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Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes

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Abstract

Background: Blumgart's pancreaticojejunostomy (PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes. Methods: We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula (CR-POPF) and analysis of its risk factors. Results: The CR-POPF rate was 12.3%. Fistula risk score (FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay. Conclusion: Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.

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... The full texts of the remaining 29 records were assessed for eligibility. Of these, 18 were excluded because they were trial protocols [50][51][52][53] , review 39 , letter 54 , studies with no comparison with BA 18,[20][21][22][23][25][26][27][28][29] and studies related with BA versus pancreaticogastrostomy 55,56 . Ultimately, one RCT 30 (from Asia) and ten non-randomized comparative studies (2 from Europe 19,38 and 8 from Asia 24,31-37 ) involving a total of 2412 patients were included in the quantitative syntheses. ...
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Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.
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Background: Postoperative pancreatic fistula (POPF), a complication frequently encountered following pancreaticoduodenectomy. Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the most frequently utilized reconstructive strategies with different anastomosis techniques. This study was conducted to evaluate the optimal surgical technique to prevent POPF. Methods: The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42023494393. Patients undergoing pancreaticoduodenectomy includes the use of PJ or PG with different anastomoses techniques and developed POPF were included. We conducted a systematic literature review from January 2019 to December 2023 using a comprehensive search strategy, through Web of Science, ProQuest, Science Direct, PubMed, and Google Scholar databases. Meta-analysis was utilized to analyze the outcomes. The risk of bias was assessed using the Newcastle-Ottawa scale. Results: Eighteen studies with 3343 patients who underwent various anastomoses (including the Modified DuVal, Heidelberg PJ, and Blumgart methods) were included. Postoperative pancreatic fistula (POPF) occurred in 27% of patients. Techniques such as modified Heidelberg, Peng, shark mouth PJ, and Kiguchi PJ were associated with lower POPF rates, whereas modified and classical Blumgart techniques exhibited higher rates. While mortality rates varied among surgical techniques, overall mortality was low. Conclusions: Data from this study can be used to shape future studies and direct physicians to develop strategies to reduce the risk of POPF and thereby reduce morbidity and mortality, leading to improved patient outcomes. Furthermore, this data can inform clinical decision-making and guide the development of evidence-based practice guidelines to optimize surgical outcomes.
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BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most serious complications after pancreaticoduodenectomy (PD), and the choice of pancreaticojejunostomy (PJ) is considered a key factor affecting the occurrence of POPF. Numerous anastomotic methods and their modifications have been proposed, and there is no method that can completely avoid the occurrence of POPF. Based on our team’s experience in pancreatic surgery and a review of relevant literature, we describe a novel invagination procedure for PJ using double purse string sutures, which has resulted in favourable outcomes. AIM To describe the precise procedural steps, technical details and clinical efficacy of the novel invagination procedure for PJ. METHODS This study adopted a single-arm retrospective cohort study methodology, involving a total of 65 consecutive patients who underwent PD with the novel invagination procedure for PJ, including the placement of a pancreatic stent, closure of the residual pancreatic end, and two layers of purse-string suturing. Baseline data included age, sex, body mass index (BMI), pancreatic texture, pancreatic duct diameter, operation time, and blood loss. Clinical outcomes included the operation time, blood loss, and incidence of POPF, postoperative haemorrhage, delayed gastric emptying, postoperative pulmonary infection, postoperative abdominal infection, and postoperative pulmonary infection. RESULTS The mean age of the patients was 59.12 (± 8.08) years. Forty males and 25 females were included, and the mean BMI was 21.61 kg/m2 (± 2.74). A total of 41.53% of patients had a pancreatic duct diameter of 3 mm or less. The mean operation time was 263.83 min (± 59.46), and the mean blood loss volume was 318.4 mL (± 163.50). Following the surgical intervention, only three patients showed grade B POPF (4.62%), while no patients showed grade C POPF. Five patients (5/65, 7.69%) were diagnosed with postoperative haemorrhage. Six patients (6/65, 9.23%) experienced delayed gastric emptying. Four patients (4/65, 6.15%) developed postoperative pulmonary infection, while an equivalent number (4/65, 6.15%) exhibited postoperative abdominal infection. Additionally, two patients (2/65, 3.08%) experienced postoperative pulmonary infection. CONCLUSION The novel invagination technique for PJ is straightforward, yields significant outcomes, and has proven to be safe and feasible for clinical application.
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Purpose Although laparoscopic pancreaticoduodenectomy (LPD) is increasingly performed in high-volume centers, pancreaticojejunostomy (PJ) is still the most challenging procedure. Pancreatic anastomotic leakage remains a major complication after PD. Thus, various technical modifications regarding PJ, such as the Blumgart technique, have been attempted to simplify the procedure and minimize anastomotic leakage. Three-dimensional (3D) laparoscopic systems have been shown to be particularly helpful in performing difficult and precise tasks. We present a modified Blumgart anastomosis in 3D-LPD and investigate its clinical outcomes. Methods A retrospective analysis of 100 patients who underwent 3D-LPD with modified Blumgart PJ from September 2018 to January 2020 was conducted. Data on the preoperative characteristics, operative outcomes, and postoperative characteristics of the patients were collected and analyzed. Results The mean operative time and duration of PJ were 348.2 and 25.1 min, respectively. The mean estimated blood loss was 112 mL. The overall rate of postoperative complications over Clavien‒Dindo classification III was 18%. The incidence of clinically relevant postoperative pancreatic fistula was 11%. The median postoperative hospital stay was 14.2 days. Only one patient required reoperation (1%), and no patient died in the hospital or 90 days after the operation. High BMI, small main pancreatic duct diameter, and soft pancreatic consistency had a significant influence on the occurrence of CR-POPF. Conclusions The surgical outcome of 3D-LPD with modified Blumgart PJ seems to be comparable to other studies in terms of operation time, blood loss, hospital stay, and complication incidence. We consider the modified Blumgart technique in 3D-LPD to be novel, reliable, safe, and favorable for PJ in the PD procedure.
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The paper presents the results of various studies and meta-analyses which focus on assessing the frequency of formation of clinically significant pancreatic fistulas in various types of pancreatic-digestive anastomoses. Pancreatodigestive anastomosis is not an independent predictive factor of pancreatic complications. None of the modern types of pancreatodigestive anastomosis has proved its superiority. The choice of the pancreatodigestive anastomosis method is based on the correct selection of the organ with which the pancreatic stump is connected and the surgeon’s experience and skill in forming the anastomosis.
Article
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Background: Surgeons continue to be concerned about complications after pancreaticoduodenectomy, especially postoperative pancreatic fistula. Among the factors that cause postoperative pancreatic fistula, the pancreaticojejunostomy technique has stood out in recent studies. In this study, we aimed to compare the surgical outcomes, especially POPF, of the modified Blumgart and the traditional anastomosis techniques in patients who underwent pancreaticoduodenectomy. Methods: A total of 144 patients who underwent pancreaticoduodenectomy were divided into 2 groups according to the performed pancreaticojejunostomy technique (modified Blumgart anastomosis, n = 91 and traditional anastomosis, n = 53). Preoperative clinicodemographic data, perioperative findings, and postoperative results were compared between the groups. Additionally, factors associated with clinically relevant postoperative pancreatic fistula were analyzed. Results: The modified Blumgart anastomosis group had lower clinically relevant postoperative pancreatic fistula rate than traditional anastomosis group (n = 8 (8.8%) versus n = 14 (26.4%), P = .005). On the contrary, the biochemical leakage rate was higher in the modified Blumgart anastomosis group (n = 30 (33%) versus n = 9 (17%), P = .037). While postoperative pancreatic fistula-related reoperation rate was lower (n = 2 (2.2%) versus n = 7 (13.2%), P = .013), the length of hospital stay was also shorter (11 days (5-47 days) versus 21 days (6-46 days), P < .001) in the modified Blumgart anastomosis group. Univariate and multivariate analyses revealed that modified Blumgart anastomosis was an independent and negative predictive factor for clinically relevant postoperative pancreatic fistula (odds ratio = 0.274, 95% confidence interval = 0.103-0.728, P = .009). Conclusion: Compared to the traditional anastomosis, modified Blumgart anastomosis decreases the rate of transition from biochemical leakage to clinically relevant postoperative pancreatic fistula and postoperative pancreatic fistula-related reoperation and also shortens the length of hospital stay. In addition, modified Blumgart anastomosis is an independent and negative predictive factor for the development of clinically relevant postoperative pancreatic fistula.
