were identified in a prospective database. The primary endpoint was QoL, prospectively assessed using EORTC QLQ-C30 questionnaires at 3, 6, and 12months after surgery and then annually until death. Secondary endpoints were morbidity and mortality. Seventy-one patients were included, 17 after TP and 54 after PD. Insulin-dependent DM occurred in 21 (39%) of the PD patients. QoL was worse after TP, especially in terms of physical functioning (-31.7 points; 95% CI: -50.0 to -13.3; P < 0.001), role functioning (-41.3 points; 95% CI: -61.3 to -21.3; P < 0.001), emotional functioning (-27.5 points; 95% CI: -50.4 to -4.6; P = 0.019), fatigue symptoms (20 points; 95% CI: 2.7 to 37.4; P = 0.024) and pain symptoms (30.2 points; 95% CI: 4.1 to 56.3; P = 0.024). The rates of postoperative major complications (29% vs. 35%; P = 0.853) and mortality (11% vs. 7%; P = 0.857) were similar between TP and PD. Postoperative morbidity and mortality were comparable between PD and TP, however QoL is significantly lower after TP. Importantly, patients with preoperative DM have a 60% chance of remaining noninsulin-dependent after PD.

Pancreatoduodenectomy or total pancreatectomy in patients with high-risk pancreatic fistula

Pancreatoduodenectomy or total pancreatectomy in patients with high-risk pancreatic fistula

Metabolic and surgical factors affecting postoperative quality of life in patients with total pancreatectomy with or without splenectomy: Single center results.

Pancreatic resection may be required in the treatment of patients with pathologies of the pancreas. Total pancreatectomy is a major surgical procedure with serious risk of mortality and morbidity, and patient selection is important for prognosis. The endocrine and exocrine pancreatic insufficiency that develops in patients after total pancreatectomy can lead to a serious decrease in the quality of life of the patients due to pain, diarrhea, vomiting etc. Our aim was to evaluate the effect of total pancreatectomy with spleen preservation as well as splenectomy on the quality of life of the patients. In our study, we retrospectively analyzed the data of patients diagnosed with pancreatic cancer, intrapapillary mucinous neoplasia, pancreatic neuroendocrine tumors, and chronic pancreatitis undergoing from partial to total pancreatic resections in our clinic between 12/2017 and 12/2022. Quality of life was compared using the EORTC QLQ-C30 scale. A total of 47 total pancreatectomy patients, 30 (63.8%) males and 17 (36.2%) females, were included in the study. Mean age of the patients was 61.38 (39-83) years. Five (35.7%) patients underwent perioperative total pancreatectomy because of high risk of pancreatic fistula development due to hard parenchyma and narrow pancreatic duct. Patients had a perioperative blood loss of 500 mL or more, and there was a statistically significant increase in perioperative blood loss compared to patients without vascular resection (p <0.001). Forty (85.1%) patients used enzyme preparations to replace pancreatic enzymes. After total pancreatectomy, quality of life of the patients is reduced both by surgical factors and by metabolic factors due to endocrine and exocrine insufficiency in the postoperative period.

Pancreatoduodenectomy and Total Pancreatectomy in Patients with High-risk of Pancreatic Fistula

Pancreatoduodenectomy and Total Pancreatectomy in Patients with High-risk of Pancreatic Fistula

Intraportal Islet Autotransplantation Independently Improves Quality of Life After Total Pancreatectomy in Patients With Chronic Refractory Pancreatitis.

