1
|
Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1724-1785. [PMID: 39389105 DOI: 10.1055/a-2338-3716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
2
|
Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:e874-e995. [PMID: 39389103 DOI: 10.1055/a-2338-3533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
3
|
Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
4
|
Houghton EJ, Rubio JS. Surgical management of the postoperative complications of hepato-pancreato-biliary surgery. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Eduardo Javier Houghton
- Teaching and Research Department, DAICIM Foundation, Buenos Aires, Argentina
- Surgery Division, B. Rivadavia Hospital, Buenos Aires, Argentina
- Department of Surgery, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Juan Santiago Rubio
- Solid Organ Transplant Service, Hospital de Alta Complejidad en Red El Cruce Dr. Néstor Carlos Kirchner, Buenos Aires, Argentina
| |
Collapse
|
5
|
Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
6
|
Effects of Fasting and Administration of Octreotide Acetate and Ulinastatin on Clinical Outcomes of Pancreatic Fistula after Pancreatoduodenectomy. Int Surg 2022. [DOI: 10.9738/intsurg-d-21-00022.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: Postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy is the most serious complication of these surgical procedures; therefore, we examine the effectiveness of fasting, and administration of octreotide acetate and ulinastatin as a method of prevention. Summary of Background Data : Although various drug therapies and surgical techniques have been used for the treatment of POPF, no decisive treatment for POPF exists. Methods: The clinical course of 30 patients who developed POPF was retrospectively evaluated and compared between no dietary intake (n=18), octreotide acetate (n=8), and ulinastatin (n=8) using an overlapping design. Patients were allocated to either the dietary intake or fasting (no dietary intake) group, and those in the no dietary intake group were further divided into the octreotide acetate or ulinastatin group. Results: Length of hospitalization was longer for the no dietary intake group than for the dietary intake group (p=0.002). When considering only grade B or C POPF cases, the no dietary intake group had a longer length of hospitalization and a higher white blood cell count on day 7 after the diagnosis of POPF than the dietary intake group (p<0.05). The white blood cell count was also higher in the octreotide acetate group than in the ulinastatin group (p=0.021). The length of hospitalization was shorter in the ulinastatin group than in the octreotide acetate group (p=0.025). Conclusions: The use of no dietary intake, octreotide acetate, and ulinastatin do not seem to contribute to the clinical course of patients with POPF after pancreatoduodenectomy.
Collapse
|
7
|
Qiu J, Li M, Du C. Antecolic reconstruction is associated with a lower incidence of delayed gastric emptying compared to retrocolic technique after Whipple or pylorus-preserving pancreaticoduodenectomy. Medicine (Baltimore) 2019; 98:e16663. [PMID: 31441841 PMCID: PMC6716732 DOI: 10.1097/md.0000000000016663] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The aim of present study is to investigate the relationship between the antecolic (AC) route of gastrojejunostomy (GJ) after pancreaticoduodenectomy (PD) or duodenojejunostomy (DJ) reconstruction after pylorus-preserving pancreaticoduodenectomy (PPPD), and the incidence of delayed gastric emptying (DGE). METHODS An electronic search of 4 databases to identify all articles comparing AC and retrocolic (RC) reconstruction after PD or PPPD was performed. RESULTS Fifteen studies involving 2270 patients were included for final pooled analysis. The overall incidence of DGE was 27.2%. Meta-analysis results showed AC group had lower incidence of DGE (odds ratio, 0.29; 95% confidence interval [CI], 0.16-0.52, P < .0001) and shorter hospital length of stay (weight mean difference, -3.29; 95% CI, -5.2 to -1.39, P = .0007). Days until to liquid and solid diet in the AC group were also significantly earlier than that in the RC group (P = .0006 and P < .0001). There was no difference in operative time, incidence of pancreatic fistula and bile leakage, and mortality, respectively. CONCLUSIONS AC route of GJ after PD or DJ after PPPD is associated with a lower incidence of DGE. However, the preferred route for GJ or DJ reconstruction remains to be investigated in well-powered, randomized, controlled trial.
Collapse
|
8
|
Li Y, Wu W, Zhang T, Liao Q, Zhao Y, Dai M. Comparison of long-term benefits of organ-preserving pancreatectomy techniques for benign or low-grade malignant tumors at the pancreatic head. Medicine (Baltimore) 2017; 96:e9420. [PMID: 29390567 PMCID: PMC5758269 DOI: 10.1097/md.0000000000009420] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The aim of this article was to investigate and emphasize the clinical benefits of organ-preserving surgeries by comparing the pancreatic head resection with segmental duodenectomy (PHRSD), pylorus-preserving pancreatoduodenectomy (PPPD), and classic pancreatoduodenectomy (PD).A retrospective analysis of PHRSD (20 patients), PPPD (42 patients), and PD (92 patients) with benign lesions, low-grade malignancies, or early-stage carcinomas at the pancreatic head was performed since 2008. The intraoperative and postoperative courses and a long-term statuses were compared.The overall average age of the patients in 3 groups was 48.82 years old (range 12-76). The mean operative time and the blood loss were significantly less in the PHRSD and PPPD groups than that in the PD group (P < .05), but there were no differences between the PHRSD and PPPD groups. The possibilities of postoperative complications were equivalent in all 3 groups. During an average follow-up time of 61.1 months, there were no recurrence or distant metastasis happened. Patients in the PHRSD and PPPD groups had a better long-term nutritional status because they had less body weight loss (P < .01), and suffered less from long-term diarrhea (P < .001) than that in the PD group. However, the results in the PPPD group seemed to be better than that in the PHRSD group.PHRSD and PPPD are ideal procedures of organ-preserving pancreatectomy to fulfill the curative goals of benign lesions, low-grade malignancies, or early-stage carcinomas at the pancreatic head. It was proved to be operative safe and could bring patients with a better nutritional status and quality of life after surgery. However, PHRSD was more difficult with no better long-term benefits than PPPD, which asked a comprehensive consideration when made the surgical choice.
Collapse
|
9
|
Kamo H, Tashiro S, Yoshioka K, Sumise Y, Okitsu N, Harino Y, Yamaguchi T, Ikeyama S, Yamanaka A. No-touch pylorus-resecting pancreatoduodenectomy can reduce postoperative complications even in low volume center. THE JOURNAL OF MEDICAL INVESTIGATION 2015; 62:188-94. [PMID: 26399346 DOI: 10.2152/jmi.62.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
PURPOSES Pancreatoduodenectomy (PD) was performed for 6 periampullary cancer patients by using methods verified by quality randomized controlled trials (RCT) in a low-volume center (LVC). The purpose of this study was to verify the clinical results. METHODS No-touch pylorus-resecting pancreatoduodenectomy (PrPD), antecolic gastrojejunostomy, pancreatico-jejunostomy with a lost stent tube to the main pancreatic duct, and early removal of a prophylactic drain were performed. RESULTS The drain could be removed 4 days after operation, and no pancreatic fistula was observed in all cases. Solid food could be started on POD4 after removing the drain. Furthermore, postoperative systemic chemotherapy could be started earlier. CONCLUSION Although we have only a few PD cases a year in our institution, PD can be conducted safely without complications by using the methods verified by quality RCTs.