Article
Background Postoperative pancreatic fistula (POPF) is the most serious complication in patients who underwent pancreaticoduodenectomy (PD). The Blumgart anastomosis and its modifications are the favorable techniques of pancreaticojejunostomy anastomosis (PJ) performed worldwide. This report proposed the surgical outcomes of combined the new technique of modified Blumgart anastomosis with the long internal pancreatic duct stent for the (PJ). Study design We evaluated the surgical outcomes of a consecutive series of the patients at Panyananthaphikkhu Chonprathan Medical Center who underwent PD from June 2017 to June 2020. PJ was conducted in all cases using the transpancreatic mattress suture modified from the original Blumgart's technique and the long pancreatic duct stent was placed across the anastomosis. The primary endpoints were clinically relevant postoperative pancreatic fistula (CR-POPF) and 30-day mortality rate. The secondary endpoints were the early postoperative complications. Results Twelve patients underwent PD using the proposed technique. Overall mortality was 8.3%. The rate of CR-POPF was 33.3%, two patients had a prolonged period of the intraabdominal drain, and one patient underwent the percutaneous drainage of the intraabdominal collection. The only patient with Grade C-POPF died after re-exploration due to severe septicemia. The median postoperative length of stay (LOS) was 12 days. Conclusions The combination of the new technique of modified Blumgart PJ with the long internal pancreatic duct stent is an alternative technique that may prevent the pancreatic fistula. The CR-POPF rate and the overall survival are comparable to prior literature. However, further study is needed to clarify the definite outcomes.
Article
The fistula risk score (FRS) has been developed to predict clinically relevant postoperative pancreatic fistula (CR-POPF). This study aimed to validate its applicability in patients undergoing pancreatoduodenectomy at a tertiary care teaching centre in northern India. Historical records of 105 patients who underwent pancreatoduodenectomy between January 2010 and December 2017 were reviewed. The FRS was calculated for each patient based on operative records. Various outcome parameters, including POPF, were evaluated across four discrete risk zones. The performance of the model was assessed by area under the receiver operating curve. Based on FRS, patients were grouped into 4 risk zones: Group A (negligible risk, score 0): 4 patients (3.8%); Group B (low risk, score 1–2): 35 patients (33.3%); Group C (moderate risk, score 3–6): 54 patients (51.4%), and Group D (high risk, score 7–10): 12 patients (11.4%). Overall incidence of CR-POPF was 15.2%. The incidence of CR-POPF in negligible, low, moderate, and high-risk patients was 0%, 8.5%, 14.8%, and 41.6%, respectively (p = 0.003). Increasing FRS correlated well with the CR-POPF development on univariate (p < 0.03) and multivariate (p < 0.04) analysis. Upon assessing the model performance for fistula risk zones using area under the receiver operating curve, an overall result of 0.80 (95 CI 0.71–0.87) was obtained, indicating good ability of the FRS to predict the development of CR-POPF. This single institutional experience validates FRS as a good and reliable tool for predicting the development of CR-POPF after pancreatoduodenectomy. This study affirms its universal applicability.
Article
Background The volume–outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact. MethodA systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded.ResultsA total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10–25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10–25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively). Conclusion With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.
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Resection of pancreas, in particular pancreaticoduodenectomy, is a complex procedure, commonly performed in appropriately selected patients with benign and malignant disease of the pancreas and periampullary region. Despite significant improvements in the safety and efficacy of pancreatic surgery, pancreaticoenteric anastomosis continues to be the “Achilles heel” of pancreaticoduodenectomy, due to its association with a measurable risk of leakage or failure of healing, leading to pancreatic fistula. The morbidity rate after pancreaticoduodenectomy remains high in the range of 30% to 65%, although the mortality has significantly dropped to below 5%. Most of these complications are related to pancreatic fistula, with serious complications of intra-abdominal abscess, postoperative bleeding, and multiorgan failure. Several pharmacological and technical interventions have been suggested to decrease the pancreatic fistula rate, but the results have been controversial. This paper considers definition and classification of pancreatic fistula, risk factors, and preventive approach and offers management strategy when they do occur.
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Leakage of pancreatojejunostomies after pancreatic resections remains a challenge even at high volume centers. We here utilized a simple pancreas anatomy classification to study the effect of pancreatic anatomy on the development of pancreatic fistula after pancreas resection and pancreatojejunostomies. Also, the effect of surgical experience on the development of pancreatic fistulas was studied. Three hundred ninety-one patients undergoing pancreatic resections and reconstruction with a pancreatojejunostomy were studied. Closed suction drain was placed behind the anastomosis, and drainage fluid was collected postoperatively. A twofold increase over the serum amylase level was considered a fistula and was classified as described by the International Study Group on Pancreatic Fistula Definition. In 67 patients, the structural quality of the pancreatic parenchyma and the diameter of the pancreatic duct were classified as being <2 mm (2 points), between 2 and 5 mm (1 point), or >5 mm (0 points). The pancreatic parenchyma was assessed as being soft (2 points), intermediate (1 point), or hard (0 points). Pancreatic leakage as a function of surgeons' experience was also studied. Leakage was found in 25.1%, 8.9% being of type A, 10.2% being of type B, and 5.9% of type C. Pancreatic fistulas were only observed in patients with a score of 2 points or more. Age over 70 years, operations >6 h, and extended lymphadenectomy or surgeons experience were not associated with a higher leakage rate. In this study, leakage after pancreatojejunostomy was only associated with pancreatic anatomy, classified with a simple score. That score might improve comparability of studies on pancreatic leakage. Furthermore, drainage of pancreatic anastomosis might safely be omitted in patients with a low risk score for leakage.
Article
Background: This study is to clarify the feasibility of robotic pancreaticoduodenectomy in terms of surgical risks, clinically relevant postoperative pancreatic fistula, and oncologic outcomes compared with open pancreaticoduodenectomy by using propensity score matching. Traditional open pancreaticoduodenectomy and robotic pancreaticoduodenectomy have been compared only in small, retrospective, and nonrandomized cohort studies with variable quality. Methods: Prospectively collected data for pancreaticoduodenectomy were evaluated. Comparison between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy was carried out after propensity-score matching. A total of 117 robotic pancreaticoduodenectomy and 128 open pancreaticoduodenectomy cases were performed during the study period. After propensity score matching, 87 cases were included for comparison in each cohort. Results: Longer operation time, less blood loss, more lymph nodes harvested, and less delayed gastric emptying were noted in the robotic pancreaticoduodenectomy cases. We found no significant difference regarding the overall postoperative complications by Clavien-Dindo classification, postpancreatectomy hemorrhage, wound infection rate, and postoperative hospital stay. Clinically relevant postoperative pancreatic fistula was not significantly different between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy, regardless of the Callery risk factor, with overall clinically relevant postoperative pancreatic fistula of 8.0% by robotic pancreaticoduodenectomy and 12.6% by open pancreaticoduodenectomy after propensity score matching. We found no survival difference between robotic pancreaticoduodenectomy and open pancreaticoduodenectomy when the comparison was specifically performed for each primary periampullary malignancy. Conclusion: Robotic pancreaticoduodenectomy is associated with less blood loss, less delayed gastric emptying, and more lymph node yield. Propensity scored-matched analysis revealed that robotic pancreaticoduodenectomy is not inferior to open pancreaticoduodenectomy in terms of clinically relevant postoperative pancreatic fistula, surgical risks, and survival outcomes.
