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Çolakoğlu Y, Özlü DN, Ayten A, Savun M, Simsek A. Does the suturing technique (barbed continuous versus conventional interrupted) impact the outcome of anastomotic urethroplasty? Int Urol Nephrol 2025; 57:363-369. [PMID: 39382602 DOI: 10.1007/s11255-024-04223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 09/28/2024] [Indexed: 10/10/2024]
Abstract
PURPOSE To evaluate and compare continuous suture (CS) and interrupted suture (IS) techniques applied in excision and primary anastomosis (EPA) urethroplasty in terms of surgical success and complication rates. METHODS A retrospective evaluation was conducted on patients with bulbar urethral strictures measuring ≤ 2.5 cm who underwent EPA between April 2020 and December 2022. Patients with a history of urethral reconstruction, multiple strictures, a history of pelvic radiotherapy, a diagnosis of Lichen sclerosis, a history of surgery due to congenital penile curvature or Peyronie's disease, and a follow-up period of less than 12 months were excluded. The patients were divided into two groups according to the suture technique used (CS or IS), and the groups were compared for demographic and perioperative data. RESULTS A total of 97 patients (CS n = 52, IS n = 55) were included in the sample. The mean age of the entire patient group was calculated to be 56.2 years and the mean stricture length was 19.3 mm. Operation time and postoperative catheter time were shorter in the CS group (94.7 ± 7.3 vs. 117.2 ± 5.7 min and 9.9 ± 1.6 vs. 15.8 ± 1.9 min, p < 0.001, respectively). The groups were similar regarding anatomical success, stress urinary incontinence, penile numbness, curvature, and postoperative infection (p > 0.05). CONCLUSION No significant difference was observed in terms of success or complications between the CS and IS techniques employed during EPA urethroplasty. However, in addition to reducing the operation time, the CS technique offers the advantage of safely removing the urethral catheter earlier.
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Affiliation(s)
- Yunus Çolakoğlu
- Department of Urology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | | | - Ali Ayten
- Department of Urology, University of Health Sciences Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Metin Savun
- Department of Urology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Abdulmuttalip Simsek
- Department of Urology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
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Xue K, Wang L, Chen L, Liu X, Li A, Wang Z, Hou S, Xiong J, Tian B. Development and validation of a novel pancreaticojejunostomy strategy based on the anatomical location of the main pancreatic duct that can reduce the risk of postoperative pancreatic fistula after pancreatoduodenectomy. Gland Surg 2024; 13:1693-1707. [PMID: 39544981 PMCID: PMC11558298 DOI: 10.21037/gs-24-235] [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: 06/13/2024] [Accepted: 09/30/2024] [Indexed: 11/17/2024]
Abstract
Background Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD). The effect of the location of the main pancreatic duct on POPF development is not completely elucidated. This study aimed to investigate the association between the location of the main pancreatic duct and POPF, and the effect of pancreaticojejunostomy based on the location of the main pancreatic duct on the risk of POPF. Methods This retrospective study enrolled 871 patients who underwent PD between January 2018 and December 2021. Logistic regression analysis was performed to identify the independent risk factors associated with POPF. Predictive performance was evaluated using the receiver operating characteristic curves. In addition, a novel pancreaticojejunostomy strategy that could reduce the risk of POPF was adopted. Results Based on the multivariate analysis, the pancreatic texture and the location of the main pancreatic duct were the independent risk factors of POPF. A threshold ratio of 0.397 was used to distinguish the central from the eccentric pancreatic ducts. Notably, patients with the central pancreatic duct had a significantly lower incidence rate of POPF than those with the eccentric pancreatic ducts (10.6% vs. 44.8%, P<0.001). The novel group exhibited a significantly lower incidence rate of POPF than the conventional group (13.7% vs. 23.0%, P=0.02), and the incidence rate of other complications was not high. Conclusions The location of the main pancreatic duct is associated with POPF development. However, implementing the novel pancreaticojejunostomy approach can effectively reduce the risk of POPF while ensuring safety.