Collapse
|
10
|
Skipenko OG, Bedzhanjan K, Shatverjan D, Bagmet K, Chardarov K. [Prevention of gastrostasis after pancreaticoduodenal resection: new technique of gastroenterostomy]. Khirurgiia (Mosk) 2015:17-30. [PMID: 26081183 DOI: 10.17116/hirurgia2015417-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It was performed a retrospective comparative analysis of treatment results of 113 patients with pancreatic head and periampular cancer. The main group consisted of 58 patients in whom pancreaticoduodenal resection was performed according to an original technique of Russian Scientific Center of Surgery. Control group included 55 patients who underwent end-to-side gastrojejunostomy reconstruction. We have analyzed immediate postoperative complications in 2 groups without taking into consideration nosological forms of the disease. Pancreaticojejunostomy failure was diagnosed postoperatively in 5 (8.6%) patients in main group and in 10 (18.2%) patients in control group. There was no hepaticoentero- and gastroenterostomy failure in patients who underwent new technique of gastrojejunostomy while these events were observed in 8 (14.5%) and 3 (5.5%) patients respectively in control group. Mortality was 1.7% (n=1) in main group and 5.5% (n=3) in control group (p=0.29). Mild degree of gastrostasis (A class) was observed in 54 (93.7%) patients of main group and in 34 (61.8%) patients of control group (p=0.0004). There was B class of gastrostasis in 4 (6.9%) patients of main group. Severe gastrostasis (C class) was not revealed in any observation. In control group B class of gastrostasis was diagnosed in 14 (25.5%) patients, severe degree - in 7 (12.7%) patients. Univariant analysis showed hemotransfusion (p=0.037), pancreatic fistula (p=0.001), enteric fistula (p=0.005) and reconstruction technique (p=0.00004) as predictors of gastrostasis. Multivariant analysis defined pancreatic fistula (p=0.01), enteric fistula (p=0.04) and reconstruction technique (p=0.001) as significant predictors of gastrostasis. Thus, our study revealed significant decreasing gastrostasis incidence in case of original technique in comparison with conventional anastomosis, as well as demonstrated effect of anastomoses failure on augmentation of gastrostasis frequency after pancreaticoduodenal resection. Further randomized investigations are necessary to confirm our results.
Collapse
Affiliation(s)
- O G Skipenko
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Bedzhanjan
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - D Shatverjan
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Bagmet
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Chardarov
- acad. B.V. Petrovskiy Russian Research Surgery Center
| |
Collapse
|
11
|
Cao SS, Lin QY, He MX, Zhang GQ. Effect of antecolic versus retrocolic reconstruction for gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A meta-analysis. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Shuang-Shuang Cao
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Qi-Yuan Lin
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Man-Xi He
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Guang-Quan Zhang
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| |
Collapse
|
12
|
Kawai M, Tani M, Hirono S, Okada KI, Miyazawa M, Yamaue H. Pylorus-Resecting Pancreaticoduodenectomy Offers Long-Term Outcomes Similar to Those of Pylorus-Preserving Pancreaticoduodenectomy: Results of a Prospective Study. World J Surg 2013; 38:1476-83. [DOI: 10.1007/s00268-013-2420-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
13
|
Usuba T, Iino T, Hanyu N. Relative displacement of anastomotic site of pancreato-jejunostomy in pancreatico-duodenectomy: a novel surgical reconstructive technique. J Med Case Rep 2013; 7:209. [PMID: 23945081 PMCID: PMC3765080 DOI: 10.1186/1752-1947-7-209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 05/02/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Intra-abdominal hemorrhage following pancreatic fistula is a fatal complication after pancreatico-duodenectomy. Intra-abdominal hemorrhage has reportedly decreased with the use of fibrin glue or polyglycolic acid felt and wrapping of the skeletonized vessels by omentum or falciform ligament. However, there are no extremely effective methods for the prevention of hemorrhage. Here, we report our novel and simple method for the prevention of intra-abdominal hemorrhage due to pancreatic fistula. METHODS The anastomotic site of the pancreato-jejunostomy in pancreatico-duodenectomy is displaced from the superior to inferior side of the transverse mesocolon through a small window created on the left side of the middle colic artery of the transverse mesocolon. This procedure is expected to prevent exposure of the skeletonized vessels to activated pancreatic juice from a pancreatic fistula after lymph node dissection, decreasing the incidence of hemorrhage. Two drains are placed on the superior and inferior sides of the transverse mesocolon. We performed this procedure in seven patients and compared the amylase level in the drainage fluid from the superior and inferior sides. RESULTS There was no difference in the fluid amylase level from the drains between the superior and inferior sides, because a pancreatic fistula was not present in all our patients. Therefore, we could not evaluate the efficacy of this method in the current study. CONCLUSIONS Our procedure is theoretically expected to prevent intra-abdominal hemorrhage and will be an option in pancreatico-duodenectomy, especially for patients with a soft pancreas. However, it is necessary to evaluate the performance and results of this procedure in many more patients.
Collapse
Affiliation(s)
- Teruyuki Usuba
- Department of Surgery, Machida Municipal Hospital, Asahicho 2-15-41, Machida-shi, Tokyo 194-0023, Japan.
| | | | | |
Collapse
|
14
|
Su AP, Cao SS, Zhang Y, Zhang ZD, Hu WM, Tian BL. Does antecolic reconstruction for duodenojejunostomy improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? A systematic review and meta-analysis. World J Gastroenterol 2012; 18:6315-6323. [PMID: 23180954 PMCID: PMC3501782 DOI: 10.3748/wjg.v18.i43.6315] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate whether antecolic reconstruction for duodenojejunostomy (DJ) can decrease delayed gastric emptying (DGE) rate after pylorus-preserving pancreaticoduodenectomy (PPPD) through literature review and meta-analysis.
METHODS: Articles published between January 1991 and April 2012 comparing antecolic and retrocolic reconstruction for DJ after PPPD were retrieved from the databases of MEDLINE (PubMed), EMBASE, OVID and Cochrane Library Central. The primary outcome of interest was DGE. Either fixed effects model or random effects model was used to assess the pooled effect based on the heterogeneity.
RESULTS: Five articles were identified for inclusion: two randomized controlled trials and three non-randomized controlled trials. The meta-analysis revealed that antecolic reconstruction for DJ after PPPD was associated with a statistically significant decrease in the incidence of DGE [odds ratio (OR), 0.06; 95% CI, 0.02-0.17; P < 0.00 001] and intra-operative blood loss [mean difference (MD), -317.68; 95% CI, -416.67 to -218.70; P < 0.00 001]. There was no significant difference between the groups of antecolic and retrocolic reconstruction in operative time (MD, 25.23; 95% CI, -14.37 to 64.83; P = 0.21), postoperative mortality, overall morbidity (OR, 0.54; 95% CI, 0.20-1.46; P = 0.22) and length of postoperative hospital stay (MD, -9.08; 95% CI, -21.28 to 3.11; P = 0.14).
CONCLUSION: Antecolic reconstruction for DJ can decrease the DGE rate after PPPD.
Collapse
|
15
|
Oida T, Mimatsu K, Kano H, Kawasaki A, Kuboi Y, Fukino N, Kida K, Amano S. Delayed gastric emptying after pancreaticoduodenectomy in diabetes mellitus. ANZ J Surg 2012; 83:973-7. [PMID: 22943798 DOI: 10.1111/j.1445-2197.2012.06242.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2012] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) is one of the most troublesome complications of pancreaticoduodenectomy (PD). Diabetes mellitus (DM) is one of the risk factors for pancreatic cancer. Moreover, several studies have shown that diabetic patients tend to have a high incidence of upper gastrointestinal symptoms such as nausea, vomiting and DGE. Here, we compared the influence of DM on the incidence of DGE after PD. METHODS We retrospectively analysed 67 cases of PD with pancreaticogastrostomy. These patients were categorized into the following two groups: the DM group included patients with DM, and the NDM group included patients without DM. The incidence of DGE was determined and compared between the two groups. RESULTS In the DM group, 76.5%, 5.9% and 17.6% of the subjects developed classes A, B and C DGE, respectively; the corresponding values in the NDM group were 58%, 22%, and 20%. The incidence of DGE did not differ between the two groups (P < 0.2771). CONCLUSIONS DM does not accelerate DGE in patients who have undergone PD. Preoperative DM does not appear to play a key role in post-operative DGE after PD.