Article
Background: Many pancreatic anastomoses have been proposed to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, but a complete overview is lacking. This systematic review and meta-analysis aims to provide an online overview of all pancreatic anastomosis techniques and to evaluate the incidence of clinically relevant POPF in randomized controlled trials (RCTs). Methods: A literature search was performed to December 2017. Included were studies giving a detailed description of the pancreatic anastomosis after open pancreatoduodenectomy and RCTs comparing techniques for the incidence of POPF (International Study Group of Pancreatic Surgery [ISGPS] Grade B/C). Meta-analyses were performed using a random-effects model. Results: A total of 61 different anastomoses were found and summarized in 19 subgroups (www.pancreatic-anastomosis.com). In 6 RCTs, the POPF rate was 12% after pancreaticogastrostomy (n = 69/555) versus 20% after pancreaticojejunostomy (n = 106/531) (RR0.59; 95%CI 0.35-1.01, P = 0.05). Six RCTs comparing subtypes of pancreaticojejunostomy showed a pooled POPF rate of 10% (n = 109/1057). Duct-to-mucosa and invagination pancreaticojejunostomy showed similar results, respectively 14% (n = 39/278) versus 10% (n = 27/278) (RR1.40, 95%CI 0.47-4.15, P = 0.54). Conclusion: The proposed online overview can be used as an interactive platform, for uniformity in reporting anastomotic techniques and for educational purposes. The meta-analysis showed no significant difference in POPF rate between pancreatic anastomosis techniques.
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Several definitions for pancreatic leakage after pancreaticodoudenectomy exist, and the reported range of 2–50% underscores this variation. The goal was to determine if drain data alone was predictive of a leak and validate International Study Group on Pancreatic Fistula (ISGPF) leak criteria. Participating surgeons entered de-identified data into a web-based database designed to collect Whipple-related data. Definitions used were the ISGPF definition, ≥3 days, amylase 3× normal; and Sarr’s definition, ≥5 days, amylase 5× normal, >30 ml. We compared how well these two definitions were at detecting a leak and its complications. There were 1,507 cases submitted from 16 international institutions. A pancreaticoduodenectomy (PPPD) was performed in 76.2%. Drain placement occurred in 98.0%. Using the ISGPF definition, the pancreatic leak rate was 26.7 and 14.3% with the Sarr definition. There were more grades A and B leaks detected by the ISGPF definition. Both determined grade C leaks equally. Both d
Article
Background: In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of the present report is to verify the value of the International Study Group of Pancreatic Fistula definition and grading of postoperative pancreatic fistula and to update the International Study Group of Pancreatic Fistula classification in light of recent evidence that has emerged, as well as to address the lingering controversies about the original definition and grading of postoperative pancreatic fistula. Methods: The International Study Group of Pancreatic Fistula reconvened as the International Study Group in Pancreatic Surgery in order to perform a review of the recent literature and consequently to update and revise the grading system of postoperative pancreatic fistula. Results: Based on the literature since 2005 investigating the validity and clinical use of the original International Study Group of Pancreatic Fistula classification, a clinically relevant postoperative pancreatic fistula is now redefined as a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula. Consequently, the former "grade A postoperative pancreatic fistula" is now redefined and called a "biochemical leak," because it has no clinical importance and is no longer referred to a true pancreatic fistula. Postoperative pancreatic fistula grades B and C are confirmed but defined more strictly. In particular, grade B requires a change in the postoperative management; drains are either left in place >3 weeks or repositioned through endoscopic or percutaneous procedures. Grade C postoperative pancreatic fistula refers to those postoperative pancreatic fistula that require reoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula. Conclusion: This new definition and grading system of postoperative pancreatic fistula should lead to a more universally consistent evaluation of operative outcomes after pancreatic operation and will allow for a better comparison of techniques used to mitigate the rate and clinical impact of a pancreatic fistula. Use of this updated classification will also allow for more precise comparisons of surgical quality between surgeons and units who perform pancreatic surgery.
Article
Background: Clinically relevant postoperative pancreatic fistula (grades B and C of the ISGPS definition) remains the most troublesome complication after pancreatoduodenectomy. The approach to management of the pancreatic remnant via some form of pancreatico-enteric anastomosis determines the incidence and severity of clinically relevant postoperative pancreatic fistula. Despite numerous trials comparing diverse pancreatico-enteric anastomosis techniques and other adjunctive strategies (pancreatic duct stenting, somatostatin analogues, etc), currently, there is no clear consensus regarding the ideal method of pancreatico-enteric anastomosis. Methods: An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the best contemporary literature concerning pancreatico-enteric anastomosis and worked to develop a position statement on pancreatic anastomosis after pancreatoduodenectomy. Results: There is inherent risk assumed by creating a pancreatico-enteric anastomosis based on factors related to the gland (eg, parenchymal texture, disease pathology). None of the technical variations of pancreaticojejunal or pancreaticogastric anastomosis, such as duct-mucosa, invagination method, and binding technique, have been found to be consistently superior to another. Randomized trials and meta-analyses comparing pancreaticogastrostomy versus pancreaticojejunostomy yield conflicting results and are inherently prone to bias due to marked heterogeneity in the studies. The benefit of stenting the pancreatico-enteric anastomosis to decrease clinically relevant postoperative pancreatic fistula is not supported by high-level evidence. While controversial, somatostatin analogues appear to decrease perioperative complications but not mortality, although consistent data across the more than 20 studies addressing this topic are lacking. The Fistula Risk Score is useful for predicting postoperative pancreatic fistula as well as for comparing outcomes of pancreatico-enteric anastomosis across studies. Conclusion: Currently, no specific technique can eliminate development of clinically relevant postoperative pancreatic fistula. While consistent practice of any standardized technique may decrease the rate of clinically relevant postoperative pancreatic fistula, experienced surgeons can have lower postoperative pancreatic fistula rates performing a variety of techniques depending on the clinical situation. There is no clear evidence on the benefit of internal or external stenting after pancreatico-enteric anastomosis. The use of somatostatin analogues may be important in decreasing morbidity after pancreatoduodenectomy, but it remains controversial. Future studies should focus on novel approaches to decrease the rate of clinically relevant postoperative pancreatic fistula with appropriate risk adjustment.