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Affiliation(s)
- Kang Xue
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Li Wang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lang Chen
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaofeng Liu
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Angzhi Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zihe Wang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Shengzhong Hou
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Junjie Xiong
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bole Tian
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
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Zhang B, Li L, Liu H, Li L, Wang H, Li Y, Wang Y, Sun B, Chen H. A modified single-needle continuous suture of duct-to-mucosa pancreaticojejunostomy in pancreaticoduodenectomy. Gland Surg 2023; 12:1642-1653. [PMID: 38229848 PMCID: PMC10788565 DOI: 10.21037/gs-23-340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/17/2023] [Indexed: 01/18/2024]
Abstract
Background The pancreatic reconstruction technique decides the incidence of postoperative pancreatic fistulas (POPF) in pancreaticoduodenectomy (PD). This study aims to evaluate the safety of modified single-needle continuous suture (SNCS) of duct-to-mucosa and compare the efficacy with double-layer continuous suture (DLCS) of duct-mucosa pancreaticojejunostomy (PJ) in open PD (OPD). Methods A total of 266 patients that received PD between January 2019 and May 2023 were retrospectively analyzed. Among them, 130 patients underwent DLCS, and 136 patients underwent SNCS [73 OPD and 63 laparoscopic PD (LPD)]. The primary outcome was clinically relevant POPF (CR-POPF) according to the definition of the revised 2016 International Study Group of Pancreatic Fistula (ISGPF). Propensity score matching (PSM) was conducted to reduce confounding bias. Results A total of 66 pairs were successfully matched using PSM in OPD. No significant difference was observed in the occurrence of CR-POPF between the two groups (9.1% vs. 21.2%, P=0.052). However, the median duration of operation and PJ was shorter in the SNCS group. The incidence of CR-POPF in LPD was 9.5%. Furthermore, regarding the alternative fistula risk score (a-FRS), the CR-POPF rate were 2.1%, 10.5%, and 15.6% in low-, intermediate-, and high-risk groups (P=0.067). Conclusions The SNCS is a facile, safe, and effective PJ technique and does not increase the incidence of POPF, regardless of a-FRS stratification, pancreatic texture, and main pancreatic duct (MPD) size.
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Affiliation(s)
- Binru Zhang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Le Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongyang Liu
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Linfeng Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Haonian Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yilong Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yongwei Wang
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hua Chen
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery, Ministry of Education, The First Affiliated Hospital of Harbin Medical University, Harbin, China
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Schuh F, Mihaljevic AL, Probst P, Trudeau MT, Müller PC, Marchegiani G, Besselink MG, Uzunoglu F, Izbicki JR, Falconi M, Castillo CFD, Adham M, Z'graggen K, Friess H, Werner J, Weitz J, Strobel O, Hackert T, Radenkovic D, Kelemen D, Wolfgang C, Miao YI, Shrikhande SV, Lillemoe KD, Dervenis C, Bassi C, Neoptolemos JP, Diener MK, Vollmer CM, Büchler MW. A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery. Ann Surg 2023; 277:e597-e608. [PMID: 33914473 PMCID: PMC9891297 DOI: 10.1097/sla.0000000000004855] [Citation(s) in RCA: 101] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). SUMMARY BACKGROUND DATA Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking. METHODS A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort. RESULTS Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001). CONCLUSION For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.