Collapse
Affiliation(s)
- Takatsugu Oida
- Department of Surgery, Social Insurance Yokohama Central Hospital, Naka-ku, Yokohama, Japan
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Muniz CK, Braga CBM, Kemp R, Santos JSD, Cunha SFDCD. Clinical and nutritional status in the late postoperative of pancreaticoduodenectomy: influence of pylorus preservation procedure. Acta Cir Bras 2012; 27:123-30. [DOI: 10.1590/s0102-86502012000200005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 12/21/2011] [Indexed: 11/21/2022] Open
Abstract
PURPOSE: To evaluate the nutritional status of patients in the late postoperative period of pancreaticoduodenectomy (PD) and compare the long-term outcome according to pylorus-preserving (PPPD) or the standard technique (SPD) in which the pylorus is resected. METHODS: This prospective study was conducted twelve months prior or more in patients who had underwent PD (PD Group, n=15) and health volunteers (Control Group, n=15). At a post hoc analysis, the PD Group was divided in PPPD Subgroup (n=9) and SPD Subgroup (n=6), according to the PD techniques. Gastrointestinal complaints and nutritional status were evaluated, apart from a biochemical assessment; Student t-test or Mann-Whitney test were used. RESULTS: The patients recovered their body weight and the gastrointestinal complaints were uncommon. The PD Group showed higher energy and protein intake even though BMI was lower than in Control Group. There were no differences in laboratorial data, except for higher glycemia, serum alkaline phosfatase and C-reactive protein in PD Group. There was no difference in the various parameters evaluated when the Subgroups (PPPD and SPD) were compared. CONCLUSION: For long-term pancreaticoduodenectomy, the gastrointestinal symptoms are minimal and the patients had the clinical and nutritional status preserved, regardless of pylorus preservation.
Collapse
|
17
|
Delayed gastric emptying improved by straight stomach reconstruction with twisted anastomosis to the jejunum after pylorus-preserving pancreaticoduodenectomy (PPPD) in 118 consecutive patients at a single institution. Surg Today 2011; 42:441-6. [PMID: 22173649 DOI: 10.1007/s00595-011-0097-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 04/20/2011] [Indexed: 02/08/2023]
Abstract
PURPOSE Delayed gastric emptying (DGE) is a leading cause of complication after pylorus-preserving pancreaticoduodenectomy (PPPD). Its incidence has been reported to range from 5 to 57%. We describe a modified reconstruction method, which resulted in a low rate of DGE. METHODS Between April 2003 and March 2008, we performed PPPD and reconstruction using an antecolic method in 118 consecutive patients. After PPPD, reconstruction was done using conventional Child procedure in 12 patients (PPPD group) and with the following modifications in the remaining 106 patients (PPPDR group): duodenojejunostomy was performed using the straight method and the jejunum was anastomosed with a 30° counterclockwise twist. We evaluated the incidence of DGE based on the grading system defined by the International Study Group of Pancreatic Surgery (ISGPS). RESULTS The PPPDR group had a lower incidence of DGE than the PPPD group (PPPD), occurring in 7 patients (7%) versus 4 patients (33%), respectively. However, the overall morbidity rates and postoperative hospital stays of the two groups did not differ significantly. CONCLUSIONS Straight stomach reconstruction with a twisted anastomosis could reduce the incidence of DGE after PPPD reconstruction.
Collapse
|
18
|
Basu S, Srivastava V, Shukla VK. Reviewing the standard of care in pancreatic adenocarcinoma: A critical appraisal. SURGICAL PRACTICE 2011. [DOI: 10.1111/j.1744-1633.2011.00549.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
19
|
Kawai M, Yamaue H. Analysis of clinical trials evaluating complications after pancreaticoduodenectomy: a new era of pancreatic surgery. Surg Today 2010; 40:1011-7. [PMID: 21046497 DOI: 10.1007/s00595-009-4245-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 09/16/2009] [Indexed: 12/18/2022]
Abstract
Pancreatic fistula and delayed gastric emptying (DGE) are the major postoperative complications of pancreaticoduodenectomy (PD). Pancreatic fistula is life-threatening and DGE, while not life-threatening, prolongs the hospital stay, increasing costs and compromising quality of life. To establish the current consensus of pancreatic fistula and DGE after PD, we analyzed the results of randomized controlled trials (RCTs) designed to prevent these postoperative complications. Five RCTs comparing PD with pylorus-preserving pancreaticoduodenectomy (PpPD) performed for periampullary tumors showed that the two procedures were equally effective with respect to morbidity, mortality, and survival. We reviewed 15 RCTs, 2 prospective nonrandomized studies, and 2 meta-analyses of operative techniques and postoperative management designed to prevent pancreatic fistula. The results of the RCTs designed to prevent pancreatic fistula recommended duct-to-mucosa pancreaticojejunostomy or one-layer end-to-side pancreaticojejunostomy, equally. We also reviewed five RCTs of operative techniques and postoperative management designed to prevent DGE, which revealed that the antecolic route for duodenojejunostomy significantly reduced the incidence of DGE. Further RCTs to study innovative approaches to prevent postoperative complications after PD are warranted.
Collapse
Affiliation(s)
- Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | | |
Collapse
|
20
|
[Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation. A systematic review with meta-analysis]. Chirurg 2010; 81:454-71. [PMID: 20020091 DOI: 10.1007/s00104-009-1829-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Two surgical procedures are mainly performed for the treatment of pancreatic head cancer and periampullary carcinoma: the classical Whipple operation and the pylorus-preserving Whipple operation. METHODS This manuscript represents an extension of a systematic review and meta-analysis previously published in the Annals of Surgery. A systematic literature search was performed in MEDLINE, EMBASE and the Cochrane Library (central) to identify randomized controlled trials (RCTs) and observational studies. A meta-analysis based on a random-effects model was performed for the hazard ratios (HR) of survival and the odds ratios (OR) of postoperative mortality. The results of the different studies on quality of life (QoL) could not be summarized quantitatively in a meta-analysis and were therefore summarized qualitatively. Subgroup analyses were performed by study type, RCTs, prospective cohort studies (PSs), retrospective cohort studies (RSs), study quality and tumor localization (pancreatic head cancer versus periampullary carcinoma). RESULTS The systematic literature search retrieved 4,503 studies of which 4,460 did not fulfill the inclusion criteria. The remaining 43 studies (6 RCTs, 12 PSs and 25 RSs) representing 3,893 patients were finally included in the review. There was neither a significant survival difference for patients with pancreatic head cancer in the pooled estimate of the RCTs (HR 0.80; 95% CI 0.53-1.22; p=0.16) nor in the pooled estimate of the PSs (HR 0.84; 95% CI 0.7-1.0; p=0.95) or the RSs (HR 0.84; 95% CI 0.7-1.01; p=0.21). Survival of patients with periampullary carcinoma was not significantly different in the RCTs (HR 1.02; 95% CI 0.49-2.13; p=0.3), the PSs (HR 1.26; 95% CI 0.46-3.42; p=0.65) or the RSs (HR 0.86; 95% CI 0.6-1.24; p=0.33). Postoperative mortality was not significantly different after both types of operations (RCTs: HR 0.49; 95% CI 0.17-1.4; p=0.18; PSs: HR 0.63; 95% CI 0.34-1.18; p=0.15; RSs: HR 0.7; 95% CI 0.37-1.31; p=0.27). QoL was reported as either the same in both groups or in favor of the pylorus-preserving Whipple operation. CONCLUSIONS Mortality, survival and QoL were not significantly different between the classical Whipple and the pylorus-preserving Whipple operations. Given the poor quality of the underlying trials a pragmatic RCT is recommended to prove the findings of this systematic review.