To determine if islet autotransplantation (IAT) independently improves the quality of life (QoL) in patients after total pancreatectomy and islet autotransplantation (TP-IAT). TP-IAT is increasingly being used for intractable chronic pancreatitis. However, the impact of IAT on long-term islet function and QoL is unclear. TP-IAT patients at our center >1 year after TP-IAT with ≥1 Short Form-36 QoL measure were included. Patients were classified as insulin-independent or insulin-dependent, and as having islet graft function or failure by C-peptide. The associations of insulin use and islet graft function with QoL measures were analyzed by using a linear mixed model, accounting for time since transplant and within-person correlation. Among 817 islet autograft recipients, 564 patients [median (interquartile range) age: 34 (20, 45) years, 71% female] and 2161 total QoL surveys were included. QoL data were available for >5 years after TP-IAT for 42.7% and for >10 years for 17.3%. Insulin-independent patients exhibited higher QoL in 7 of 8 subscale domains and for Physical Component Summary and Mental Component Summary scores ( P <0.05 for all). Physical Component Summary was 2.91 (SE=0.57) higher in insulin-independent patients ( P <0.001). No differences in QoL were observed between those with and without graft function, but islet graft failure was rare (15% of patients). However, glycosylated hemoglobin was much higher with islet graft failure. QoL is significantly improved when insulin independence is present, and glycosylated hemoglobin is lower with a functioning islet graft. These data support offering IAT, rather than just performing total pancreatectomy and treating with exogenous insulin.

Is There a Benefit From Islet Autotransplantation in Patients With Type 1 Diabetes Mellitus Undergoing Total Pancreatectomy?

Children with acute recurrent and chronic pancreatitis (CP) experience abdominal pain that leads to hospitalizations, opioid dependence, and poor quality of life. Total pancreatectomy with islet autotransplantation (TPIAT) is offered as a surgical option in management of debilitating pancreatitis that fails medical and endoscopic therapy to reduce or eliminate pain. Given that patients with type 1 diabetes mellitus (T1DM) lack insulin-producing β cells, the outcomes from autotransplanting islet isolates back into total pancreatectomy patients with T1DM are not fully known.We performed TPIAT in 2 CP patients who also had a diagnosis of T1DM for at least 6 years before the operation and evaluated the clinical and laboratory outcomes before and after the operation. Postoperatively both patients' abdominal pain had significantly subsided, they were weaned off opioid medications, and they were able to return to full-time school attendance. In addition, total daily dose of insulin in 1 patient was able to be slightly reduced at 12 months post-TPIAT. We observed in vitro that residual α cells and β cells in T1DM islets were able to secrete a small amount of glucagon and insulin, respectively.

Insulin protocol to control post-pancreatectomy diabetes

Diabetes is a disease by which blood glucose level is elevated by defects in insulin secretion or by resistance to insulin. As pancreatectomy inevitably results in the reduction of the total islet mass, the majority of clinicians tended to believe that pancreatectomy itself would immediately cause blood glucose elevation and subsequent diabetes development. In partial pancreatectomy surgery (distal pancreatectomy or PPPD), however, not all patients develop diabetes for at least a number of years after. This is because the remnant pancreatic islets can produce relatively enough amount of insulin to maintain blood glucose level. After this compensatory time period passes after partial pancreatectomy, the pancreas eventually undergoes atrophy after surgery and the insulin secretory function decreases in the remnant islet. This will lead to delayed development of diabetes after pancreatectomy. Under these situations, insulin injection together with oral anti-diabetic medication would be critical for controlling the blood glucose level. In contrast, patients who undergo total pancreatectomy will develop diabetes immediately after the surgery because of the absolute deficiency of insulin. In this situation, the patients will need a tightly-controlled, delicate insulin injection protocol with multiple subcutaneous insulin injections. Recently, with only a small patch applied to the body, continuous glucose monitoring system (CGMS) enables the reporting of the blood glucose level into the patient's smartphone every 1-5 minutes. The CGMS has gained popularity, is clinically helpful, and is even supported by the health insurance system for type 1 diabetes patients (the patients who undergoes total pancreatectomy can be categorized as type 1 diabetes by the Health Insurance Review System). In this lecture, I will be addressing the different glucose management protocols and/or methods in a variety of pancreatectomy cases and will also introduce the usefulness of CGMS for total pancreatectomy patients.