Article
Background: Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting, with or without replacement, is preferable. This is an update of a systematic review. Objectives: To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and four major Chinese biomedical databases up to November 2015. We also searched several major trials registers. Selection criteria: Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents, replacement versus no replacement following pancreaticoduodenectomy. Data collection and analysis: Two review authors independently extracted the data. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. We showed the results as risk ratio (RR) or mean difference (MD), with 95% confidence interval (CI). We assessed the quality of evidence using GRADE (http://www.gradeworkinggroup.org/). Main results: We included eight studies (1018 participants). The average age of the participants ranged from 56 to 68 years. Most of the studies were conducted in single centers in Japan (four studies), China (two studies), France (one study), and the USA (one study). The risk of bias was low or unclear for most domains across the studies. Stents versus no stentsThe effect of stents on reducing pancreatic fistula in people undergoing pancreaticoduodenectomy was uncertain due to the low quality of the evidence (RR 0.67, 95% CI 0.39 to 1.14; 605 participants; 4 studies). The risk of in-hospital mortality was 3% in people who did receive stents compared with 2% (95% CI 1% to 6%) in people who had stents (RR 0.73, 0.28 to 1.94; 605 participants; 4 studies; moderate-quality evidence). The effect of stents on reoperation was uncertain due to wide confidence intervals (RR 0.67, 0.36 to 1.22; 512 participants; 3 studies; moderate-quality evidence). We found moderate-quality evidence that using stents reduces total hospital stay by just under four days (mean difference (MD) -3.68, 95% CI -6.52 to -0.84; 605 participants; 4 studies). The risk of delayed gastric emptying, wound infection, and intra-abdominal abscess was uncertain (gastric emptying: RR 0.75, 95% CI 0.24 to 2.35; moderate-quality evidence) (wound infection: RR 0.73, 95% CI 0.40 to 1.32; moderate-quality evidence) (abscess: RR 1.38, 0.49 to 3.85; low-quality evidence). Subgroup analysis by type of stent provided limited evidence that external stents lead to lower risk of fistula compared with internal stents. External versus internal stentsThe effect of external stents on the risk of pancreatic fistula, reoperation, delayed gastric emptying, and intra-abdominal abscess compared with internal stents was uncertain due to low-quality evidence (fistula: RR 1.44, 0.94 to 2.21; 362 participants; 3 studies) (reoperation: RR 2.02, 95% CI 0.38 to 10.79; 319 participants; 3 studies) (gastric emptying: RR 1.65, 0.66 to 4.09; 362 participants; 3 studies) (abscess: RR 1.91, 95% CI 0.80 to 4.58; 362 participants; 3 studies). The rate of in-hospital mortality was lower in studies comparing internal and external stents than in those comparing stents with no stents. One death occurred in the external-stent group (RR 0.33, 0.01 to 7.99; low-quality evidence). There were no cases of pancreatitis in participants who had internal stents compared with three in those who had external stents (RR 0.15, 0.01 to 2.73; low-quality evidence). The difference between internal and external stents on total hospital stay was uncertain due to the wide confidence intervals around the average effect of 1.7 days fewer with internal stents (9.18 days fewer to 5.84 days longer; 262 participants; 2 studies; low-quality evidence). The analysis of wound infection could not exclude a protective effect with either approach (RR 1.41, 0.44 to 4.48; 319 participants; 2 studies; moderate-quality evidence). Operative replacement of pancreatic juice versus not replacing pancreatic juice There was insufficient evidence available from a small trial to ascertain the effect of replacing pancreatic juice. Authors' conclusions: This systematic review has identified limited evidence on the effects of stents. We have not been able to identify convincing direct evidence of superiority of external over internal stents. We found a limited number of RCTs with small sample sizes. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.
Article
Background: The aim of this study was to compare perioperative outcomes after Blumgart pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) for pancreatic-enteric reconstruction following pancreaticoduodenectomy. Methods: Data of patients undergoing Blumgart PJ and PG were retrieved from prospectively-collected database. Matched patients in each surgical groups were included based on the Callery risk scoring system for clinically relevant postoperative pancreatic fistula (CR-POPF) (grades B and C). Surgical parameters and risks were compared between these two groups. Results: A total of 206 patients undergoing PD were included. Blumgart PJ was associated with shorter postoperative hospital stay (median (range) 25 (10-99) vs. 27 (10-97) days, P = 0.022). There was no surgical mortality in the Blumgart PJ group, but a 4.9% perioperative mortality in the PG, P = 0.030. The CR-POPF by Blumgrt PG is significantly lower than that by PG for overall patients (7% vs. 20%, P = 0.007), especially for those in intermediate fistula risk zone (6% vs. 21%, P =0.048) and high fistula risk zone (14% vs. 47%, P=0.038). Conclusions: Blumgart PJ is superior to PG in terms of pancreatic leakage and surgical mortality. Blumgart PJ can be recommended for pancreatic reconstruction after PD for all pancreatic remnant subtypes.
Article
Objectives This study aimed to compare pancreaticojejunostomy (PJ) with pancreaticogastrostomy (PG) after pancreaticoduodenectomy (PD).MethodsA literature search of PubMed and the Cochrane Central Register of Controlled Trials for studies comparing PJ with PG after PD was conducted. The primary outcome for meta-analysis was pancreatic fistula. Secondary outcomes were morbidity, mortality, biliary fistula, intra-abdominal fluid collection, hospital length of stay (LoS), postoperative haemorrhage and reoperation. Outcome measures were odds ratios (ORs) and mean differences with 95% confidence intervals (CIs).ResultsSeven recent RCTs encompassing 1121 patients (559 PJ and 562 PG cases) were involved in this meta-analysis. Incidences of pancreatic fistula (10.6% versus 18.5%; OR 0.52, 95% CI 0.37–0.74; P = 0.0002), biliary fistula (2.3% versus 5.7%; OR 0.42, 95% CI 0.03–3.15; P = 0.03) and intra-abdominal fluid collection (8.0% versus 14.7%; OR 0.50, 95% CI 0.34–0.74; P = 0.0005) were significantly lower in the PG than the PJ group, as was hospital LoS (weighted mean difference: −1.85, 95% CI −3.23 to −0.47; P = 0.008). Subgroup analysis indicated that severe pancreatic fistula (grades B or C) occurred less frequently in the PG than the PJ group (8.3% versus 20.5%; OR 0.37, 95% CI 0.23–0.59; P < 0.00001). However, there was no significant difference in morbidity (48.9% versus 51.0%; OR 0.90, 95% CI 0.70–1.16; P = 0.41), mortality (3.2% versus 3.5%; OR 0.82, 95% CI 0.43–1.58; P = 0.56), delayed gastric emptying (16.6% versus 14.7%; relative risk: 1.02, 95% CI 0.62–1.68; P = 0.94), postoperative haemorrhage (9.6% versus 11.1%; OR 0.82, 95% CI 0.54–1.24; P = 0.35) or reoperation (9.9% versus 9.8%; OR 0.93, 95% CI 0.60–1.43; P = 0.73).Conclusions Pancreaticogastrostomy provides benefits over PJ after PD, including in the incidences of pancreatic fistula, biliary fistula and intra-abdominal fluid collection and in hospital LoS. Therefore, PG is recommended as a safer and more reasonable alternative to PJ reconstruction after PD.
Article
Postoperative pancreatic fistula (POPF) is the main cause of fatal complications after pancreatoduodenectomy. There is still no universally accepted technique for pancreaticoenterostomy, especially in patients with soft pancreas. Between July 2008 and June 2013, 240 patients who underwent pancreatoduodenectomy were enrolled in this single-institution matched historical control study. To approximate the pancreatic parenchyma to the jejunal seromuscular layer, 120 patients underwent anastomosis using the Kakita method (three or four interrupted penetrating sutures) and 120 underwent anastomosis using the modified Blumgart anastomosis (m-BA) method (one to three transpancreatic/jejunal seromuscular sutures to completely cover the pancreatic stump with jejunal serosa). The rate of clinically relevant POPF formation was significantly lower in the m-BA group than that in the Kakita group (2.5 vs 36 %; p < 0.001). The duration of drain placement and the length of postoperative hospital stay were significantly shorter in the m-BA group. Multivariate analysis showed that m-BA was an independent predictor of non-formation of POPF (hazard ratio, 0.02; 95 % confidence interval, 0.01-0.08; p < 0.001). The m-BA method is safe and simple and improves postoperative outcomes. We suggest that the m-BA is suitable for use as a standard method of pancreaticojejunostomy after pancreatoduodenectomy.