Collapse
|
21
|
Beger's operation and the Berne modification: origin and current results. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:735-44. [PMID: 19798464 DOI: 10.1007/s00534-009-0179-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 08/12/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this paper is to illuminate the origin and current results of the duodenum-preserving pancreatic head resection (DPPHR) developed by Beger in the 1970s, as well as its simplified Berne modification, for patients suffering from chronic pancreatitis (CP). Indications for the procedures and their results are presented on the basis of available data. METHODS A selected review was made of the available data on the DPPHR developed by Beger and its modifications. RESULTS The organ-sparing DPPHR developed by Beger, and its modifications, provide better pain relief, better preservation of exocrine and endocrine pancreatic function, and a superior quality of life compared with the more radical pancreaticoduodenectomy (PD, with or without pylorus-preservation), once the standard treatment for patients with CP. Recently published data on the long-term follow-up of studies comparing PD to DPPHR indicate that the initial benefits of DPPHR over PD might be less pronounced in the long-run. CONCLUSIONS The organ-preserving DPPHR developed by Beger, and its modifications, have become established and well-evaluated surgical treatment options for patients with CP.
Collapse
|
22
|
Abstract
Curative resection is crucial to survival in pancreatic cancer; however, despite optimization and standardization of surgical procedures, this is not always achieved. This review highlights that the rates of microscopic margin involvement (R1) vary markedly between studies and, although resection margin status is believed to be a key prognostic factor, the rates of margin involvement and local tumour recurrence or overall survival of pancreatic cancer patients are often incongruent. Recent studies indicate that the discrepancy between margin status and clinical outcome is caused by frequent underreporting of microscopic margin involvement. Lack of standardization of pathological examination, confusing nomenclature and controversy regarding the definition of microscopic margin involvement have resulted in the wide variation of reported R1 rates that precludes meaningful comparison of data and clinicopathological correlation.
Collapse
Affiliation(s)
- Caroline S Verbeke
- Department of Histopathology, St James's University Hospital, Leeds, UK.
| | | |
Collapse
|
23
|
Yokoyama Y, Nimura Y, Nagino M. Advances in the treatment of pancreatic cancer: limitations of surgery and evaluation of new therapeutic strategies. Surg Today 2009; 39:466-75. [PMID: 19468801 DOI: 10.1007/s00595-008-3904-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2008] [Accepted: 04/02/2008] [Indexed: 01/21/2023]
Abstract
Pancreatic ductal carcinoma is one of the most dismal malignancies of the gastrointestinal system. Even after curative resection, the actual 5-year survival is only 10%-20%. Of all the treatments used against pancreatic cancer, surgery is still the only one that can achieve complete cure. Pancreatic cancer spreads easily to the adjacent tissues and distant metastasis is common. Typically, this cancer invades the retropancreatic neural tissue, duodenum, portal vein (PV), and superior mesenteric vein (SMV), or regional lymph nodes. For this reason, aggressive surgery that removes the cancerous lesion completely is recommended. Several retrospective and prospective studies have been conducted to validate the usefulness of aggressive surgery for pancreatic cancer in the past few decades. Surprisingly, the survival benefits of aggressive surgery have been denied by most randomized controlled trials (RCTs). This implies that surgery alone is not enough. Thus, adjuvant therapy, such as radiotherapy and chemotherapy, has been given in combination with surgery to improve survival. Although the benefits of radiotherapy alone are limited, the results of chemotherapy are promising. Other newly evolving molecular targeting drugs may also improve the treatment outcomes of pancreatic cancer.
Collapse
Affiliation(s)
- Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | | | | |
Collapse
|
24
|
Pylorus-preserving pancreaticoduodenectomy versus conventional pancreaticoduodenectomy for pancreatic adenocarcinoma. Surg Today 2009; 39:219-24. [DOI: 10.1007/s00595-008-3847-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Accepted: 07/02/2008] [Indexed: 01/04/2023]
|
25
|
Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels. ACTA ACUST UNITED AC 2009; 16:184-8. [DOI: 10.1007/s00534-008-0036-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Accepted: 03/17/2008] [Indexed: 12/19/2022]
|
26
|
Chijiiwa K, Imamura N, Ohuchida J, Hiyoshi M, Nagano M, Otani K, Kai M, Kondo K. Prospective randomized controlled study of gastric emptying assessed by (13)C-acetate breath test after pylorus-preserving pancreaticoduodenectomy: comparison between antecolic and vertical retrocolic duodenojejunostomy. ACTA ACUST UNITED AC 2008; 16:49-55. [PMID: 19083149 DOI: 10.1007/s00534-008-0004-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 01/16/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND/PURPOSE To examine whether vertical retrocolic duodenojejunostomy is superior to antecolic duodenojejunostomy with respect to gastric emptying in a prospective, randomized, controlled study of patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). METHODS Thirty-five patients undergoing PpPD between March 2005 and July 2007 were enrolled in the study. All provided informed consent. During PpPD, the patients were randomly assigned to either the antecolic (antecolic group, n = 17) or vertical retrocolic route (vertical retrocolic group, n = 18) just before the reconstruction. Each patient ingested (13)C-acetate in a liquid meal before surgery and on postoperative day (POD) 30. Gastric emptying variables (Tmax, T1/2) were determined and compared between groups. RESULTS Clinical delayed gastric emptying, defined as an inability of patients to take in an appropriate amount of solid food orally by POD 14, was found in 1 of 17 patients (6%) in the antecolic group and in 4 of 18 patients (22%) in the vertical retrocolic group, but the difference was not significant (P = 0.34). Tmax and T1/2 on POD 30 were prolonged in both groups in comparison to preoperative levels, but no significant difference was found between the two groups. Follow-up examinations revealed that gastric emptying had recovered to the preoperative level by POD 30 in approximately 80% of the patients, regardless of the reconstruction route. CONCLUSIONS Vertical retrocolic duodenojejunostomy does not seem to offer an advantage with respect to gastric emptying.
Collapse
Affiliation(s)
- Kazuo Chijiiwa
- Department of Surgical Oncology and Regulation of Organ Function, Miyazaki University School of Medicine, Kiyotake, Miyazaki, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Manes K, Lytras D, Avgerinos C, Delis S, Dervenis C. Antecolic gastrointestinal reconstruction with pylorus dilatation. Does it improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? HPB (Oxford) 2008; 10:472-6. [PMID: 19088935 PMCID: PMC2597326 DOI: 10.1080/13651820802286928] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of our study focuses upon prevention of delayed gastric emptying (DGE) after pancreaticoduodenectomy using a alternative reconstruction procedure. METHOD Forty consecutive patients underwent a typical pylorus-preserving pancreaticoduodenectomy (PPPD) with antecolic reconstruction in a two-year period (January 2002 until January 2004), while a similar group of 40 consecutive patients underwent PPPD with application of pyloric dilatation between January 2004 and January 2006. Early and late complications were compared between the two groups. RESULTS DGE occurred significantly more often in the group of patients treated by the classical PPPD technique (nine patients -22%) compared with those operated on with the addition of pyloric dilatation technique (two patients -5%) (p<0.05). The incidence of other complications did not differ significantly between the two groups. CONCLUSIONS The application of dilatation may decrease the incidence of DGE after PPPD and facilitates earlier hospital discharge.
