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Seo JY, Noh JH, Ahn JY, Cho SY, Oh SP, Cha B, Na HK, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Clinical outcomes of marginal ulcer bleeding compared with those of peptic ulcer bleeding. Surg Endosc 2023; 37:3852-3860. [PMID: 36707418 DOI: 10.1007/s00464-023-09871-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/04/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Marginal ulcer bleeding (MUB) is a complication that can occur following several types of surgery. However, few studies exist on it. Therefore, this study aimed to compare the clinical outcomes of MUB with those of peptic ulcer bleeding (PUB). METHODS Between January 2013 and December 2017, 5,076 patients underwent emergent esophagogastroduodenoscopy for suspected upper gastrointestinal bleeding. We retrospectively reviewed and analyzed the medical records of MUB and PUB patients and developed a propensity score matching (PSM) method to adjust for between-group differences in baseline characteristics with 1:2 ratios. Sex, age, body mass index (BMI), underlying diseases, and drugs were included as matching factors. RESULTS A total of 64 and 678 patients were diagnosed with MUB and PUB, respectively, on emergent esophagogastroduodenoscopy, and 62 and 124 patients with MUB and PUB, respectively, were selected after PSM. Rebleeding was significantly higher in patients with MUB than in those with PUB (57.8% vs 9.1%, p < 0.001). Mortality caused by bleeding was higher in patients with MUB than in those with PUB (4.7% vs. 0.4%, p < 0.001). Multivariate analysis revealed that proton pump inhibitor (PPI) administration (odds ratio [OR], 0.14; 95% confidence interval [CI], 0.03-0.56; p = 0.011) after first bleeding was inversely correlated with MUB rebleeding. Large ulcer size (> 1 cm) (OR, 6.69; 95% CI, 1.95-27.94; p = 0.005) and surgery covering pancreas (OR, 3.97; 95% CI, 1.19-15.04) were independent risk factors for MUB rebleeding. CONCLUSIONS MUB showed a severe clinical course than PUB. Therefore, MUB should be managed more cautiously, especially for large ulcers and pancreatic surgery. Prophylactic PPI administration may be helpful in reducing rebleeding in MUB.
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Affiliation(s)
- Jun-Young Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea.
| | - Sang Yong Cho
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Seung-Pyo Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Boram Cha
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
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Bolasco G, Capriati T, Grimaldi C, Monti L, De Pasquale MD, Patera IP, Spada M, Maggiore G, Diamanti A. Long-term outcome of pancreatic function following oncological surgery in children: Institutional experience and review of the literature. World J Clin Cases 2021; 9:7340-7349. [PMID: 34616800 PMCID: PMC8464449 DOI: 10.12998/wjcc.v9.i25.7340] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/13/2021] [Accepted: 07/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic neoplasms are uncommon in children and in most cases they are benign or have low malignant potential. Pancreatoblastoma and solid pseudopapillary tumor are the most frequent types in early and late childhood, respectively. Complete resection, although burdened by severe complications, is the only curative treatment for these diseases. Pancreatic surgery may result in impaired exocrine and endocrine pancreatic function. However, limited data are available on the long-term pediatric pancreatic function following surgical resection.
AIM To investigate endocrine and exocrine pancreatic function and growth after oncological pancreatic surgery in a pediatric series.
METHODS A retrospective analysis of all pediatric patients who underwent surgery for pancreatic neoplasm in our Institution from January 31, 2002 to the present was performed. Endocrine and exocrine insufficiency, auxological and fat-soluble vitamin status (A, D, E and clotting tests) were assessed at diagnosis and at every follow-up visit. Exocrine insufficiency was defined as steatorrhea with fecal elastase-1 < 200 µg/g stool, while endocrine insufficiency was identified as onset of Diabetes or Impaired Glucose Tolerance. Growth was evaluated based on body mass index (BMI) z-score trend.
RESULTS Sixteen patients (12 girls and 4 boys, mean age 10.7 ± 5.3 years), were included. Nine patients (56%) had a neoplasm in the pancreatic head, 4 in the body/tail, 2 in the tail and 1 in the body. Histological findings were as follows: Solid pseudopapillary tumor in 10 patients (62.5%), insulinoma in 2 patients, neuroendocrine tumor in 2 patients and acinar cell carcinoma in 2 patients. The most frequent surgery was pancreaticoduodenectomy (50%). Exocrine failure occurred in 4 patients (25%) and endocrine failure in 2 patients (12.5%). Exocrine insufficiency occurred early (within 6 mo after surgery) and endocrine insufficiency later (8 and 10 years after surgery). Mean BMI z-score was 0.36 ± 1.1 at diagnosis and 0.27 ± 0.95 at the last assessment. Vitamin D was insufficient (< 30 ng/mL) in 8 of the 16 patients during the follow-up period. Vitamins A, E and clotting test were into the normal ranges in all patients.