Article
Background Complete macroscopic tumor resection is one of the most relevant predictors of long-term survival in pancreatic ductal adenocarcinoma. Because locally advanced pancreatic tumors can involve adjacent organs, “extended” pancreatectomy which includes the resection of additional organs may be needed to achieve this goal. Our aim was to develop a common consistent terminology to be used in centers reporting results of pancreatic resections for cancer. Methods An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature on extended pancreatectomies and worked together to establish a consensus on the definition and the role of extended pancreatectomy in pancreatic cancer. Results Macroscopic (R1) and microscopic (R0) complete tumor resection can be achieved in patients with locally advanced disease by extended pancreatectomy. Operative time, blood loss, need for blood transfusions, duration of stay in the intensive care unit and hospital, morbidity, and possibly also perioperative mortality are increased with extended resections. Long-term survival is similar compared to standard resections but appears to be better compared to bypass surgery or nonsurgical palliative chemotherapy or chemoradiotherapy. It was not possible to identify any clear prognostic criteria based on the specific additional organ resected. Conclusions Despite increased perioperative morbidity, extended pancreatectomy is warranted in locally advanced disease to achieve long-term survival in pancreatic ductal adenocarcinoma if macroscopic clearance can be achieved. Definitions of extended pancreatectomies for locally advanced disease (and not distant metastatic disease) are established which are crucial for comparison of results of future trials across different practices and countries, in particular for those utilizing neoadjuvant therapy.
Article
Background Postoperative pancreatic fistula is the leading cause of death and morbidity after pancreaticoduodenectomy. However, the best reconstruction method to reduce occurrence of fistula is debated. We did a multicentre, randomised superiority trial to compare the outcomes of different reconstructive techniques in patients undergoing pancreaticoduodenectomy for pancreatic or periampullary tumours. Methods Patients aged 18–85 years with confirmed or suspected neoplasms of the pancreas, distal bile duct, ampulla vateri, duodenum, or periampullary tumours were eligible for inclusion. An internet-based platform was used to randomly assign patients to either pancreaticojejunostomy or pancreaticogastrostomy as reconstruction after pancreaticoduodenectomy, using permuted blocks with six patients per block. Within each centre the randomisation was stratified on the pancreatic duct diameter (≤3 mm vs >3 mm) measured at the time of surgery. The primary endpoint was the occurrence of clinical postoperative pancreatic fistula (grade B or C) as defined by the International Study Group on Pancreatic Fistula. The study was not masked and analyses were done by intention to treat. Patient follow-up was closed 2 months after discharge from the hospital. This study is registered with ClinicalTrials.gov, number NCT00830778. Findings Between June, 2009, and August, 2012, we randomly allocated 167 patients to receive pancreaticojejunostomy and 162 to receive pancreaticogastrostomy. 33 (19·8%) patients in the pancreaticojejunostomy group and 13 (8·0%) in the pancreaticogastrostomy group had clinical postoperative pancreatic fistula (OR 2·86, 95% CI 1·38–6·17; p=0·002). The overall incidence of postoperative complications did not differ significantly between the groups (99 in the pancreaticojejunostomy group vs 100 in the pancreaticogastrostomy group), although more events in the pancreaticojejunostomy group were of grade ≥3a than in the pancreaticogastrostomy group (39 vs 35). Interpretation In patients undergoing pancreaticoduodenectomy for pancreatic head or periampullary tumours, pancreaticogastrostomy is more efficient than pancreaticojejunostomy in reducing the incidence of postoperative pancreatic fistula. Funding Funding Johnson & Johnson Medical Devices, Belgium.
Article
The Fistula Risk Score (FRS), a ten-point scale that relies on weighted influence of four variables, has been shown to effectively predict clinically relevant postoperative pancreatic fistula (CR-POPF) development and its consequences after pancreatoduodenectomy (PD). The proposed FRS demonstrated excellent predictive capacity; however, external validation of this tool would confirm its universal applicability. From 2001 to 2012, 594 PDs with pancreatojejunostomy reconstructions were performed at three institutions. POPFs were graded by International Study Group on Pancreatic Fistula standards as grades A, B, or C. The FRS was calculated for each patient, and clinical outcomes were evaluated across four discrete risk zones as described in the original work. Receiver operator curve analysis was performed to judge model validity. One hundred forty-two patients developed any sort of POPF, of which 68 were CR-POPF (11.4 % overall; 8.9 % grade B, 2.5 % grade C). Increasing FRS scores (0-10) correlated well with CR-POPF development (p < 0.001) with a C-statistic of 0.716. When segregated by discrete FRS-risk groups, CR-POPFs occurred in low-, moderate-, and high-risk patients, 6.6, 12.9, and 28.6 % of the time, respectively (p < 0.001). Clinical outcomes including complications, length of stay, and readmission rates also increased across risk groups. This multi-institutional experience confirms the Fistula Risk Score as a valid tool for predicting the development of CR-POPF after PD. Patients devoid of any risk factors did not develop a CR-POPF, and the rate of CR-POPF approximately doubles with each subsequent risk zone. The FRS is validated as a strongly predictive tool, with widespread applicability, which can be readily incorporated into common clinical practice and research analysis.
Article
Background: Clinically relevant postoperative pancreatic fistulas (CR-POPF) are serious inherent risks of pancreatic resection. Preoperative CR-POPF risk assessment is currently inadequate and rarely disqualifies patients who need resection. The best evaluation of risk occurs intraoperatively, and should guide fistula prevention and response measures thereafter. We sought to develop a risk prediction tool for CR-POPF that features intraoperative assessment and reveals associated clinical and economic significance. Study design: Based on International Study Group of Pancreatic Fistula classification, recognized risk factors for CR-POPF (small duct, soft pancreas, high-risk pathology, excessive blood loss) were evaluated during pancreaticoduodenectomy. An optimal risk score range model, selected from 3 different constructs, was first derived (n = 233) and then validated prospectively (n = 212). Clinical and economic outcomes were evaluated across 4 ranges of scores (negligible risk, 0 points; low risk, 1 to 2; intermediate risk, 3 to 6; high risk, 7 to 10). Results: Clinically relevant postoperative pancreatic fistulas occurred in 13% of patients. The incidence was greatest with excessive blood loss. Duct size <5 mm was associated with increased fistula rates that rose with even smaller ducts. These factors, together with soft pancreatic parenchyma and certain disease pathologies, afforded a highly predictive 10-point Fistula Risk Score. Risk scores strongly correlated with fistula development (p < 0.001). Notably, patients with scores of 0 points never developed a CR-POPF, while fistulas occurred in all patients with scores of 9 or 10. Other clinical and economic outcomes segregated by risk profile across the 4 risk strata. Conclusions: A simple 10-point Fistula Risk Score derived during pancreaticoduodenectomy accurately predicts subsequent CR-POPF. It can be readily learned and broadly deployed. This prediction tool can help surgeons anticipate, identify, and manage this ominous complication from the outset.