Collapse
Affiliation(s)
| | | | | | - Spiros Delis
- 1st Surgical Department, Agia Olga HospitalAthensGreece
| | | |
Collapse
|
28
|
Iqbal N, Lovegrove R, Tilney H, Abraham A, Bhattacharya S, Tekkis P, Kocher H. A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: A meta-analysis of 2822 patients. Eur J Surg Oncol 2008; 34:1237-45. [DOI: 10.1016/j.ejso.2007.12.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 12/17/2007] [Indexed: 02/06/2023] Open
|
29
|
Bahra M, Jacob D, Langrehr JM, Glanemann M, Schumacher G, Lopez-Hänninen E, Neuhaus P. [Metastatic lesions to the pancreas. When is resection reasonable?]. Chirurg 2008; 79:241-8. [PMID: 17717640 DOI: 10.1007/s00104-007-1390-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The significance of pancreatic resection for pancreatic metastatic lesions has not yet been sufficiently investigated. A retrospective analysis of patients undergoing pancreatic resections for pancreatic metastases was conducted. MATERIAL AND METHODS Twenty patients were resected due to metastatic lesions to the pancreas. Histopathological findings were: renal cell carcinoma (n=9), colon carcinoma (n=1), malignant schwannoma (n=2), leiomyosarcoma (n=2), teratocarcinoma (n=1), adenocarcinoma of the oesophagus (n=1), gallbladder carcinoma (n=1), malignant melanoma (n=1), gastrointestinal stromal tumor (n=1), and spindle cell tumor (n=1). Operative procedures were standard pancreaticoduodenectomy (n=6), pylorus-preserving pancreaticoduodenectomy (n=6), and distal pancreatectomy (n=8). RESULT The overall 5-year survival rate was 61%, for patients with renal cell carcinoma 100%. CONCLUSION Pancreatic metastasectomy is a reasonable therapeutic option in suited patients. Patients with pancreatic metastases of renal cell carcinoma achieved excellent prognoses after radical resection.
Collapse
Affiliation(s)
- M Bahra
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin.
| | | | | | | | | | | | | |
Collapse
|
30
|
Kleespies A, Albertsmeier M, Obeidat F, Seeliger H, Jauch KW, Bruns CJ. The challenge of pancreatic anastomosis. Langenbecks Arch Surg 2008; 393:459-71. [PMID: 18379817 DOI: 10.1007/s00423-008-0324-4] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Accepted: 02/21/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSION The surgeon's experience with one or the other technique of pancreatic anastomosis appears to be more important than the technique itself.
Collapse
Affiliation(s)
- Axel Kleespies
- Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilian-University of Munich, Munich, Germany.
| | | | | | | | | | | |
Collapse
|
31
|
Bahra M, Neumann U. Surgical techniques for resectable pancreatic cancer. RECENT RESULTS IN CANCER RESEARCH. FORTSCHRITTE DER KREBSFORSCHUNG. PROGRES DANS LES RECHERCHES SUR LE CANCER 2007; 177:29-38. [PMID: 18084944 DOI: 10.1007/978-3-540-71279-4_4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pancreatic cancer is a highly aggressive cancer with a rising incidence in most European countries. Due to both the aggressive biology of the disease and the late diagnosis in many cases, pancreatic duct carcinoma is still a disease with a poor prognosis. Today, surgical resection of localized tumor remains the only potentially curative option available for these patients. Advances in surgical techniques and perioperative care has improved significantly in the last 20 years, causing an extension of indications for surgical intervention. However, despite new diagnostic techniques, the surgical exploration still plays the key role for the finally assessment of resectability. For evaluation of local resectability, laparoscopy alone cannot generally be recommended today and explorative laparotomy is required. Contraindications for pancreatic resection are liver metastasis, peritoneal metastasis, and tumor infiltration of visceral arteries. The surgical management of pancreatic cancer consists of two phases: first, assessment of tumor resectability and second, if resectability is given, the pancreaticoduodenectomy with consecutive reconstruction. Standard surgical strategies are the classic pancreaticoduodenectomy including a distal gastrectomy and the pylorus-preserving pancreaticoduodenectomy (PPPD) preserving antral and pyloric function, respectively. Both surgical procedures are equally effective for the treatment of pancreatic carcinoma. Delicate lymphadenectomy during pancreaticoduodenectomy is important for radical oncological enforcement. An extended lymphadenectomy showed no benefit in several trials. Despite the encouraging advances in surgical treatment, actuarial 5-year survival rates after pancreatic resection are only at about 20%.
Collapse
Affiliation(s)
- M Bahra
- Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik für Allgemein-, Visceral- und Transplantationschirurgie, Germany
| | | |
Collapse
|
32
|
Kawamoto M, Konomi H, Kobayashi K, Shimizu S, Yamaguchi K, Tanaka M. Type of gastrointestinal reconstruction affects postoperative recovery after pancreatic head resection. ACTA ACUST UNITED AC 2007; 13:336-43. [PMID: 16858546 DOI: 10.1007/s00534-005-1085-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2005] [Accepted: 11/10/2005] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE The postoperative recovery of gastric motility with various reconstructions after pancreatic head resection has been reported. However, little is known about this recovery after pancreatic head resection with segmental duodenectomy (PHRSD). Some have attributed gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD) to tube gastrostomy, but its effect on gastric motility has not been investigated. In this study, the postoperative recovery after PHRSD and PPPD, and gastric motility with and without gastrostomy after PPPD were investigated. METHODS We analyzed the first appearance of gastric phase III motility, postoperative systemic status, and body weight (BW; n = 32). The Imanaga PPPD and PHRSD were compared because the procedures differ only in the length of the remaining duodenum. Traverso and Roux-en-Y PPPDs were compared because the two procedures are similar except for the creation of gastrostomy. RESULTS (1) Times to first appearance of gastric phase III motility and BW recovery were significantly better after PHRSD than after the Imanaga PPPD (P < 0.05). (2) Times to first gastric phase III motility and resumption of a regular diet as well as periods of gastric sump tube use and postoperative hospital stay were significantly shorter after the Roux-en-Y than after the Traverso PPPD (P < 0.05). CONCLUSIONS Preservation of as long a portion of the duodenum as possible, the choice of a Roux-en-Y duodenojejunostomy, and the avoidance of peritoneal fixation of the gastric wall may be factors that improve the recovery of gastric motility and BW after pancreatic head resection.
Collapse
Affiliation(s)
- Masahiko Kawamoto
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka 812-8582, Japan
| | | | | | | | | | | |
Collapse
|
33
|
Paraskevas KI, Avgerinos C, Manes C, Lytras D, Dervenis C. Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: A review of the literature and critical reappraisal of the implicated pathomechanism. World J Gastroenterol 2006; 12:5951-8. [PMID: 17009392 PMCID: PMC4124401 DOI: 10.3748/wjg.v12.i37.5951] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pylorus-preserving pancreaticoduodenectomy (PPPD) is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying (DGE) comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/Medline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy (PD) vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported (but not yet tested in large-scale studies) modification, that is, PPPD with antecolic duodenojejunostomy.
Collapse
|
34
|
Tani M, Terasawa H, Kawai M, Ina S, Hirono S, Uchiyama K, Yamaue H. Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy: results of a prospective, randomized, controlled trial. Ann Surg 2006; 243:316-20. [PMID: 16495694 PMCID: PMC1448934 DOI: 10.1097/01.sla.0000201479.84934.ca] [Citation(s) in RCA: 215] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine if an antecolic or a retrocolic duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy (PpPD) was associated with the least incidence of delayed gastric emptying (DGE), in a prospective, randomized, controlled trial. SUMMARY BACKGROUND DATA The pathogenesis of DGE after PpPD has been speculated to be related to factors such as inflammation, ischemia, gastric atony, motilin levels, and type of surgical procedure. Previous retrospective studies have shown a lower incidence of DGE after antecolic duodenojejunostomy. A prospective trial is needed. METHODS Forty patients were enrolled in this trial between May 2002 and April 2004. Just before duodenojejunostomy during PpPD, the patients were randomly assigned to undergo either an antecolic or a retrocolic duodenojejunostomy. RESULTS DGE occurred in 5% of patients with the antecolic route for duodenojejunostomy versus 50% with the retrocolic route (P = 0.0014). Those with the antecolic route had a significantly shorter duration of postoperative nasogastric tube drainage than did those with the retrocolic route (4.2 days versus 18.9 days, respectively, P = 0.047). By postoperative day 14, all patients with the antecolic route could take solid foods, while only 55% (11 of 20) of the patients with the retrocolic route could take solid foods (P = 0.0007). The length of stay in the hospital was 28 days for the antecolic group versus 48 days for the retrocolic group (P = 0.018). CONCLUSIONS Antecolic reconstruction for duodenojejunostomy during PpPD decreases postoperative morbidity and length of hospital stay by decreasing DGE. Our data suggest that PpPD with antecolic duodenojejunostomy is a safer operation.