CONCLUSION Careful and long-term monitoring should follow any pancreatic surgery, to recognize and promptly treat exocrine and endocrine pancreatic insufficiency, which can occur after surgery.
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Affiliation(s)
- Giulia Bolasco
- Hepatology, Gastroenterology and Nutrition Unit, “Bambino Gesù” Children’s Hospital, IRCCS, Rome 00165, Italy
| | - Teresa Capriati
- Hepatology, Gastroenterology and Nutrition Unit, “Bambino Gesù” Children’s Hospital, IRCCS, Rome 00165, Italy
| | - Chiara Grimaldi
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, "Bambino Gesù" Children's Hospital, IRCCS, Rome 00165, Italy
| | - Lidia Monti
- Radiology Department, "Bambino Gesù" Children’s Hospital, IRCCS, Rome 00165, Italy
| | | | | | - Marco Spada
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, "Bambino Gesù" Children's Hospital, IRCCS, Rome 00165, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology and Nutrition Unit, “Bambino Gesù” Children’s Hospital, IRCCS, Rome 00165, Italy
| | - Antonella Diamanti
- Hepatology, Gastroenterology and Nutrition Unit, “Bambino Gesù” Children’s Hospital, IRCCS, Rome 00165, Italy
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Gastrostomy as a Preemptive Measure after Pancreatoduodenectomy against Delayed Gastric Emptying: A Small Case Series and a Review of the Literature. Case Rep Surg 2021; 2021:6649914. [PMID: 33680529 PMCID: PMC7925062 DOI: 10.1155/2021/6649914] [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: 11/29/2020] [Revised: 02/01/2021] [Accepted: 02/10/2021] [Indexed: 12/02/2022] Open
Abstract
Delayed gastric emptying (DGE) is a common (20–30%) postoperative complication following pancreatoduodenectomy (PD) (Parmar et al., 2013). Various causes and preemptive measures have been suggested to decrease the occurrence of DGE. We added a simple step in the procedure of 26 consecutive pancreatic head resections, which seems to alleviate DGE and has never been highlighted before.
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Luu AM, Vogel SR, Braumann C, Praktiknjo M, Höhn P, Förster S, Janot M, Uhl W, Belyaev O. Risk factors for perforated marginal ulcers following pancreaticoduodenectomy and prospective analysis of marginal ulcer development. Gland Surg 2021; 10:739-750. [PMID: 33708556 DOI: 10.21037/gs-20-763] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Perforated marginal ulcers (PMUs) are a feared long-term complication following pancreaticoduodenectomy (PD), which always require relaparotomy compared to marginal ulcers. Methods First, we performed a retrospective chart review for all patients who underwent PD from 2007-2016 to identify incidence and risk factors associated with PMUs. Second, we analyzed follow up gastroscopies in all patients undergoing PD from 2007-2011 to identify the overall incidence of marginal ulcers. Results A total of 725 patients underwent PD in the retrospective study period. 17 patients (2.3%) suffered from PMU at a median postoperative time of 13 months. These patients were significantly younger (median age: 49 vs. 62 years; P=0.02) and suffered most often from chronic pancreatitis (P<0.001). Smoking and alcohol consumption were significantly more common (P=0.01 and P=0.023). An elevated level of carcinoembryonic antigen and chronic pancreatitis were identified as independent risk factors. Overall, 373 patients were enrolled for prospective analysis. Marginal ulcers occurred in 5-5.9% over a postoperative period of 5 years. Conclusions Continuous treatment with proton-pump inhibitors for at least 5 years, immediate smoking cessation and follow-up gastroscopies are obligate for patients undergoing PD to avoid marginal ulcers and PMUs.