Article
Postoperative pancreatic leakage after pancreaticoduodenectomy is often serious. Although some studies have suggested that stenting the anastomosis can reduce the incidence of this complication, the value of stenting in the setting of pancreaticoduodenectomy remains unclear. Studies comparing outcomes of stent versus no stent, and internal versus external stent placement for pancreaticoduodenectomy were eligible for inclusion. Pooled odds ratios (ORs) with 95 per cent confidence intervals were calculated using fixed- or random-effects models. From a search of the literature published between January 1973 and September 2011, five randomized clinical trials (RCTs) and 11 non-randomized observational clinical studies (OCS) involving 1726 patients were selected for inclusion in this review. Meta-analysis of RCTs revealed that placing a stent in the pancreatic duct did not reduce the incidence of postoperative pancreatic fistula. External stents had no advantage over internal stents in terms of clinical outcome. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RCTs: OR 0·42, 0·24 to 0·76, P = 0·004; OCS: OR 0·43, 0·27 to 0·68, P < 0·001), delayed gastric emptying (RCTs: OR 0·41, 0·19 to 0·87, P = 0·02) and postoperative morbidity (RCTs: OR 0·55, 0·34 to 0·89, P = 0·02) compared with no stent. Pancreatic duct stenting did not reduce the incidence of pancreatic fistula and other complications in pancreaticoduodenectomy compared with no stenting. Although no difference was found between external and internal stents in terms of efficacy, external stents seemed to reduce the incidence of pancreatic fistula compared with control.
Article
Pancreaticoduodenectomy is the treatment of choice for periampullary and pancreatic head tumors. In case of hepatic artery abnormalities, early pancreatic transection during pancreaticoduodenectomy may prove inappropriate. Early retroportal lamina dissection improves exposure of the superior mesenteric vessels and anatomic variants of the hepatic artery, where safeguarding is mandatory. We describe our early retroportal lamina approach in patients with anatomic variants of the hepatic artery before pancreatic transection. This approach was used during 42 pancreaticoduodenectomies with a hepatic artery anatomic variant which was spared in 40 patients. Arterial reconstruction was performed in 2 patients. Five patients with a hepatic artery variant and adenocarcinoma involving the portomesenteric junction required venous resection and reconstruction. Early retroportal lamina dissection during pancreaticoduodenectomy in patients with hepatic artery anatomic variants enables easier exposure, avoiding injuries that might compromise the liver arterial supply. When the portomesenteric vein is involved, this approach facilitates en bloc "no touch" venous resection and reconstruction.
Article
To develop and validate a risk score to predict the 30- and 90-day mortality after a pancreaticoduodenectomy or total pancreatectomy on the basis of preoperative risk factors in a high-volume program. Data from a prospectively maintained institutional database were collected. In a random subset of 70% of patients (training cohort), multivariate logistic regression was used to develop a simple integer score, which was then validated in the remaining 30% of patients (validation cohort). Discrimination and calibration of the score were evaluated using area under the receiver operating characteristic curve and Hosmer-Lemeshow test, respectively. Tertiary referral center. The study comprised 1976 patients in a prospectively maintained institutional database who underwent pancreaticoduodenectomy or total pancreatectomy between 1998 and 2009. The 30- and 90-day mortality. In the training cohort, age, male sex, preoperative serum albumin level, tumor size, total pancreatectomy, and a high Charlson index predicted 90-day mortality (area under the curve, 0.78; 95% CI, 0.71-0.85), whereas all these factors except Charlson index also predicted 30-day mortality (0.79; 0.68-0.89). On validation, the predicted and observed risks were not significantly different for 30-day (1.4% vs 1.0%; P = .62) and 90-day (3.8% vs 3.4%; P = .87) mortality. Both scores maintained good discrimination (for 30-day mortality, area under the curve, 0.74; 95% CI, 0.54-0.95; and for 90-day mortality, 0.73; 0.62-0.84). The risk scores accurately predicted 30- and 90-day mortality after pancreatectomy. They may help identify and counsel high-risk patients, support and calculate net benefits of therapeutic decisions, and control for selection bias in observational studies as propensity scores.
Article
Although mortality of Whipple's pancreaticoduodenectomy (WPD) is reduced to <5%, morbidity still remains between 30 and 50%. Pancreaticojejunal anastomosis remains the main cause of morbidity. Blumgart anastomosis using transpancreatic U sutures has been proposed to decrease the leak rate and its associated morbidity. We analyzed the results of Blumgart anastomosis applied in consecutive cases of WPD. Of 189 patients with periampullary or pancreatic cancer admitted, 100 patients underwent WPD. Except for 2 patients (no duct identified preoperatively), all patients underwent pancreaticojejunostomy by the Blumgart anastomotic technique. The records of 98 patients were analyzed for pancreatic leak and its related complications using the definitions given by the International Study Group for Pancreatic Surgery. Of 98 patients, 63 were men. The mean operative time was 390 min (270-690 min) and blood loss was 275 ml (100-1,000 ml). Overall mortality was 3.06%. The clinically significant pancreatic anastomotic failure leak was seen in only 7 (7.14%) cases (grade B, n = 4; grade C, n = 3) with one patient requiring relaparotomy due to leak. Only one patient died due to a leak-related complication. Blumgart pancreaticojejunal anastomosis can be routinely used for reconstruction in WPD. It is a technically simple procedure and is associated with low rates of fistula and its related complications.
Article
Pancreatic anastomotic failure has traditionally been a source of significant morbidity and potential mortality after pancreaticoduodenectomy. Both patient-derived and technical factors contribute to pancreatic anastomotic failure. From a technical standpoint, an "ideal" pancreaticojejunal anastomosis would meet the following criteria: applicable to all patients, easy to teach, and associated with a low rate of pancreatic anastomotic failure-related complications. The pancreaticojejunostomy described by one of the authors (LHB) meets the criteria for an "ideal" pancreaticojejunostomy. We performed an audit of results of a consecutive series of patients at two institutions who underwent pancreaticojejunostomy using the described technique. Pancreaticojejunostomy after pancreaticoduodenectomy was performed in all cases using a novel two-layer technique consisting of an outer full thickness pancreas-to-seromuscular jejunal anastomosis and an inner duct-to-mucosal anastomosis. Incidences of pancreatic anastomotic failure (measured using the International Study Group of Pancreatic Fistula definition) and perioperative pancreatic anastomotic failure-related complications were analyzed. One hundred eighty-seven patients underwent pancreaticojejunostomy after pancreaticoduodenectomy using the described technique. Overall mortality was 1.6%. The rate of clinically significant pancreatic anastomotic failure (International Study Group of Pancreatic Fistula grade B or C) was only 6.9%. There was no bleeding, reoperation, or mortality secondary to pancreatic anastomotic failure among patients in this series. The novel pancreaticojejunostomy is applicable to all patients in whom the pancreatic duct can be identified, and it is associated with very low rates of significant postoperative morbidity and mortality. These findings support its routine use for pancreaticojejunal reconstruction after pancreaticoduodenectomy.