Prognostic impact of conservative surgery for pancreatic IPMNs

BackgroundThe extent of pancreatic resection for intraductal papillary mucinous neoplasms (IPMNs) remains an unresolved issue. The study aims at analyzing the prognostic impact of conservative surgery (CS) i.e. of pancreatoduodenectomy or distal pancreatectomy, versus total pancreatectomy (TP), for pancreatic IPMNs. MethodsWe retrospectively analyzed and compared data of patients who had undergone pancreatic resection for IPMNs at our center between November 2007 and April 2019. Patients were divided into two main groups based on the extent of surgery: TP-group and CS-group. Subsequently, the perioperative and the long-term outcomes were compared. Moreover, a sub-group analysis of patients with IPMN alone and patients with malignant IPMN, based on preoperative indications to surgery and post-operative histopathological findings, was also performed. ResultsFifty-three patients were included in the TP-group and 73 in the CS-group. In 50 (39.7%) cases the frozen section changed the pre-operative surgical planning, with an extension of the pancreatic resection, in 43 (34.1%) cases up to a total pancreatectomy. Twenty-six patients (20.6%) with low-grade dysplasia at the frozen section underwent CS, while twenty (15.8%) underwent TP. Comparing these two sub-groups no differences were found in surgical IPMN recurrence, nor progression. The rate of overall postoperative complications was 56.6% in the TP-group and 57.5% in the CS-group (p = 0.940). Fifteen patients (20.5%) developed diabetes in the CS-group.None of the patients treated with CS developed a surgical IPMN recurrence or progression during the follow-up period. Comparing OS and DFS of the two groups, we did not find any statistically significant difference (p = 0.619 and 0.315). ConclusionA timely CS can be considered an appropriate and valid strategy in the surgical treatment of the majority of pancreatic IPMNs, as it can avoid the serious long-term metabolic consequences of TP in patients with a long-life expectancy. On the contrary, TP remains mandatory in case of PDAC or high-risk features involving the entire gland.

Is primary total pancreatectomy in patients with high-risk pancreatic remnant justified and preferable to pancreaticoduodenectomy? -a matched-pairs analysis of 200 patients.

Total pancreatectomy (TP) eliminates the risk of postoperative pancreatic fistula (POPF) and its associated secondary complications. Hence, it may theoretically offer advantages over pancreaticoduodenectomy (PD) regarding early postoperative outcome of patients with high-risk pancreatic remnant. Ninety-day mortality and morbidity of 100 TP vs. 100 PD for pancreatic head lesions were retrospectively compared. Groups were matched for pancreatic texture, pancreatic duct size, final histology, age, gender and surgeon. Only patients at high risk for POPF due to soft pancreatic texture and small pancreatic duct <3 mm were included. Preoperatively, the TP-group was characterized by poorer general condition, more comorbidities and more pronounced obesity than the PD-group. Postoperatively, overall morbidity was lower after TP (63% vs. 88%, P<0.001) due to less mild complications. Postpancreatectomy hemorrhage rate was lower after TP than after PD (2% vs. 12%, P=0.014). Duration of surgery, hospital stay, major morbidity (30%) and mortality (7% vs. 5%) were the same. POPF was the most common complication after PD with 32%. Emergency completion pancreatectomy was necessary in 10% of PD with a significantly higher mortality compared to elective TP (50% vs. 7%, P=0.001). TP may reduce severe POPF-associated complications and prevent mortality related to emergency completion pancreatectomy in some elderly, obese and polymorbid patients with high-risk pancreatic remnant. Careful individual selection by an experienced pancreatic surgeon is mandatory.

Changes in the Perioperative and Postoperative Long-term Quality of Life after Total Pancreatectomy

Background: Quality of Life (QoL) is widely known to be poor after total pancreatectomy. This study was designed to evaluate the short-term and long-term consequences of endocrine and exocrine insufficiency and their associated effects on QoL and nutritional status. Methods: Prospective data was collected from patients who underwent total pancreatectomy at Seoul National University Hospital during an interval of 4 years and followed up for at least 1 year. QoL, and nutritional status were assessed by administering validated questionnaires (EORTC QLQ C-30, PAN26, GIQLI, MNA), preoperatively and 3, 12 months postoperatively. Results: A total of 30 patients were eligible for the study. 3 months after receiving total pancreatectomy, the global heath score (GHS) showed no significant difference (preoperatively 57.2 vs. 3 months postoperatively 68.3; P=0.119). By the 1st postoperative year, the GHS still showed no significant difference (preoperatively 57 vs. 1 year postoperatively 52.4; P=0.2) and no significant differences in most of the QoL categories. However, poor physical function (79.2 vs. 67.6; P=0.01), digestive difficulties (14.9 vs. 36.9; P=0.03) and altered bowel habits (9.2 vs. 25.6; P=0.03) continued even 1 year after surgery. Conclusion: The overall QoL score after total pancreatectomy was comparable to the preoperative QoL score. Some symptoms after total pancreatectomy significantly worsen after 3 months postoperatively, but then improve to a comparable level 1 year after surgery. Because some symptoms persist even after time has passed, supportive management is needed for total pancreatectomy patients, including nutritional support with pancreatic enzyme replacement and education for diabetes and diet.