Collapse
Affiliation(s)
- Masaji Tani
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | | | | | | | | | | | | |
Collapse
|
35
|
Maeda A, Ebata T, Kanemoto H, Matsunaga K, Bando E, Yamaguchi S, Uesaka K. Omental flap in pancreaticoduodenectomy for protection of splanchnic vessels. World J Surg 2006; 29:1122-6. [PMID: 16132400 DOI: 10.1007/s00268-005-7900-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2005] [Indexed: 12/17/2022]
Abstract
Intraabdominal bleeding, the most life-threatening complication following pancreaticoduodenectomy (PD), most often is associated with failure of a pancreaticojejunostomy anastomosis or with intraabdominal infection. We investigated whether placement of an omental flap around the splanchnic vessels in PD could reduce the occurrence of intraabdominal bleeding and other postoperative complications. One hundred consecutive patients who underwent PD at the authors' institution between January 2000 and October 2004 were enrolled in this prospective study. After dissection of the hepatoduodenal ligament, the major splanchnic arteries and the portal vein were covered by the omental flap. Preoperative condition, incidence of pancreatic fistula, intra-abdominal bleeding, other complications, treatment mortality, and hospital stay were analyzed for interrelationships. The frequency of pancreatic fistula (20%) differed little from those in previous reports. However, intraabdominal bleeding was observed in only 1 (1.0%) patient, who was considered to have too thin a flap. No intraabdominal abscess was encountered. No mortality or complications occurred in relation to the omental flap. Thus, wrapping an omental flap around dissected splanchnic vessels in PD reduced postoperative intraabdominal bleeding and infection, but failed to prevent pancreatic fistulas.
Collapse
Affiliation(s)
- Atsuyuki Maeda
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimo-Nagakubo, 411-8777 Sunto-Nagaizumi, Shizuoka, Japan
| | | | | | | | | | | | | |
Collapse
|
36
|
Neoptolemos JP, Russell RCG, Bramhall S, Theis B. Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. Br J Surg 2005. [DOI: 10.1111/j.1365-2168.1997.00504.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
37
|
Strömmer L, Räty S, Hennig R, Adrian TE, Friess H, Böttiger Y, Stanaitis J, Nordback I, Sand J, Arnelo U. Delayed gastric emptying and intestinal hormones following pancreatoduodenectomy. Pancreatology 2005; 5:537-44. [PMID: 16110252 DOI: 10.1159/000086544] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Accepted: 02/23/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Delayed gastric emptying (DGE) is frequently reported in patients following pancreatoduodenectomy (PD). The present study tested the hypothesis that gastrointestinal hormones known to effect gastric emptying contribute to DGE in patients after PD. METHODS Patients with (delayed, n = 9) or without clinical signs of DGE (non-delayed, n = 22) after PD were investigated. Plasma concentrations of motilin, glucagon-like peptide-1 (GLP-1), neurotensin, and peptide YY (PYY) and the gastric emptying rate (GER), assessed by the paracetamol absorption method were measured after a liquid meal on postoperative day 11. RESULTS Days with a nasogastric tube (p < 0.01), days until solid food was tolerated (p < 0.05), and hospital stay (p < 0.001) were increased in delayed compared to non-delayed patients. The total and incremental integrated peptide responses of motilin and GLP-1 were similar, but the responses of neurotensin and PYY were reduced, in delayed compared to non-delayed patients, whether considered on clinical grounds or by measured GER (p < 0.05-0.005). CONCLUSION Neurotensin and PYY slow the rate of gastric emptying in humans. Therefore, our findings suggest that reduced hormone responses were the consequence of DGE arising from delayed delivery of nutrients to the distal intestine where the endocrine cells secrete neurotensin and PYY reside.
Collapse
|
38
|
Gerdes B, Ramaswamy A, Bartsch DK, Rothmund M. Peripyloric lymph node metastasis is a rare condition in carcinoma of the pancreatic head. Pancreas 2005; 31:88-92. [PMID: 15968254 DOI: 10.1097/01.mpa.0000168221.97967.98] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Pylorus preserving pancreatoduodenectomy (PPPD) was introduced to achieve a better functional result compared with the conventional Kausch-Whipple procedure (PD). In PPPD, peripyloric and perigastric lymphatic tissue is not removed compared with PD. The aim of this prospective study was to identify the frequency of peripyloric and perigastric lymph node metastases in ductal adenocarcinoma of the pancreatic head (PC). METHODS Fifty specimens following Kausch-Whipple procedure including partial gastric resection for PC were analyzed for peripyloric and perigastric lymph node metastases by a standardized clearing technique. All lymph nodes of the specimens were counted, discriminating between those not removed ("group A") and those removed ("group B") in pylorus preserving resection of the pancreatic head. Additionally, the duodenal wall and paraduodenal tissue at a potential duodenal resection margin 2 cm distal of the pylorus were investigated histologically. RESULTS Three of the 50 specimens (6%) carried peripyloric lymph node metastases, whereas 32 of the 50 specimens (64%) contained lymph node metastases in total. Four of 362 group A and 90 of 748 group B lymph nodes showed metastatic spread of the carcinoma. The 4 lymph node metastases in group A could be identified exclusively in 88 peripyloric lymph nodes but in none of the 274 perigastric lymph nodes at the lesser or greater curvature. In 2 of the 3 patients with peripyloric lymph node metastases, these lymph nodes were the only lymph nodes with metastatic involvement in the entire specimen. In 1 specimen, a small tumor nest of less than 2 mm in diameter was detected at a distance of less than 1 mm to the pylorus, although pyloric involvement was not suspected intraoperatively. The potential PPPD resection margin of the duodenal wall was not infiltrated by intramural tumor spread in any specimen. CONCLUSION In a minority of 6%, PC metastasizes in peripyloric lymph nodes. Lymph nodes of the lesser and greater curvature of the stomach are not involved in patients with PC. Thus, we conclude by the data of this prospective study that the limited benefits of the extended lymph node dissection in a conventional Kausch-Whipple resection are far outweighed by the disadvantages construed by this procedure.
Collapse
Affiliation(s)
- Berthold Gerdes
- Department of Surgery, Philipps-University of Marburg, Marburg, Germany.
| | | | | | | |
Collapse
|
39
|
Wray CJ, Ahmad SA, Matthews JB, Lowy AM. Surgery for pancreatic cancer: recent controversies and current practice. Gastroenterology 2005; 128:1626-41. [PMID: 15887155 DOI: 10.1053/j.gastro.2005.03.035] [Citation(s) in RCA: 204] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Pancreatic duct carcinoma remains a common disease with a poor prognosis. More than 30,000 Americans will die of the disease in 2004, making it the fourth leading cause of cancer death. Despite significant advances in the treatment of many other human tumors, the 5-year survival rate for persons diagnosed with pancreatic cancer has not changed in decades and remains <5%. This is due both to the inherently aggressive biology of the disease and to its late diagnosis in most cases. Surgical resection of localized disease remains the only hope for cure of pancreatic cancer. Over the past 2 decades, significant advances in diagnostic imaging, staging, surgical technique, and perioperative care have led to marked improvement in the surgical management of pancreatic cancer patients. Operative mortality rates for pancreaticoduodenectomy are now <5% at major centers, and the average length of hospital stay has been reduced to <2 weeks. Improvements in patient outcome after pancreatic cancer surgery have made possible, for the first time, the design and conduct of large adjuvant therapy studies in pancreatic cancer. Such clinical trials are critical for improving outcomes for pancreatic cancer patients.