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Affiliation(s)
- Andreas Minh Luu
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
| | - Sina Rabea Vogel
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
| | - Chris Braumann
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine, University of Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Philipp Höhn
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
| | - Sarah Förster
- Department of Pathology, University-Hospital Bergmannsheil, Bürkle de la Camp Platz 1, 44789 Bochum, Germany
| | - Monika Janot
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
| | - Orlin Belyaev
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791 Bochum, Germany
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Analysis of Symptomatic Marginal Ulcers in Patients Who Underwent Pancreaticoduodenectomy for Periampullary Tumors. Pancreas 2020; 49:208-215. [PMID: 32011522 DOI: 10.1097/mpa.0000000000001470] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECT The objectives are to investigate the incidence and risk factors associated with symptomatic marginal ulcer (sMU) and analyze their relationship with the use of prophylactic proton pump inhibitors (PPIs) after pancreaticoduodenectomy. METHODS Clinical postoperative outcomes of 72 sMU and 1266 non-sMU were compared and analyzed. We performed a subanalysis of 72 patients with sMU diagnosed within (n = 18) and after 4 months (n = 54). The risk factors associated with sMU incidence were analyzed. RESULTS Of the 1338 patients, 72 (5.4%) were diagnosed as having sMU. Eighteen patients (25.0%) were diagnosed during the first 4 months, and 48 (66.7%), within 16 months. Cumulative sMU incidence differed according to the duration of prophylactic PPI use (≥4 months: 7.1% vs <4 months: 10.1%, P < 0.001). The duration of prophylactic PPI use was identified as a risk factor in the multivariable analysis (hazard ratio, 2.294; 95% confidence interval, 1.436-3.664; P = 0.001). CONCLUSIONS Two-thirds or more of the patients were diagnosed as having sMU within 16 months after surgery. The duration of the prophylactic PPI use was an independent risk factor. We recommend the use of prophylactic PPI for more than 16 months after pancreaticoduodenectomy for periampullary tumors.
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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.
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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
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Is antisecretory therapy after pancreatoduodenectomy necessary? Meta-analysis and contemporary practices of pancreatic surgeons. J Gastrointest Surg 2015; 19:604-12. [PMID: 25691111 DOI: 10.1007/s11605-015-2765-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Marginal ulcer (MU) is a well-described complication of pancreatoduodenectomy (PD) whose incidence remains unclear. Gastric antisecretory medications likely attenuate the risk of marginal ulceration after PD; however, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known. The aims of this study were to document the incidence of MU after PD, identify any relationship between MU and gastric antisecretory medication, and survey current practice of MU prophylaxis among experienced pancreatic surgeons. METHODS the MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials, and Cochrane Database of Systematic Reviews databases were searched from their inception to May 2014 for abstracts documenting ulceration after pancreatoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Contemporary practice was assessed through a four-question survey distributed globally to 200 established pancreatic surgeons. RESULTS After a review of 208 abstracts, 54 studies were graded as relevant. These represented a cohort of 212 patients with marginal ulcer after PD (n = 4794). A meta-analysis of the included references shows mean incidence of ulceration after PD of 2.5% (confidence interval (CI) 1.8-3.2%) with a median time to diagnosis of 15.5 months. Pylorus preservation was associated with a MU rate of 2.0% (CI 1.0-2.9%), while "classic" PD procedures report an overall rate of 2.6% (CI 1.6-3.6%). Documented use of postoperative antisecretory medication was associated with a reduced rate of 1.4% (CI 0.1-1.7%). One hundred forty-four of 200 (72%) surveys were returned, from which it was determined that 92% of pancreatic surgeons have dealt with this complication, and 86% routinely prescribe prophylactic antisecretory medication after PD. CONCLUSIONS The incidence of MU after PD is 2.5% with a median time to occurrence of 15.5 months postoperatively. Gastric antisecretory medication prescription may affect the incidence of MU. The majority of pancreatic surgeons surveyed have encountered MU after PD; most (86%) routinely prescribe prophylactic gastric antisecretory medication.
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Nikfarjam M, Kimchi ET, Gusani NJ, Shah SM, Sehmbey M, Shereef S, Staveley-O'Carroll KF. A reduction in delayed gastric emptying by classic pancreaticoduodenectomy with an antecolic gastrojejunal anastomosis and a retrogastric omental patch. J Gastrointest Surg 2009; 13:1674-82. [PMID: 19548039 DOI: 10.1007/s11605-009-0944-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 06/03/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) continues to be a major cause of morbidity following pancreaticoduodenectomy (PD). A change in the method of reconstruction following PD was instituted in an attempt to reduce the incidence DGE. METHODS Patients undergoing PD from January 2002 to December 2008 were reviewed and outcomes determined. Pylorus-preserving pancreaticoduodenectomy (PPPD) with a retrocolic duodenojejunal anastomosis (n = 79) or a classic PD with a retrocolic gastrojejunostomy (n = 36) was performed prior to January 2008. Thereafter, a classic PD with an antecolic gastrojejunal anastomosis and placement of a retrogastric vascular omental patch was undertaken (n = 36). RESULTS A statistically significant decrease in DGE was noted in the antecolic group compared to the entire retrocolic group (14% vs 40%; p = 0.004) and compared to patients treated by classic PD with a retrocolic anastomosis alone (14% vs 39%; p = 0.016). On multivariate analysis, the only modifiable factor associated with reduced DGE was the antecolic technique with an omental patch, odds ratio (OR) 0.3 (confidence interval (CI) 0.1-0.8) p = 0.022. Male gender was associated with an increased risk of DGE with OR 2.3 (CI 1.1-4.8) p = 0.026. CONCLUSION A classic PD combined with an antecolic anastomosis and retrogastric vascular omental patch results in a significant reduction in DGE.