Total pancreatectomy and salvage completion pancreatectomy-early and late outcomes without Islet cell auto-transplantation

Background: Total pancreatectomy was abandoned for decades because of high peri and post-operative morbidity and mortality. However, with better peri-operative outcome and post-operative management of exocrine and endocrine insufficiency, the hesitancy to perform total pancreatectomy has been disappearing. &#x0D; Objectives: This study aims to study exocrinal and endocrinal effects of total pancreatectomy without Islet cell auto-transplantation and compare quality of life index among total pancreatectomy with Whipple patients.&#x0D; Methodology: This is a prospectively conducted matched-pairs study. Group A underwent total or completion pancreatectomy after non-salvageable complications of Whipple operation. A matched-pairs analysis of quality of life index of these patients by using SF-36 questionnaire were compared with Group B who underwent Whipple operation during the same period of time, according to age, gender and pre-operative diagnosis. &#x0D; Results: In four years (from February 2016 to February 2020), 160 patients underwent Whipple operation. The mean age of the patients was 59.9 +/-14.3 years. A total of nine patients underwent total pancreatectomy, among which two had per-operative decision of total pancreatectomy and seven had completion pancreatectomy. Median post-operative hospital stay was 11 days with two mortalities. Median follow-up of 12 months and quality of life index of total pancreatectomy patients were comparable to Whipple patients, although a few single quality of life items were reduced. &#x0D; Conclusion: Exocrinal pancreatic supplements and long acting insulin have augmented control of diabetes despite of not using Islet cell auto-transplantation. Quality of life index of total pancreatectomy patients were comparable to that of Whipple patients. Hence, this study signifies the importance of completion pancreatectomy following non-salvageable complications after Whipple operation in order to save life.

Long-term health after pancreatic surgery: The view from 9 years

Background: Pancreatic surgery is increasingly performed for prophylaxis in healthy individuals. Informed consent requires that patients understand the probable long-term consequences of surgery. There is a scarcity of such information, as most quality of life surveys are completed soon after recovery, or in cancer patients with short overall follow up. Methods: Only patients surviving greater than 5 years from pancreatic surgery as of January 2014 for benign or malignant indications were surveyed using a written instrument designed to query information about hospitalizations, operations, pain, nutrition and diabetes following surgery. Patients operated for necrotizing pancreatitis were excluded. Patients were accrued from a prospectively maintained institutional database. Variables were analyzed according to pre-operative conditions validated from their medical records and operations performed. Results: 89 consented individuals completed surveys. 48% were female, 71% were Caucasian, and the median age at surgery was 65.7 years (IQR:55.6,70.3). The median follow-up from surgery was 9.3 years (IQR:8.7,9.9). 44% underwent a Whipple, 29% a distal, 16% a total and 11% a central pancreatectomy. 51% had cystic neoplasms, 33% adenocarcinoma and 16% neuroendocrine tumors. Currently, 33% reported unintentionally weighing less than before surgery, and 18% weighed intentionally less; the remainder weighed more or the same. Although only 2% took pancreatic enzyme replacement therapy prior to surgery, 41% currently utilized enzymes: 44% had a Whipple, 41% had a total, and 15% had a distal. Only 6% regularly took analgesia they attributed to their pancreatic operation, of which 50% took narcotics. Whereas 14% had diabetes before surgery, an additional 21% developed diabetes in the interval after their operations: 36% had a Whipple, 36% had a distal, and 28% had a total. Of the new, post-operative diabetics, 71% required insulin and 29% required oral medications. Overall, 12% of diabetics reported related complications, namely retinal and neuropathies; 50% in total pancreatectomy patients. 24% reported hospitalizations distant from recovery they attributed to their pancreatic operations: 31% for pancreatitis, 31% for small bowel obstruction without operation, 20% for gastrointestinal bleeding, 13% for hypoglycemia and 5% for infections. 18% underwent an ERCP following recovery, 66% of whom had multiple such procedures. 23% underwent additional operations they attributed to their pancreatic operation: 88% for incisional hernia, 6% for pancreaticojejunostomy revision, and 6% gastrojejunostomy revision. 3% of patients underwent additional cancer operations related to their original malignancy. Conclusion: This long-term survey details post-pancreatectomy health in 89 patients having undergone pancreatic surgery, and suggests that new-onset diabetes and pancreatic insufficiency are more common than typically reported in long-term survivors of pancreatic surgery. Additionally, nearly a quarter of patients require hospitalizations, endoscopic procedures and operations they attribute to their original operation during a median 9.3 years of follow-up. Further study is needed to determine if respondents were dissatisfied with their post-operative health therefore deleteriously biasing the findings. According to this study, surgeons need to be more guarded about life after pancreatic surgery, and prospective studies of long-term survivors are necessary.