Article
Leakage from the pancreaticojejunostomy is the major cause of septic complications after partial pancreaticoduodenectomy. This study evaluated a new transpancreatic U-suture technique (Blumgart anastomosis, BA), which aims to avoid shear forces during knot-tying. Using a before-after study design, BA was compared with a modified Cattell-Warren anastomosis (CWA). Two patient cohorts (CWA, 90; BA, 92), which were similar with respect to primary diagnosis, age, sex and American Society of Anesthesiologists score, were compared retrospectively. Dependent variables were surgical and overall morbidity and mortality after partial pancreaticoduodenectomy. Duration of operation (354 versus 328 min for CWA versus BA; P = 0.002), pancreatic leakage rate (13 versus 4 per cent; P = 0.032), postoperative haemorrhage (11 versus 3 per cent; P = 0.040), total surgical complications (31 versus 15 per cent; P = 0.011), general complications (36 versus 17 per cent; P = 0.005) and length of intensive care unit stay (median 5.4 versus 2.8 days; P = 0.015) were significantly reduced after BA. These effects were not related merely to an improvement over time. BA appears to be a fast, simple and safe technique for pancreaticojejunostomy. It might reduce leakage rates and surgical complications after partial pancreaticoduodenectomy.
Article
To identify individual risk factors and to establish an index of risk in biliary tract surgery, data on 16 potential predictive factors were compiled from a series of 186 biliary tract operations excluding simple cholecystectomy. Eight factors had a significant association with postoperative mortality. Linear discriminant analysis showed that serum creatinine, serum albumin and serum bilirubin levels in the week before surgery had independent significance in predicting postoperative mortality. The discriminant function derived identified a high risk group of patients and the predictive value was confirmed in an independent series of 54 biliary tract operations carried out in another surgical unit. The discriminant function derived for patients jaundiced before surgery also defined a high and low risk group and was similarly validated. Identification of high risk patients undergoing surgery for obstructive jaundice may be useful in defining a group of patients to be considered for trials of preliminary biliary drainage.
Article
The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula. 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. 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. 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% (17/145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatic 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. 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.
Article
A review of mortality and morbidity for pancreaticoduodenectomy was performed for 145 consecutive patients who underwent the operative procedure between 1988 and 1991. In the past, pancreaticoduodenectomy has carried a high hospital morbidity and mortality. During the 1970s, many considered that the operation should be abandoned. Recent data, however, suggest that a marked drop in both morbidity and mortality have occurred for this operative procedure. Among the 145 consecutive patients who underwent pancreaticoduodenectomy, 108 patients were 69 years of age or younger, and 37 were 70 years of age or older. Four patients were 80 years of age or older. One hundred and seven patients had a malignant neoplasm, whereas 38 patients had benign disease. There were no significant differences in preoperative risk factors when the younger and older, and benign disease and malignant disease groups were compared. Mean operative time was 7.3 hours. Median blood loss was 0, indicating that more than one-half of the patients underwent pancreaticoduodenectomies without blood transfusions. There were no significant differences in postoperative complications when the younger and older, and benign disease and malignant disease groups were compared. There was no hospital or 30-day mortality. With appropriate preoperative selection, virtually any patient in any age group, with benign or malignant disease, can undergo pancreaticoduodenectomy with minimal risk of hospital mortality.
Article
The records of 131 consecutive patients with periampullary carcinoma who underwent pancreaticoduodenectomy within a 12-year period were reviewed to determine the perioperative risk factors of pancreaticojejunal (PJ) anastomotic leak. Twenty-one PJ leaks were identified, for a frequency of 16% (21 of 131); 19% (4 of 21) of these patients eventually died of PJ leak-related complications. A total of 23 items of perioperative data, presumed as risk factors predisposing to PJ leak, were examined. By univariate analysis, advanced age, prolonged duration of untreated jaundice, deep jaundice, decreased creatinine clearance, increased intraoperative blood loss, and shock during operation were statistically significant. However, by multivariate analysis, only duration of jaundice, creatinine clearance, and intraoperative blood loss turned out to be independent risk factors. Noteworthily, jaundiced patients with impaired creatinine clearance not only had a higher incidence of PJ leak, but were also more liable to experience sepsis and intraabdominal bleeding, which uniformly elicited a grave clinical course. Routine preoperative biliary drainage failed to enhance the security of PJ. Completion pancreatectomy continued to carry a poor prognosis, and should be avoided when possible and replaced by early, aggressive radiologic intervention.
Article
The authors reviewed the pathology, complications, and outcomes in a consecutive group of 650 patients undergoing pancreaticoduodenectomy in the 1990s. Pancreaticoduodenectomy has been used increasingly in recent years to resect a variety of malignant and benign diseases of the pancreas and periampullary region. Between January 1990 and July 1996, inclusive, 650 patients underwent pancreaticoduodenal resection at The Johns Hopkins Hospital. Data were recorded prospectively on all patients. All pathology specimens were reviewed and categorized. Statistical analyses were performed using both univariate and multivariate models. The patients had a mean age of 63 +/- 12.8 years, with 54% male and 91% white. The number of resections per year rose from 60 in 1990 to 161 in 1995. Pathologic examination results showed pancreatic cancer (n = 282; 43%), ampullary cancer (n = 70; 11%), distal common bile duct cancer (n = 65; 10%), duodenal cancer (n = 26; 4%), chronic pancreatitis (n = 71; 11%), neuroendocrine tumor (n = 31; 5%), periampullary adenoma (n = 21; 3%), cystadenocarcinoma (n = 14; 2%), cystadenoma (n = 25; 4%), and other (n = 45; 7%). The surgical procedure involved pylorus preservation in 82%, partial pancreatectomy in 95%, and portal or superior mesenteric venous resection in 4%. Pancreatic-enteric reconstruction, when appropriate, was via pancreaticojejunostomy in 71% and pancreaticogastrostomy in 29%. The median intraoperative blood loss was 625 mL, median units of red cells transfused was zero, and the median operative time was 7 hours. During this period, 190 consecutive pancreaticoduodenectomies were performed without a mortality. Nine deaths occurred in-hospital or within 30 days of operation (1.4% operative mortality). The postoperative complication rate was 41%, with the most common complications being early delayed gastric emptying (19%), pancreatic fistula (14%), and wound infection (10%). Twenty-three patients required reoperation in the immediate postoperative period (3.5%), most commonly for bleeding, abscess, or dehiscence. The median postoperative length of stay was 13 days. A multivariate analysis of the 443 patients with periampullary adenocarcinoma indicated that the most powerful independent predictors favoring long-term survival included a pathologic diagnosis of duodenal adenocarcinoma, tumor diameter <3 cm, negative resection margins, absence of lymph node metastases, well-differentiated histology, and no reoperation. This single institution, high-volume experience indicates that pancreaticoduodenectomy can be performed safely for a variety of malignant and benign disorders of the pancreas and periampullary region. Overall survival is determined largely by the pathology within the resection specimen.
Article
Since 1968, there have been three published reports in the United States literature of 41, 118, and 145 consecutive patients undergoing pancreaticoduodenectomy without mortality. In all of these series, the pancreatic remnant was anastomosed to the jejunum. This study was designed to review 152 consecutive patients who underwent pancreaticoduodenectomy in whom the pancreatic remnant was anastomosed to the stomach (pancreaticogastrostomy). A total of 152 patients underwent pancreaticoduodenectomy with pancreaticogastrostomy between July 1992 and May 2002. There were 85 men and 67 women with a mean age of 65.7 years (range 31 to 90 years). Of the patients, 87 were less than 69 years of age and 65 were more than 69 years. A total of 114 patients had a malignant neoplasm and the remaining 38 had either cystic neoplasms or benign disease. When the two groups were compared, the patients who were more than 69 years of age had a significantly high incidence of hypertension, previous cancer, atrial fibrillation, and coronary artery disease. In addition, patients more than 69 years of age had a significantly high incidence of jaundice and placement of preoperative stents. Patients more than 69 years of age had significantly less operative time but there was no between-group difference in estimated blood loss, transfusion, number of units transfused, and postoperative length of stay. There was no postoperative mortality [corrected] in this series. Pancreatic leak and fistulae were the most common complications, followed by intraabdominal abscess, wound infection, and delayed gastric emptying. In this study, 152 consecutive patients underwent pancreaticoduodenectomy with pancreaticogastrostomy without postoperative mortality. Morbidity was mostly because of pancreatic leaks and fistulae, which were successfully treated nonoperatively. With proper selection, careful preoperative preparation, and proper intraoperative conduct of operation, the Whipple procedure can be performed without postoperative mortality.