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Affiliation(s)
- Mehrdad Nikfarjam
- Liver, Pancreas and Foregut Unit, Department of Surgery, Penn State College of Medicine, Hershey, PA 17033-0850, USA.
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Ohtsuka T, Tanaka M, Miyazaki K. Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy. ACTA ACUST UNITED AC 2006; 13:218-24. [PMID: 16708298 DOI: 10.1007/s00534-005-1067-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Accepted: 10/26/2005] [Indexed: 12/20/2022]
Abstract
The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreatoduodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.
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Affiliation(s)
- Takao Ohtsuka
- Department of Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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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.
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11
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Lytras D, Paraskevas KI, Avgerinos C, Manes C, Touloumis Z, Paraskeva KD, Dervenis C. Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection. Langenbecks Arch Surg 2006; 392:1-12. [PMID: 17021788 DOI: 10.1007/s00423-006-0096-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Accepted: 08/11/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality. METHODS We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were "delayed gastric emptying," "pancreaticoduodenectomy," "Whipple procedure," "pylorus-preserving pancreaticoduodenectomy," and "complications following pancreatic resection" in various combinations. RESULTS A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported. CONCLUSIONS The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as "centralizing" pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.
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Affiliation(s)
- Dimitrios Lytras
- 1st Department of Surgery, Agia Olga Hospital, 3-5 Agias Olgas Street, 14233 Nea Ionia, Greece
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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.
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Affiliation(s)
- E de Bree
- Department of Surgical Oncology, University Hospital, Medical School of Crete, Herakleion, Greece.
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Watanabe H, Sumi S, Xu G, Kitamura Y, Nio Y, Higami T, Funakoshi A. Studies on hypertrophic effect of 90% partial pancreatectomy on the stomach in rats. Pancreas 2003; 26:e43-7. [PMID: 12604927 DOI: 10.1097/00006676-200303000-00025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Stomach changes after major pancreatectomy (Px) are unclear. We previously reported that 90% Px increased stomach weight in rats similarly to endogenous hypergastrinemia by lansoprazole, a proton-pump inhibitor. AIM To investigate the role of endogenous gastrin in gastric hypertrophy after Px. METHODOLOGY In male Wistar rats, we compared the wet weight of the stomach and serum gastrin levels between normal (n = 10) or sham-operated controls (n = 10) and 90% partially pancreatectomized rats (n = 7). Then, using Northern blot analysis, we compared gene expression of gastrin, cholecystokinin-B (CCK-B) receptor, and somatostatin in the stomach among normal controls (n = 7), sham-operated rats (n = 7), and 90% partially pancreatectomized rats (n = 8). The samples were obtained on the third and seventh postoperative days (POD). RESULTS Wet weight of the stomach was significantly heavier in the Px rats than in the sham-operated controls (3.90 +/- 0.12 mg/g vs 2.63 +/- 0.07mg/g; p< 0.0001) on the 14th POD. Serum gastrin levels were also higher in the Px rats than in controls (161.4 +/- 13.35 pg/mL vs 110.6 +/- 5.67 pg/mL; p< 0.005) on the 14th POD. Gene expression of gastrin in the stomach on the 7th POD was significantly higher in the Px rats than in the sham-operated rats (p < 0.05), and gene expression of CCK-B receptor clearly increased in the Px rats on the 7th POD, when compared with that of controls (p < 0.05). Gastric somatostatin gene expression in both operated groups increased approximately twice as much as in normal controls after operation (p < 0.005). However, on the 7th POD, it returned to control levels only in Px rats and not in sham-operate rats (p < 0.05). CONCLUSION Increased gene expression of gastrin and CCK-B receptor suggests that gastrin may act as a trophic factor on the stomach after partial Px. Moreover, the relative decrease in gastric somatostatin gene expression may also influence gastric hypertrophy after Px.