Combined hepatic arterial resection in pancreatic resections for locally advanced pancreatic cancer.

Arterial involvement in advanced pancreatic cancer generally defines local unresectability. This study was aimed to evaluate the clinical outcomes of combined common hepatic arterial resection with pancreaticoduodenectomy or total pancreatectomy in patients with locally advanced pancreatic cancer involving the hepatic artery. Of 348 patients with pancreatic head cancers who underwent surgical resection between June 1999 and September 2015, 21 underwent combined common hepatic arterial resection with pancreaticoduodenectomy (17) or total pancreatectomy (4). Preoperative common hepatic arterial embolization was performed in 12 patients. Preoperative CT findings of hepatic arterial involvement, postoperative complications, survival rates, and prognostic factors for survival were analyzed. Twenty-one unresectable patients with locally advanced pancreatic cancer who underwent laparotomy in this study period were selected as the control group. Rates of pathological arterial invasion were significantly higher in patients with level III (>1800) CT findings (90%,9/10) than in patients with levels I and II (<1800) (27%, 3/11) (p<0.01). No surgical deaths occurred. Survival after surgical resection in all 21 patients was 47.6%, 6.6%, and 6.6% at 1, 3, and 5years, and median survival was 11months. The preoperative serum CA19-9 level was a significant prognostic factor for overall survival, median survivals were 21.5 and 8.3months in the low CA19-9 and high CA19-9 groups, respectively. No significant difference in survival between the high-CA19-9 group and the unresectable group was found. Combined common hepatic arterial resection in pancreaticoduodenectomy or total pancreatectomy might be feasible with an acceptable rate of surgical complications, and may have a beneficial effect on the prognosis only in patients with low preoperative serum CA19-9 levels.

Sirolimus in the treatment of three infants with diffuse congenital hyperinsulinism

Congenital hyperinsulinism (CHI) is a major cause of persistent hypoglycemia and brain damage. Therapeutic strategies to avoid near total pancreatectomy in patients who are unresponsive to maximum doses of diazoxide and octreotide remain to be identified, although sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, has been used successfully to treat diffuse type CHI. We used sirolimus to treat three infants with diffuse CHI. Diagnosis was confirmed clinically, biochemically and by genetic testing. Homozygous mutations in KCNJ11, ABCC8 and KCNJ11 were identified in infants 1, 2 and 3, respectively. Each infant had received the therapy for at least 2 months with close monitoring of glycemic response, serum insulin and C-peptide. None of the infants responded to the therapy. We conclude that sirolimus is less effective in the treatment of diffuse CHI in patients with severe mutations in the homozygous state compared with those with the mutations in the heterozygous.

Expanding the indications of pancreas transplantation alone.