Article
Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time. A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide. The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons. The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Article
Postoperative pancreatic fistula (POPF) is still regarded as a major complication. The incidence of POPF varies greatly in different reports, depending on the definition applied at each surgical center. Our aim was to agree upon an objective and internationally accepted definition to allow comparison of different surgical experiences. An international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easy-to-apply definition of POPF, graded primarily on clinical impact. A POPF represents a failure of healing/sealing of a pancreatic-enteric anastomosis or a parenchymal leak not directly related to an anastomosis. An all-inclusive definition is a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase activity. Three different grades of POPF (grades A, B, C) are defined according to the clinical impact on the patient's hospital course. The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed.
Article
The aim of the study is to validate a new classification of pancreatic fistula (PF) and to document risk factors for PF. A retrospective study was performed on 100 patients who underwent pancreaticoduodenectomy (PD) within a 2-year period. PF was diagnosed according to the criteria developed by an International Study Group on Pancreatic Fistula (ISGPF). Sixteen pre- and intraoperative risk factors for PF were analyzed. Of 100 patients 32 developed PF; grade A in 21 patients, grade B in 10, and grade C in 1. Four risk factors including pathological diagnosis, concomitant surgery, diameter of pancreatic duct, and texture of the remnant pancreas were found to be significantly associated with PF by univariate analysis. Texture of the remnant pancreas and concomitant surgery were demonstrated to be independent risk factors by multivariate logistic regression. If a PF occurred, advanced age was found to be a risk factor for PF grade B by univariate analysis, but age was not an independent risk factor by multivariate logistic regression. The status of the remnant pancreas is identified asa substantial risk factor for PF after PD. When soft remnant pancreas is encountered, more careful handling is required in an attempt to minimize the rate of PF. This study confirms that the ISGPF classification of PF is useful.
Article
Postoperative hemorrhage is one of the most severe complications after pancreatic surgery. Due to the lack of an internationally accepted, universal definition of postpancreatectomy hemorrhage (PPH), the incidences reported in the literature vary considerably, even in reports from randomized controlled trials. Because of these variations in the definition of what constitutes a PPH, the incidences of its occurrence are not comparable. The International Study Group of Pancreatic Surgery (ISGPS) developed an objective, generally applicable definition of PPH based on a literature review and consensus clinical experience. Postpancreatectomy hemorrhage is defined by 3 parameters: onset, location, and severity. The onset is either early (< or =24 hours after the end of the index operation) or late (>24 hours). The location is either intraluminal or extraluminal. The severity of bleeding may be either mild or severe. Three different grades of PPH (grades A, B, and C) are defined according to the time of onset, site of bleeding, severity, and clinical impact. An objective, universally accepted definition and clinical grading of PPH is important for the appropriate management and use of interventions in PPH. Such a definition also would allow comparisons of results from future clinical trials. Such standardized definitions are necessary to compare, in a nonpartisan manner, the outcomes of studies and the evaluation of novel operative treatment modalities in pancreatic surgery.
Article
Delayed gastric emptying (DGE) is one of the most common complications after pancreatic resection. In the literature, the reported incidence of DGE after pancreatic surgery varies considerably between different surgical centers, primarily because an internationally accepted consensus definition of DGE is not available. Several surgical centers use a different definition of DGE. Hence, a valid comparison of different study reports and operative techniques is not possible. After a literature review on DGE after pancreatic resection, the International Study Group of Pancreatic Surgery (ISGPS) developed an objective and generally applicable definition with grades of DGE based primarily on severity and clinical impact. DGE represents the inability to return to a standard diet by the end of the first postoperative week and includes prolonged nasogastric intubation of the patient. Three different grades (A, B, and C) were defined based on the impact on the clinical course and on postoperative management. The proposed definition, which includes a clinical grading of DGE, should allow objective and accurate comparison of the results of future clinical trials and will facilitate the objective evaluation of novel interventions and surgical modalities in the field of pancreatic surgery.
Article
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.
Article
Significant progress in surgical technique and perioperative management has substantially reduced the mortality rate of pancreatic surgery. However, morbidity remains considerably high, even in expert hands and leakage from the pancreatic stump still accounts for the majority of surgical complications after pancreatic head resection. For that reason, management of the pancreatic remnant after partial pancreatoduodenectomy remains a challenge. This review will focus on technique, pitfalls, and complication management of pancreaticoenteric anastomoses. A medline search for surgical guidelines, prospective randomized controlled trials, systematic metaanalysis, and clinical reports was performed with regard to surgical technique and complication management of pancreatic anastomoses. Pancreaticojejunostomy appears to be most widely performed, but pancreaticogastrostomy is a reasonable alternative. Postoperative treatment with octreotide can be recommended only for patients with soft pancreatic tissue, and neither stents of the pancreatic duct nor drainages have proven to effectively reduce anastomotic complications. Gastroparesis remains the most common complication after pancreatic surgery and should be treated conservatively. However, it may be a symptom of other local complications, such as anastomotic leakage, pancreatic fistula or abscess. All septic complications may finally result in late postoperative hemorrhage, which requires immediate diagnostic workup and therapy. Today, interventional radiology has emerged as a standard tool in the management of local septic complications and bleeding. Therefore, relaparotomy has become less frequent and salvage pancreatectomy is now a rare procedure in case of local complications. The surgeon's experience with one or the other technique of pancreatic anastomosis appears to be more important than the technique itself.
Article
Pancreatic neuroendocrine tumors constitute a small percentage of pancreatic tumors. Surgical resection is the best treatment for these types of tumors. Aggressive surgical resection including multivisceral resection provides long-term survival. Even palliative resection of the tumor is justifiable. Here we share our experience with the management of pancreatic neuroendocrine tumors. Between January 1993 and April 2007 we operated on 54 patients with pancreatic neuroendocrine tumor. We have analyzed our data retrospectively. Patients were analyzed in terms of demographic characteristics, operative procedure, postoperative outcome and survival. Out of 54 patients, 31 patients had nonfunctional tumor and 23 patients had functional tumors. Neuroendocrine carcinoma was found in 19 patients. Pancreaticoduodenectomy was performed in 21 patients. Simultaneous liver resection was performed in 4 patients and multiorgan resection for locally advanced pancreatic tumor was performed in 3 patients. Surgical resection is the best option for the treatment of pancreatic neuroendocrine tumors. Aggressive resection provides survival benefit and a better quality of life. If the entire gross tumor can be resected, multiorgan resection or simultaneous liver resection is justifiable.
pancreaticoduodenectomy: from skill to indications
pancreaticoduodenectomy: from skill to indications. Gastroenterol Res Pract 2014;2014:210835.
postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors
postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors. Am J Surg 2009;197:702-709.
Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume
  • D J Gouma
  • R C Van Geenen
  • T M Van Gulik
  • R J De Haan
  • L T De Wit
  • O R Busch
Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 2000;232:786-795.
proposal with evaluation in a cohort of 6336 patients and results of a survey
proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-213.