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Affiliation(s)
- Hiroaki Watanabe
- First Department of Surgery, Shimane Medical University, Izumo, Japan
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Tanaka A, Ueno T, Oka M, Suzuki T. Effect of denervation of the pylorus and transection of the duodenum on acetaminophen absorption in rats; possible mechanism for early delayed gastric emptying after pylorus preserving pancreatoduodenectomy. TOHOKU J EXP MED 2000; 192:239-47. [PMID: 11286314 DOI: 10.1620/tjem.192.239] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Early delayed gastric emptying has been reported as a frequent complication following pylorus preserving pancreatoduodenectomy (PPPD). We investigated the effect of division of the pyloric branch of the vagus nerve and/or transection of the duodenum on gastric emptying using the acetaminophen method in rats to speculate the unknown etiology of early delayed gastric emptying after PPPD. Twenty-four male Wistar rats were divided into the following four groups; Group S, sham operation as controls; Group N, disturbance of neuro-vascular supply to the pylorus; Group D, temporary interference of the duodenal continuity; and Group N+D, with both procedures in Group N and Group D. Gastric emptying was measured using the acetaminophen method at 1, 2, and 4 weeks after operations in each group. No significant difference was observed in Group S at any intervals after the operation. Gastric emptying was prolonged significantly in Group N, Group D and Group N+D compared to Group S until 2 weeks following surgery. Significant delayed gastric emptying was sustained in Group N+D at 4 weeks, although gastric emptying in Group N and Group D was improved by 4 weeks. The results in rodent models suggest that both dissection of the pyloric branch of the vagus and transection of the duodenum might be causative factors of postoperative delayed gastric emptying following PPPD.
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Affiliation(s)
- A Tanaka
- Department of the Second Surgery, Yamaguchi University School of Medicine, Ube, Japan
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Xu G, Sumi S, Koike M, Tanigawa K, Nio Y, Tamura K. Role of endogenous hypergastrinemia in regenerating endocrine pancreas after partial pancreatectomy. Dig Dis Sci 1996; 41:2433-9. [PMID: 9011454 DOI: 10.1007/bf02100139] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We studied the possible role of endogenous gastrin in the regenerating pancreas. Male Wistar rats underwent sham operation or 90% partial pancreatectomy (Px). Lansoprazole (30 mg/kg body wt), a proton pump inhibitor (PPI), was given p.o. for 3 weeks after surgery. Plasma glucose levels were higher in Px rats than in shams. Lansoprazole lowered plasma glucose levels in the Px rats. In addition, integrated insulin secretion during an oral glucose tolerance test (2 g/kg body wt) was significantly (p < 0.01) higher in lansoprazole-treated Px rats than in control Px rats, while lansoprazole did not affect insulin secretion in shams. Fasting serum gastrin levels were higher (p < 0.01) in lansoprazole-treated animals than in controls both in sham rats and in Px rats. Furthermore, lansoprazole increased the pancreas weight per body weight and elevated the insulin content of the pancreas in Px rats. These results suggest that endogenous hypergastrinemia has a trophic effect on endocrine pancreas during regenerating processes and that administration of PPI may be clinically beneficial to the remnant pancreas after pancreatectomy if the whole stomach is preserved.
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Affiliation(s)
- G Xu
- First Department of Surgery, Shimane Medical University, Izumo, Japan
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Pylorus-preserving pancreatoduodenectomy is applicable to patients with carcinoma of the head of the pancreas: Studies of lymph node metastasis and quality of life. ACTA ACUST UNITED AC 1995. [DOI: 10.1007/bf02348741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Kingsnorth AN, Formela LJ, Chen D, Rehfeld JF. Plasma gastrin and cholecystokinin responses after pylorus-preserving pancreatoduodenectomy and defunctioned Roux loop pancreaticojejunostomy. Br J Surg 1994; 81:1356-9. [PMID: 7953412 DOI: 10.1002/bjs.1800810933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Several methods can be used to re-establish gastrointestinal continuity after the standard Whipple's Billroth II procedure or Longmire pylorus-preserving pancreatoduodenectomy (PPPD). Standard pancreatoduodenectomy abolishes the postprandial gastrin response whereas the response after Longmire PPPD is similar to that in controls. A novel reconstruction after PPPD has been designed to separate the biliary and pancreatic secretions by restoring continuity in the Billroth I manner, retaining the gastric antrum and with the pancreatic remnant anastomosed to a separate defunctioned Roux loop. Gastrin and cholecystokinin (CCK) responses were measured in the fasting state and after a standard liquid meal of 250 ml containing 15 per cent protein, 30 per cent fat and 55 per cent carbohydrate with an energy value of 525 kJ. Basal gastrin and CCK concentrations were similar in five healthy unoperated controls, and after standard pancreatoduodenectomy (five patients) and isolated Roux loop PPPD (six patients). In controls and after the new PPPD operation, but not after standard pancreatoduodenectomy, mean(s.e.m.) postprandial plasma gastrin values rose from 8.66(0.33) to 13.00(0.33) pmol l-1 at 10 min (controls) and from 7.66(1.56) to 15.00(1.36) pmol l-1 at 10 min (defunctioned Roux loop PPPD); the concentration remained raised for 20 min then fell transiently; a second peak was maintained for 40 min (controls) to 60 min (modified PPPD). In controls, mean(s.e.m.) postprandial plasma CCK concentrations rose from 0.43(0.12) basal to 10.50(1.03) pmol l-1 and returned to basal after 60 min. After standard pancreatoduodenectomy postprandial CCK concentrations rose at a similar rate and remained raised for 80 min. After isolated Roux loop PPPD plasma CCK concentrations remained low (mean(s.e.m.) 0.38(0.29) pmol l-1) after the test meal.