Total pancreatectomy (TP) is associated with postoperative endocrine and exocrine insufficiency. Especially, insulin therapy reduces quality of life and may lead to long-term complications. We review the literature with regard to the potential option of pancreas transplantation alone (PTA) after TP in patients with chronic pancreatitis or benign tumors. A MEDLINE search (1958-2013) using the terminologies pancreas transplantation, pancreas transplantation alone, total pancreatectomy, morbidity, mortality, insulin therapy, and quality of life was performed. In addition, the current book and congress publications were reviewed. Total pancreatectomy after benign and borderline tumors as well as chronic pancreatitis is continuously increasing. Despite improvement of exogenous insulin therapy, more than 50% of these patients experience severe glucose control problems, which cause up to 50% long-term mortality. Pancreas transplantation alone can cure both endocrine and exocrine insufficiency and reduce the associated risks. The 3-year graft and patient survival rates after PTA are up to 73% and 100%, respectively. Pancreas transplantation alone after TP in patients with pancreatitis or benign tumors improves the recipient's quality of life and reduces long-term mortality. Considering the amount of available organs and potential candidates, PTA can be a treatment option for patients after TP with chronic pancreatitis or benign tumors.

SS9. Vascular Reconstruction plays an Important Role in the Treatment of Pancreatic Adenocarcinoma

Previous studies have proven the feasibility of performing a pancreaticoduodenectomy (Whipple) in patients with portal veinn/superior mesenteric vein (PV/SMV) or arterial invasion. We report our institutional experience with the use of a variety of vascular reconstructive methods during pancreatic resections for adenocarcinoma. A retrospective review was performed identifying all Whipple and total pancreatectomy patients from January 2003 through February 2013. All venous (PV/SMV) and arterial (SMA/hepatic) reconstructions were extracted and reviewed to determine survival and perioperative complications. During the 10-year study period, 270 Whipple and total pancreatectomy procedures were performed, of which 183 were for adenocarcinoma of the pancreas. A total of 60 of 183 (32.8%) vascular reconstructions were found, 49 venous and 11 arterial. Venous reconstruction included 37 (61.7%) primary repairs, 4 (6.7%) reconstructions with cryovein, 3 (5.0%) repairs with autologous vein patch, 3 (5.0%) autologous saphenous reconstructions, and 2 (3.33%) portocaval shunts. Additionally, there were 11 (18.3%) arterial reconstructions (seven hepatic artery and four superior mesenteric artery). There was one perioperative death (1.7%). One-year survival for all reconstructions was 70.3%, which is equivalent to T3 lesions that did not receive vascular reconstruction (72.6%), with a median survival time of 515 days and 12 patients still alive. Survival time was comparable with each type of venous reconstruction, averaging 528 days (11 of 49 patients still alive). Of the venous reconstructions, four of 49 (8.2%) resulted in PV thrombosis, three within the primary repair group and one delayed thrombosis within the cryovein group. There was no thrombosis in any patients after arterial reconstruction. An aggressive approach for stage II pancreatic cancers with venous or arterial invasion can be performed with comparable results when executed by an experienced institution with skilled oncologic and vascular surgeons.

Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension

Our aim was to evaluate the perioperative morbidity and survival of a selected group of patients with locally advanced pancreatic ductal adenocarcinoma (PDAC) and malignant obstruction of portal axis inducing portal hypertension (PH) who underwent a curative intent pancreatic resection, after neoadjuvant chemotherapy, adopting a new type of temporary intraoperative mesentericoportal shunt (TMPS). We analyzed the perioperative data and survival outcome of 15 patients with locally advanced PDAC and PH who underwent pancreatoduodenectomy combined with vascular resections between October 2008 and October 2012 using this TMPS. There was no perioperative mortality. Postoperative morbidity occurred in 7 patients without any postoperative liver failure. All patients underwent mesentericoportal venous resection, 11 of whom had a concomitant arterial resection. The mean ± SD follow-up was 16 ± 10 months (range, 4-40; median 15). Overall survival rates of patients were 78% and 11% at 1 and at 3 years, respectively. Median survival was 17 months. The 1-year disease-free survival was 36%. The use of this form of TMPS allowed us to achieve PD or total pancreatectomy in patients with locally advanced PDAC and PH without postoperative mortality but with increased morbidity. The relevance of such an aggressive approach is yet to be determined.

Reduction in delayed gastric emptying following non-pylorus preserving pancreaticoduodenectomy by addition of a Braun enteroenterostomy.