Collapse
Affiliation(s)
- Curtis J Wray
- Department of Surgery, Division of Surgical Oncology, The Pancreatic Disease Center, University of Cincinnati, Ohio 45219-0772, USA
| | | | | | | |
Collapse
|
40
|
de Bree E, Melissas J, Schoretsanitis G, Sanidas E, Tsiftsis DD. Pylorus-preserving pancreaticoduodenectomy with external pancreatic remnant drainage. Acta Chir Belg 2004; 104:668-672. [PMID: 15663272 DOI: 10.1080/00015458.2004.11679640] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy is the mainstay of surgical treatment for various benign and malignant diseases of the head of the pancreas and the periampullar region. The incidence of postoperative morbidity remains significantly high. Various modifications have been advocated for the restoration of the digestive continuity and drainage of bile and pancreatic ducts in order to diminish this high morbidity rate. METHODS A new modification with the combination of an end-to-end duodenojejunal anastomosis and creation of an external pancreatic fistula following pylorus-preserving pancreaticoduodenectomy is described. Our initial experience with this modification in seven patients is reported and its advantages are discussed. RESULTS There was no mortality, while morbidity was 29%, including postoperative pneumonia and psychosis in one patient, and intra-abdominal abscess in another patient. No significantly delayed gastric emptying was observed and no patient developed diabetes, anastomotic ulcer or reflux cholangitis postoperatively. CONCLUSIONS The reported technique seems to be a safe modification of restoration after pancreaticoduodenectomy, with maintenance of anatomical gastrointestinal continuity, avoidance of complications from anastomosis with the pancreatic remnant, as well as maintenance of endocrine pancreatic function. However, long-term follow-up and larger comparative studies are needed to evaluate the impact of this modification on morbidity and mortality, including long-term nutritional complications.
Collapse
Affiliation(s)
- E de Bree
- Department of Surgical Oncology, University Hospital, Medical School of Crete, Herakleion, Greece.
| | | | | | | | | |
Collapse
|
41
|
Alexakis N, Halloran C, Raraty M, Ghaneh P, Sutton R, Neoptolemos JP. Current standards of surgery for pancreatic cancer. Br J Surg 2004; 91:1410-27. [PMID: 15499648 DOI: 10.1002/bjs.4794] [Citation(s) in RCA: 205] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Background
Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.
Methods
An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.
Results
Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.
Conclusion
The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.
Collapse
Affiliation(s)
- N Alexakis
- Department of Surgery, University of Liverpool, Royal Liverpool University Hospital, 5th floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | | | | | | | | | | |
Collapse
|
42
|
Sugiyama M, Abe N, Ueki H, Masaki T, Mori T, Atomi Y. A new reconstruction method for preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. Am J Surg 2004; 187:743-6. [PMID: 15191869 DOI: 10.1016/j.amjsurg.2003.10.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2003] [Revised: 10/17/2003] [Indexed: 12/28/2022]
Abstract
BACKGROUND With the aim of preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy (PPPD), we devised a new reconstruction method in which the pancreas and the bile duct are anastomosed to the proximal jejunum brought through the transverse mesocolon, and the duodenum is antecolically anastomosed to the jejunum below the mesocolon. The right gastric artery is divided in order to place the stomach, the duodenum, and the jejunum in a straight line. METHODS Thirty patients underwent PPPD with the new reconstruction method (n = 12) or the conventional method (all anastomoses performed retrocolically; n = 18). Early and late complications were compared between the two groups. RESULTS Delayed gastric emptying occurred respectively in 1 patient (8%) and 13 patients (72%) operated on by the new and conventional method (P <0.001). The incidences of other complications did not differ significantly between the two groups. CONCLUSIONS The new reconstruction method may prevent delayed gastric emptying after PPPD.
Collapse
Affiliation(s)
- Masanori Sugiyama
- First Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan.
| | | | | | | | | | | |
Collapse
|
43
|
Horstmann O, Markus PM, Ghadimi MB, Becker H. Pylorus preservation has no impact on delayed gastric emptying after pancreatic head resection. Pancreas 2004; 28:69-74. [PMID: 14707733 DOI: 10.1097/00006676-200401000-00011] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Delayed gastric emptying (DGE) has been specifically attributed to pylorus-preserving pancreaticoduodenectomy (PPPD). As PPPD has been shown to be comparable with the classic Kausch-Whipple pancreaticoduodenectomy (KWPD) in terms of oncological radicality, DGE has advanced to be the leading argument for hemigastrectomy in PD. METHODS A prospective, nonrandomized comparison of patients undergoing PPPD (n = 113), KWPD (n = 19), and duodenum-preserving, pancreatic head resection (DPPHR, n = 18) for various diseases was performed. First, groups were analyzed with regard to structural similarity; then, they were compared with special emphasis on DGE and other postoperative complications. Finally, further prognostic factors were sought that had an impact on DGE. RESULTS The PPPD group was comparable with the KWPD group, but not to the DPPHR population. The in-clinic course after DPPHR compared favorably with PPPD as well as KWPD, and, here, no DGE occurred. The overall morbidity rates of PPPD and KWPD were comparable; 1 patient died in hospital (mortality rate, 0.7%). The gastric tube after PPPD and KWPD could be withdrawn at a median of 2 and 3 days, respectively, a liquid diet was started after 4 and 5 days, respectively, and a full diet was tolerated after 10 days each (n.s.). DGE was distributed evenly among PPPD (12%) and KWPD patients (21%, n.s.), and it was noted almost exclusively when other postoperative complications were present (P < 0.0001). No further prognostic factors influencing DGE could be identified. CONCLUSION Pylorus preservation does not increase the frequency of DGE. DGE almost exclusively occurs as a consequence of other postoperative complications. Therefore, DGE should not be used as an argument to advocate hemigastrectomy in PPPD.
Collapse
Affiliation(s)
- Olaf Horstmann
- Department of Surgery, University Clinic, Göttingen, Germany.
| | | | | | | |
Collapse
|
44
|
Abstract
The value of surgical resection for patients with chronic pancreatitis has been debated on account of persistent symptoms and the morbidity of the operative procedure, both immediate and delayed. This paper explores the consequence of pancreatoduodenectomy in 175 patients with chronic pancreatitis who were operated on between 1976 and 1997. All patients were carefully selected after varying periods of conservative management. The operation was a classical Kausch-Whipple resection in 98 patients and a pylorus-preserving procedure in 67. There were four postoperative deaths (days 7, 10, 35, and 70), and only two reoperations were performed. The median number of postoperative events was one, with delayed gastric emptying being the most common (31 patients). The median length of in-hospital stay was 20 days (range: 8-215 days), but no patient was discharged until medical and social disabilities were resolved. There were seven late deaths, most of them linked to cigarette smoking and alcohol consumption; 75% of patients had a good clinical outcome, but 18 patients required further pancreatic surgery at a mean of 12 months, either a pancreatojejunostomy or a completion pancreatectomy. Diabetes occurred in 40% of patients by 5 years, and most, at some stage of their postoperative period, required pancreatic enzyme supplementation. It is suggested that resection of the pancreas provides a reasonable life-style in 75% of patients, but the outcome depends in large part on the predisposing disease.