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Fleming WR, Williamson RCN. Preservation of the pylorus in resection of the head of the pancreas. ACTA ACUST UNITED AC 1994. [DOI: 10.1007/bf02391096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Braasch JW. Preservation of the pylorus and resection of the head of the pancreas. ACTA ACUST UNITED AC 1994. [DOI: 10.1007/bf02391094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Carter D, Trede M, Beger HG, Roder JD, Siewert JR. [Does saving the pylorus in pancreatoduodenectomy for periampullary cancer have a value?]. LANGENBECKS ARCHIV FUR CHIRURGIE 1994; 379:58-63. [PMID: 7511770 DOI: 10.1007/bf00206564] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Klinkenbijl JH, van der Schelling GP, Hop WC, van Pel R, Bruining HA, Jeekel J. The advantages of pylorus-preserving pancreatoduodenectomy in malignant disease of the pancreas and periampullary region. Ann Surg 1992; 216:142-5. [PMID: 1354435 PMCID: PMC1242585 DOI: 10.1097/00000658-199208000-00004] [Citation(s) in RCA: 134] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The aim of this study was to establish whether the pylorus-preserving pancreatoduodenectomy (PPPD) is a safe and radical procedure in malignant disease of the head of the pancreas and periampullary region, without increased morbidity and mortality rates compared with the standard Whipple's procedure. During the period 1984 to 1990, a Whipple's procedure (n = 44) or PPPD (n = 47) was performed in 91 patient. In-hospital mortality rates were 2% after PPPD and 5% after Whipple's procedure. Median duration of the resection procedure and median blood loss in the PPPD group were 210 minutes and 1800 mL, respectively. After Whipple's procedure, these figures were 255 minutes and 2500 mL, both significantly different (p less than 0.01) as compared with PPPD. No difference was found during follow-up with respect to days of gastric suctioning, start of liquid diet, normal diet, complaints of ulcer disease, postoperative complications, recurrence of disease, and survival. In all patients, curative resection was performed with comparable TNM (tumor, nodes, metastases) staging. The number of tumor-containing duodenal or gastric resection margins did not differ in both groups of patients (two patients after PPPD, two patients after Whipple's procedure). Hospital stay was significantly (p = 0.02) shorter after PPPD; median 14 days, compared with median 18 days after Whipple's procedure. The advantage of the PPPD is that it is an easier and less time-consuming operation, with less blood loss, a shorter hospital stay, and better weight gain (p = 0.02) during follow-up. In conclusion, PPPD is a safe and radical procedure for cancer in the head of the pancreas or periampullary region, with the same survival and appearance of locoregional recurrence and distant metastases as after standard Whipple's resection.