Delayed gastric emptying is a major cause of morbidity following pancreaticoduodenectomy.The impact of a Braun enteroenterostomy on delayed gastric emptying, used in reconstruction following classic pancreaticoduodenectomy, was assessed.Forty-four consecutive patients undergoing non-pylorus preserving pancreaticoduodenectomy from 2009 to 2011 by a single surgeon were included in this study.The first 20 patients had a standard antecolic gastroenterostomy and the subsequent 24 had the addition of a Braun enteroenterostomy.Patient characteristics, the extent of surgery, surgical findings and tumor characteristics were similar between the two groups. The delayed gastric emptying rate in the Braun enteroenterostomy (1/24, 4.2%) was significantly lower (P=0.008) than the standard reconstruction group (7/20, 35.0%). In the standard group, 6 of 7 cases (85.7%) of delayed gastric emptying were class C in nature. After exclusion of 8 total pancreatectomy patients, the pancreatic fistula rate in the Braun enteroenterostomy group (4/19, 21.1%) was similar (0.706) to the standard reconstruction group (5/17, 29.4%) as was the median length of hospital stay (10 days vs. 15 days; P=0.291). Braun enteroenterostomy technique was the only significant independent factor associated with reduced delayed gastric emptying with an odds ratio of 0.08 (95% confidence interval: 0.01-0.73; P=0.025).The use of Braun enteroenterostomy following non-pylorus preserving pancreaticoduodenectomy appears to result in a significant reduction in delayed gastric emptying.

Total Pancreatectomy for Pancreatic Adenocarcinoma

To analyze relative perioperative and long-term outcomes of patients undergoing total pancreatectomy versus pancreaticoduodenectomy. The role of total pancreatectomy has historically been limited due to concerns over increased morbidity, mortality, and perceived worse long-term outcome. Between 1970 and 2007, patients who underwent total pancreatectomy (n = 100) or pancreaticoduodenectomy (n = 1286) for adenocarcinoma were identified. Clinicopathologic, morbidity, and survival data were collected and analyzed. Total pancreatectomy patients had larger median tumor size (4 cm vs. 3 cm; P < 0.001) but similar rates of vascular (50.0% vs. 54.7%) and perineural invasion (90.7% vs. 91.8%) (total pancreatectomy vs. pancreaticoduodenectomy, respectively, both P > 0.05). A similar proportion of total pancreatectomy (74.7%) and pancreaticoduodenectomy (78.3%) patients had N1 disease (P = 0.45). Total pancreatectomy patients had more lymph nodes harvested (27 vs. 16) and were less likely to have positive resection margins (22.2% vs. 43.7%) (total pancreatectomy vs. pancreaticoduodenectomy, respectively, both P < 0.0001). Total pancreatectomy was increasingly used over time (1970-1989, n = 10, 1990-1999, n = 37, 2000-2007, n = 53). Total pancreatectomy was associated with higher 30-day mortality compared with pancreaticoduodenectomy (8.0% vs. 1.5%, respectively; P = 0.0007). However, total pancreatectomy operative mortality decreased over time (1970-1989, 40%; 1990-1999, 8%; 2000-2007, 2%; P = 0.0002). While operative morbidity was higher following total pancreatectomy (69.0% vs. 38.6% for pancreaticoduodenectomy; P < 0.0001), most complications were minor (Clavien Grade 1-2) (59%). Total pancreatectomy and pancreaticoduodenectomy patients had comparable 5-year survival (18.9% vs. 18.5%, respectively, P = 0.32). Total pancreatectomy perioperative mortality dramatically decreased over time. Long-term survival following total pancreatectomy versus pancreaticoduodenectomy was equivalent. Total pancreatectomy should be performed when oncologically appropriate.

Total Pancreatectomy for Chronic Pancreatitis

Pain from chronic pancreatitis can lead to narcotic addiction, frequent hospitalization, and disruption of daily activities. Total pancreatectomy has been considered a treatment of last resort because it leads to development of postoperative “brittle diabetes.” However, advances such as improved autologous islet cell transplantation have resulted in more-frequent use of total pancreatectomy in patients with disabling symptoms whose pancreatic morphology is not conducive to resection or decompressive surgery. Now, researchers in the U.K. have prospectively examined outcomes of …