Collapse
Affiliation(s)
- R Christopher G Russell
- University College London Hospitals, NHS Trust, The Middlesex Hospital, Mortimer Street, W1T 3AA, London, UK.
| | | |
Collapse
|
45
|
Park YC, Kim SW, Jang JY, Ahn YJ, Park YH. Factors influencing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. J Am Coll Surg 2003; 196:859-65. [PMID: 12788421 DOI: 10.1016/s1072-7515(03)00127-3] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is the most frequent postoperative complication after pylorus-preserving pancreatoduodenectomy (PPPD). This study was undertaken to determine which factors influence the development of DGE after PPPD. STUDY DESIGN We studied 150 consecutive patients who underwent PPPD performed by one surgeon between 1996 and 2000. The variables analyzed were age, gender, diagnosis, laboratory data, operative time, transfusion, preoperative cholangitis, and complications. The operative factors included were route of the afferent jejunal limb (retromesenteric versus antemesenteric), type of pancreatoenteric anastomosis, and preservation of the right gastric artery. DGE was defined as nasogastric drainage for more than 10 days or delay of regular diet until 14 days postoperatively. RESULTS Univariate analysis showed preoperative cholangitis, intraabdominal complication, and the jejunal reconstruction method were significantly associated with DGE. Preservation of the right gastric artery was not associated with gastric emptying ability. Multivariate analysis by logistic regression showed that DGE was significantly more frequent among patients with preoperative cholangitis (15 of 36 [41.7%] versus 19 of 114 [16.7%], p=0.0031), postoperative intraabdominal complications (15 of 36 [41.7%] versus 10 of 114 [8.8%], p = 0.0001), and in the retromesenteric group (33 of 104 [31.7%] versus 3 of 46 [6.5%], p = 0.0174). CONCLUSIONS Preoperative cholangitis and postoperative leakage problems affect gastric emptying after PPPD during the early postoperative period. The retromesenteric route is not recommended for pancreato- and biliary-enteric anastomosis. We speculate that retromesenteric passage of afferent jejunum can cause venous congestion and bowel edema, which can in turn retard the recovery of jejunal peristalsis at the duodenojejunostomy site resulting in disturbance from food passage.
Collapse
Affiliation(s)
- Yoon-Chan Park
- Department of Surgery, Seoul National University College of Medicine, Clinical Research Institute, Seoul National University Hospital, South Korea
| | | | | | | | | |
Collapse
|
46
|
Schäfer M, Müllhaupt B, Clavien PA. Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis. Ann Surg 2002; 236:137-48. [PMID: 12170018 PMCID: PMC1422559 DOI: 10.1097/00000658-200208000-00001] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology. SUMMARY BACKGROUND DATA Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate. METHODS Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001. RESULTS The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. CONCLUSIONS Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.
Collapse
Affiliation(s)
- Markus Schäfer
- Department of Surgery and Division of Gastroenterology, University of Zürich, Zürich, Switzerland
| | | | | |
Collapse
|
47
|
Pirro N, Sielezneff I, Cesari J, Consentino B, Gregoire R, Brunet C, Sastre B. [Cephalic pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas: does pylorus preservation change morbidity and prognosis?]. ANNALES DE CHIRURGIE 2002; 127:95-100. [PMID: 11885380 DOI: 10.1016/s0003-3944(01)00706-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
STUDY AIM To evaluate the influence of a pylorus-preserving on the morbidity and prognosis of patient with pancreaticoduodenectomy for adenocarcinoma of pancreas. PATIENTS AND METHODS Between 1985 and 1999, 183 patients were operated on for pancreatic adenocarcinoma. Among them, 63 patients (40 men, mean age 63 years, range 41-77 years) had curative resection and were included in this retrospective study. They were classified according to the type of resection. In the group I, the procedure included a pylorus-preserving pancreaticoduodenectomy (n = 35). In the group II, the procedure included polar inferior gastrectomy (n = 28). The prognosis was compared. Parameters for comparison were rate of local recurrence, rate of metastatic evolution and duration of survival. RESULTS The operative length and mortality rate (group I: 0%, group II: 3%), general (p = 0.37) and specific morbidity (p = 0.30), frequency of delayed gastric emptying were similar in the 2 groups (group I: 20%, group II: 35%, p = 0.88). The duration of naso-gastic aspiration was shorter in the group I (6 days vs 8, p = 0.01). The prognosis was the same in the 2 groups (metastasis: group I: 39%, group II: 56%, p = 0.12, local recurrence: group I: 58%, group II: 43%, p = 0.09, mean survival: group I: 18 months, group II: 19 months, p = 0.77). CONCLUSION These results suggest that pylorus preserving pancreatoduodenectomy could be performed for patients with adenocarcinoma of the head of the pancreas and does not compromise survival.
Collapse
Affiliation(s)
- N Pirro
- Service de chirurgie digestive, hôpital Sainte-Marguerite, 270, boulevard de Sainte-Marguerite, 13274 Marseille, France.
| | | | | | | | | | | | | |
Collapse
|
48
|
Affiliation(s)
- A Shankar
- Department of Surgery, The Middlesex Hospital, Mortimer Street, London, W1N 8AA,UK
| | | |
Collapse
|
49
|
Abstract
Despite accurate diagnosis, better radiologic techniques, and safer surgery, long-term survival after surgical therapy for pancreatic cancer is disappointing. Median survival following pancreaticoduodenal resection is 12 to 15 months independent of surgical expertise, hospital size, or technical factors. Subsets of favorable tumors and longer survival times after surgery have been defined and include: small tumor size and low-grade lesions, tumor-free margins, and absence of nodal, venous, or perineural invasion; however, long-term survivors of pancreatic cancer may have none of these favorable features, and their tumors commonly manifest the most adverse tumor prognostic features. The converse that small-sized, histologically favorable tumors result in long-term survivors, also is not true. Five-year survival rates average 5% or less after all resections. In a large series in which 118 pancreatic resections were performed in 684 evaluated patients over a 6-year period, there were 12 5-year survivors, 5 of whom died in the sixth year. A report of 10-year survivors after surgery numbered 13 patients. The best actual 5-year survival rate was reported by Trede et al. Of the 37, 5-year survivors from a cohort of 118 patients, more than half died of cancer. This far exceeds any other actual survival rate and may be explained by a smaller tumor size. Farnell et al reported a 5-year survival rate difference (i.e., actuarial survival) in a subset of 174 resected patients with adenocarcinoma without perineural or duodenal invasion and with negative nodes (23% versus 6.8%), respectively. An impressive, large series of 616 patients with resected adenocarcinoma of the pancreas who underwent PDR (85%), distal pancreatectomy (9%), and total pancreatectomy (6%), has been reported. The mortality rate was 2.1%, and postoperative complications occurred in 30%. The five-year survival rate was 15%. The author's best result was observed among 20 initially "unresectable" patients who were treated with chemoradiation therapy, followed by tumor extirpation. Among the 18 surgical survivors there are seven five-year survivors, three of whom are in their tenth year of survival. They are discussed in the article by Cooperman et al ("Long-term Follow-up...") elsewhere in this issue.
Collapse
Affiliation(s)
- A M Cooperman
- Institute for Liver, Biliary, and Pancreatic Surgery, Community Hospital at Dobbs Ferry, New York 10522, USA
| |
Collapse
|
50
|
Costa OL. Anastomose duodenoduodenal na pancreatoduodenectomia por pancreatite crônica. Rev Col Bras Cir 2001. [DOI: 10.1590/s0100-69912001000200012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|