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Affiliation(s)
- J H Klinkenbijl
- Department of General Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands
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Naito H, Sasaki I, Takahashi M, Rahman MM, Matsuno S. An experimental study on the gastric acid and gut hormone secretion after pylorus preserving duodenectomy in dogs. ACTA ACUST UNITED AC 1992; 27:317-26. [PMID: 1352508 DOI: 10.1007/bf02777749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To clarify changes in gastric acid and gut hormone secretion after pylorus-preserving pancreaticoduodenectomy (PPPD), an experimental study was performed using a model of pylorus-preserving duodenectomy in dogs previously provided with Heidenhain pouch (HP). The duodenectomy involves resection of the duodenum and 10 cm of the proximal jejunum preserving 2 cm of juxtapyloric duodenum and round-shaped duodenal wall around pancreatic papilla. Reconstruction was done by anastomosing the rho-shaped jejunal loop to gallbladder, juxtapyloric duodenum and peripapillar round-shaped duodenal wall with ligation of the common bile duct. For these dogs, intravenous glucose tolerance test (IVGTT), oral glucose tolerance test (OGTT), meal ingestion test (TM) and histological studies of pancreatic specimen obtained at autopsy were performed investigating pancreatic, gastric acid and gut hormone secretion. Preservation of endocrine and exocrine pancreatic secretion after operation demonstrated our experimental model to be adequate for evaluation of the factor of duodenectomy in PPPD on gastric acid and gut hormone secretion avoiding the influences of changes in pancreatic secretion. Postprandial gastric acid secretion from HP did not change significantly after operation. Postprandial secretion of gastrin, glucagon, GIP and enteroglucagon did not alter significantly after operation. These results indicated that in the clinical PPPD procedure, preservation of more than 2 cm of duodenum from the pylorus produced neither postprandial gastric acid hypersecretion, which might be cause of postoperative stomal ulcer, nor any change of related gut hormone secretion.
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Affiliation(s)
- H Naito
- First Department of Surgery, Tohoku University School of Medicine, Sendai, Japan
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Abstract
The duodenal switch operation is a new form of pancreaticobiliary diversion with superior physiologic consequences compared with the Roux-en-Y procedure. The new technique has been extensively tested in the laboratory and found to be nonulcerogenic and to be less disruptive of foregut physiology than the Roux-en-Y procedure. The duodenal switch has been used in more than 40 patients with confirmed duodenogastric reflux and has proved to be well tolerated and successful in long-term follow-up.
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Affiliation(s)
- R A Hinder
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska
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Welch NT, Yasui A, Kim CB, Barlow AP, Hinder RA, DeMeester TR, Polishuk PV, Clark GW, Adrian TE. Effect of duodenal switch procedure on gastric acid production, intragastric pH, gastric emptying, and gastrointestinal hormones. Am J Surg 1992; 163:37-44; discussion 44-5. [PMID: 1733373 DOI: 10.1016/0002-9610(92)90250-u] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The duodenal switch operation preserves the pylorus and the proximal 3 to 7 cm of duodenum in continuity with the stomach while diverting pancreaticobiliary secretions. We compared it with the Roux-en-Y without vagotomy or antrectomy in 12 dogs with innervated gastric pouches. Acid secretion was inhibited between tests using ranitidine in the Roux-en-Y group only, but two of the six dogs still developed stomal ulcers and the remainder showed stomal hyperemia. This may be due to a significant increase in gastric acid output after Roux-en-Y, but gastric emptying and plasma gastrin, cholecystokinin, secretin, gastric inhibitory polypeptide, peptide YY, and neurotensin were similar after both procedures. In 12 patients and a further 6 dogs, the duodenal switch caused no significant change in the intragastric pH environment as assessed by intragastric pH monitoring. The duodenal switch is a suitable procedure for pancreaticobiliary diversion.
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Affiliation(s)
- N T Welch
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131
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Watanabe Y, Tsumura H, Sakurai H, Haba T, Ono S, Aonuma H. Gastric emptying after pancreatoduodenectomy with total stomach preservation and selective proximal vagotomy. Surg Today 1992; 22:426-31. [PMID: 1358290 DOI: 10.1007/bf00308792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This study evaluates postoperative gastric emptying following a new method of pancreatoduodenectomy with total stomach preservation and selective proximal vagotomy performed on 10 patients with diseases affecting the head of the pancreas, 7 being malignant and 3 benign. Reconstruction was carried out using the Billroth I and Billroth II techniques in 5 patients each, respectively. Early postoperative gastric emptying was evaluated by the time before intragastric tube removal and the resumption of oral intake, as well as by barium gastric radiography, while late postoperative gastric emptying was evaluated by the acetaminophen method. No difference was seen in early postoperative gastric emptying between the two surgical techniques, the mean time which elapsed before intragastric tube removal being 4.4 days for the Billroth I and 4.5 days for the Billroth II patients, and the mean time until the resumption of oral intake being 6.8 days for the Billroth I and 7.0 days for the Billroth II patients. A significant delay in gastric emptying was seen in the Billroth II patients compared to a normal control group, 30 and 45 min after acetaminophen administration, but the difference in gastric emptying between the Billroth I and II patients was not significant. Moreover, both techniques impaired gastric emptying much less than Traverso's pylorus-preserving pancreatoduodenectomy.
