Surgical resection remains the best treatment for patients with periampullary tumors. Many series have been reported with low or zero mortality, however, high incidence of complications is the rule. This study aims to present the results of pancreaticoduodenectomy and factors predisposing to postoperative complications, especially pancreatic leak, at our center.
Between January 2000 and December 2006, 216 periampullary tumors were treated by Whipple pancreaticoduodenectomy. Pancreaticogastrostomy was done in 183 patients and pancreaticojejunostomy in 33 patients. Hospital mortality and surgical complications were recorded with special emphasis on pancreatic leak. All specimens were histologically examined for the presence and origin of malignant tissue.
The mean age was 58 years and male to female ratio was 2:1. The commonest symptom was jaundice (97.7%) followed by abdominal pain (74%). Operative mortality in 7 patients (3.2%). 71 (33%) patients developed 1 or more complications, pancreatic leak occurred in 23 (10.6%) patients, abdominal collection in 23 patients (10.6%) and delayed gastric emptying in 19 (8.8%) patients. Factors that influenced the development of postoperative complications included type of pancreaticoenteric anastomosis, pancreatic texture and intraoperative blood transfusion of 4 or more blood units. Pancreatic leak was commoner with PJ (p=0.001), soft pancreatic texture (p=0.008), intraoperative blood transfusion of 4 or more units (p<0.0001). Periampullary adenocarcinoma was found in 204 (94.4%) patients, chronic pancreatitis in 9 (4.2%) patients, 2 patients with solid and papillary neoplasm, and 1 patient with NHL (Non-Hodgkin's Lymphoma).
Surgery is the only hope for patients with periampullary tumors. Postoperative complications after pancreaticoduodenectomy depend largely on surgical technique and can be reduced reasonably with the adoption of pancreaticogastrostomy, which is safer and easier to learn than pancreaticojejunostomy.
"Afferent loop obstruction (ALO) is a rare complication of pancreaticoduodenectomy (PD), with a reported incidence varying from 1.2 to 13% . Pannala et al. , in their retrospective cohort study, reported 24 (13%) patients who developed ALO among 186 pancreatic cancer patients treated with PD; in 9 (38%) patients, obstruction was caused by radiation enteritis of the afferent loop. "
[Show abstract][Hide abstract] ABSTRACT: As the literature on afferent loop obstruction (ALO) after pancreaticoduodenectomy (PD) is very limited, standardized rules for its management do not exist. Herein, we report the case of a 65-year-old male patient with chronic ALO who had undergone PD with single Roux-en-Y limb reconstruction and adjuvant chemoradiation therapy for pancreatic head adenocarcinoma 2 years earlier. The patient was brought to the operating room with the diagnosis of radiation enteritis of the afferent loop with segmental involvement and concurrent hepaticojejunostomy (HJ) and pancreaticojejunostomy (PJ) stricture. Complete mobilization of the afferent loop, removal of the affected segment and reconstruction were performed. Reconstruction of the afferent loop was a one-way option for the surgeons because the Roux-en-Y reconstruction limited endoscopic access to the afferent loop, and the segmental radiation injury of the afferent loop ruled out bypass surgery. However, mobilization of the affected segment through a field of dense adhesions and revision of the HJ and PJ were technically demanding.
Case Reports in Oncology 08/2013; 6(2):424-9. DOI:10.1159/000354576
"Endoscopic therapy, using either a nasobiliary drain or an internal stent, restores normal bile flow and facilitates leak closure. Endoscopic drainage appears to reduce or eliminate the transpapillary pressure gradient maintained by the sphincter of Oddi, diverting bile preferentially into the duodenum and away from the leakage site . In the present case, we performed abdominal computed tomography, however we had only a limitedly accurate diagnosis at our disposal. "
[Show abstract][Hide abstract] ABSTRACT: A 70-year-old man had undergone pancreaticoduodenectomy due to a distal common bile duct malignancy. After the operation, serous fluid discharge decreased from two drain tubes in the retroperitoneum. Over four weeks, the appearance of the serous fluid changed to a greenish bile color and the patient persistently drained over 300 ml/day. Viewed as bile leak at the choledochojejunostomy, treatment called for endoscopic diagnosis and therapy. Cap-fitted forward-viewing endoscopy demonstrated that the distal tip of a pancreatic drain catheter inserted at the pancreaticojejunostomy site had penetrated the opposite jejunum wall. One of the drain tubes primarily placed in the retroperitoneum had also penetrated the jejunum wall, with the distal tip positioned near the choledochojejunostomy site. No leak of contrast appeared beyond the jejunum or anastomosis site. Following repositioning of a penetrating catheter of the pancreaticojejunostomy, four days later, the patient underwent removal of two drain tubes without additional complications. In conclusion, the distal tip of the catheter, placed to drain pancreatic juice, penetrated the jejunum wall and may have caused localized perijejunal inflammation. The other drain tube, placed in the retroperitoneal space, might then have penetrated the inflamed wall of the jejunum, allowing persistent bile drainage via the drain tube. The results masqueraded as bile leakage following pancreaticoduodenectomy.
Case Reports in Gastroenterology 05/2011; 5(2):295-300. DOI:10.1159/000329172
[Show abstract][Hide abstract] ABSTRACT: As the life expectancy of people in Western countries continues to rise, so too does the number of elderly patients. In parallel,
robotic surgery continues to gain increasing acceptance, allowing for more complex operations to be performed by minimally
invasive approach and extending indications for surgery to this population. The aim of this study is to assess the safety
of robotic general surgery in patients 70years and older. From April 2007 to December 2009, patients 70years and older,
who underwent various robotic procedures at our institution, were stratified into three categories of surgical complexity
(low, intermediate, and high). There were 73 patients, including 39 women (53.4%) and 34 men (46.6%). The median age was 75years
(range 70–88years). There were 7, 24, and 42 patients included, respectively, in the low, intermediate, and high surgical
complexity categories. Approximately 50% of patients underwent hepatic and pancreatic resections. There was no statistically
significant difference between the three groups in terms of morbidity, mortality, readmission or transfusion. Mean overall
operative time was 254±133min (range 15–560min). Perioperative mortality and morbidity was 1.4% and 15.1%, respectively.
Transfusion rate was 9.6%, and median length of stay was 6days (range 0–30days). Robotic surgery can be performed safely
in the elderly population with low mortality, acceptable morbidity, and short hospital stay. Age should not be considered
as a contraindication to robotic surgery even for advanced procedures.
KeywordsRobotic surgery-Elderly-Pancreatic surgery-Liver resection-Outcomes-Complications
Journal of Robotic Surgery 08/2010; 4(2):91-98. DOI:10.1007/s11701-010-0191-1
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