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Affiliation(s)
- Y Watanabe
- Department of Surgery, Izunagaoka Hospital, Juntendo University School of Medicine, Shizuoka, Japan
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Tangoku A, Nishikawa M, Adachi A, Suzuki T. Plasma gastrin and cholecystokinin response after pylorus-preserving pancreatoduodenectomy with Billroth-I type of reconstruction. Ann Surg 1991; 214:56-60. [PMID: 2064472 PMCID: PMC1358414 DOI: 10.1097/00000658-199107000-00009] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Plasma gastrin and cholecystokinin (CCK) responses were measured after a pancreatoduodenectomy (PD) using the Billroth-I type reconstruction combined with distal partial gastrectomy (standard PD) and combined with preservation of the pylorus and the duodenal bulb (PPPD). Six unoperated patients, 4 men and 2 women, were studied as control subjects. Basal plasma levels of gastrin were significantly higher in controls than in patients who had a standard PD (p less than 0.05) and gastrin responses to a meal were also blunted in these patients. In contrast basal and postprandial levels of gastrin after PPPD were significantly higher than these found in patients with standard PD (p less than 0.05). Postprandial gastrin response after PPPD were similar in pattern to these found in controls. Integrated gastrin release after PPPD was less than that of the control but was significantly greater than that in patients with standard PD. Basal plasma levels of CCK in the patients after the standard PD were significantly lower than in controls and significantly higher postprandial levels of CCK were found after PPPD compared to standard PD (p less than 0.05). However integrated CCK from 0 to 120 minutes were not significantly different between PPPD and standard PD groups. Based on these observations concerning hormonal release of gastrin and CCK, preservation of the stomach and the duodenal bulb appears to be a more physiologic reconstructive procedure than the standard PD. In addition the operation probably has more beneficial effect on the injured pancreas in time.
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Affiliation(s)
- A Tangoku
- Department of Surgery II, Yamaguchi University School of Medicine, Ube, Japan
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Russell RC. Surgical resection for cancer of the pancreas. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1990; 4:889-916. [PMID: 2078790 DOI: 10.1016/0950-3528(90)90025-c] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Pitt HA, Grace PA. Cancer of the pancreas. Pylorus-preserving resection of the pancreas. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1990; 4:917-30. [PMID: 2078791 DOI: 10.1016/0950-3528(90)90026-d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pylorus-preserving pancreaticoduodenectomy represents an important advance in the history of pancreatic surgery. The operation can be performed with a low operative mortality and morbidity, is technically easier than the standard Whipple resection, and it minimizes the long-term physiological disturbance to the patient. Clinical and experimental evidence has substantiated the view that preservation of the pylorus reduces the incidence of marginal anastomotic ulceration following pancreatectomy. Although gastric emptying may be prolonged transiently in the immediate postoperative period, this complication is easily managed, and is hardly a frequent long-term problem. PPPD is associated with a lower incidence of enterogastric reflux, dumping and diarrhoea than the classical Whipple operation, and patients who have had PPPD are more likely to regain their preoperative and preillness weight. Initial concerns about the use of PPPD in malignant disease have not been borne out, and should now be considered for curative or palliative resections of lesions in the periampullary region including the head of the pancreas. Present data suggest that PPPD does not compromise the long-term survival in patients with periampullary cancers. There is little doubt that the excellent results reported with this procedure as with other forms of major pancreatic surgery, are not simply related to improvements in surgical technique but to establishment of specialist pancreatic surgery.
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Abstract
Pylorus preserving pancreatoduodenectomy (PPPD) was reintroduced 12 years ago. Since that time, over 400 patients have undergone PPPD with approximately 41 per cent having chronic pancreatitis and 54 per cent having pancreatic and other periampullary malignancies. Reported 5-year survivals in this latter group have been comparable to those achieved by the classic Whipple procedure. The postoperative mortality rate in 339 reported patients has been 3.8 per cent. Postoperative morbidity, including delayed gastric emptying, has been similar to that of the classic Whipple operation. However, PPPD has been associated with fewer late problems with dumping, diarrhoea, delayed gastric emptying (8.6 per cent), and marginal ulceration (3.6 per cent). Moreover, most patients undergoing PPPD have been able to return to their preoperative and preillness weight. The additional advantage of decreased operative time makes PPPD an attractive alternative to the classic pancreatoduodenectomy.
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Affiliation(s)
- P A Grace
- Department of Surgery, Royal College of Surgeons, Ireland, Dublin
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