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Affiliation(s)
- Fabian Schuh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Maxwell T Trudeau
- Department of Surgery, The University of Pennsylvania, Philadelphia, PA
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Faik Uzunoglu
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, ''Vita-Salute'' University, Milan, Italy
| | | | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hospital Edouard Herriot, Lyon, France
| | | | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dezso Kelemen
- Department of Surgery, University of Pécs, Medical School, Pécs, Hungary
| | - Christopher Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Y I Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and the Harvard Medical School, Boston, MA
| | | | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Charles M Vollmer
- Department of Surgery, The University of Pennsylvania, Philadelphia, PA
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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5
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Kang YH, Kang JS, Lee M, Jung HS, Yun WG, Cho YJ, Han Y, Kwon W, Jang JY. Comparisons of short-term outcomes of anastomotic methods of duct-to-mucosa pancreaticojejunostomy: out-layer continuous suture versus modified Blumgart method. Ann Surg Treat Res 2022; 103:331-339. [PMID: 36601337 PMCID: PMC9763782 DOI: 10.4174/astr.2022.103.6.331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/12/2022] [Accepted: 09/27/2022] [Indexed: 12/15/2022] Open
Abstract
Purpose Postoperative pancreatic fistula (POPF) is the most troublesome complication after pancreaticojejunostomy (PJ). This study aimed to compare the short-term outcomes of 2 different methods of duct-to-mucosa PJ; out-layer continuous suture anastomosis (OCA) and the modified Blumgart method (mBM). Methods This retrospective cohort study enrolled patients who underwent curative-intent, open PD between 2015 and 2020. In mBM, 2 transpancreatic U-sutures were performed between the pancreatic margin and jejunum, with reinforced sutures in the central region. Patient demographics, diagnosis, intraoperative factors, postoperative complications, and POPF defined by the International Study Group on Pancreatic Fistula were investigated. Clinically relevant POPF (CR-POPF) included grades B and C POPF. Results A total of 184 patients underwent OCA, and 96 patients underwent mBM. The mBM group had more patients who underwent neoadjuvant therapy. The fistula risk scores were comparable between the 2 groups. Both groups showed no significant differences in CR-POPF and overall surgical complication rates. The total operation time was comparable, although the operation time for PJ was shorter in mBM. Conclusion No significant differences were observed in the postoperative outcomes between each group; the operation time for PJ in mBM was shorter. Therefore, mBM may be considered for utilization in duct-to-mucosa PJ.
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Affiliation(s)
- Yoon Hyung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hye-Sol Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Gun Yun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young Jae Cho
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Köhler N, El-Bandar N, Maxeiner A, Ralla B, Miller K, Busch J, Friedersdorff F. Early Continence and Extravasation After Open Retropubic Radical Prostatectomy - Interrupted vs Continuous Suturing for Vesicourethral Anastomosis. Ther Clin Risk Manag 2021; 16:1289-1296. [PMID: 33380800 PMCID: PMC7767697 DOI: 10.2147/tcrm.s278454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/23/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare running suture (RS) and interrupted suture (IS) of vesicourethral anastomosis (VUA) during open retropubic radical prostatectomy (RRP) on early urinary continence and extravasation. Patients and Methods Single center analysis of 211 patients who underwent RRP performed by a single surgeon during 2008 to 2017 was retrospectively analyzed. For VUA, we used the standard interrupted suture technique (n=100) with a 3-0 PDS suture. The RS (n=111) was performed with 12-bite suture using 3-0 PDS. The primary endpoints were extravasation and early continence. Demographic and peri-operative data were collected and analyzed using Pearson's chi-square, t-Test and Mann-Whitney U-test. A binary logistic regression analysis was carried out to explore predictors that affected early continence after catheter removal. Results The rates of early urinary incontinence (UI) were 7.7% vs 42.2% (p<0.001). The duration of catheterization and hospitalization was significantly shorter in the interrupted group (4 days vs 5 days, p<0.001 and 5 days vs 6 days, p<0.001). The groups did not differ significantly in body mass index or prostate volume. There were older patients and higher PSA levels in the group with RS technique. No significant difference was found in the postoperative extravasation rates between both groups (13.5% vs 12%, p=0.742). Conclusion Running vesicourethral anastomosis increased the rate of early urinary incontinence. Both anastomosis techniques provided a similar rate of postoperative urine extravasation. VUA should only be one of the many criteria that must be considered for the preservation of urinary continence of patients after RRP.
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Affiliation(s)
- Nora Köhler
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität Zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Nasrin El-Bandar
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität Zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Andreas Maxeiner
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität Zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Bernhard Ralla
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität Zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Kurt Miller
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität Zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Jonas Busch
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität Zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
| | - Frank Friedersdorff
- Department of Urology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität Zu Berlin, and Berlin Institute of Health, Berlin 10117, Germany
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Kamarajah SK, Bundred JR, Lin A, Halle-Smith J, Pande R, Sutcliffe R, Harrison EM, Roberts KJ. Systematic review and meta-analysis of factors associated with post-operative pancreatic fistula following pancreatoduodenectomy. ANZ J Surg 2020; 91:810-821. [PMID: 33135873 DOI: 10.1111/ans.16408] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/05/2020] [Accepted: 10/11/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only 'clinically relevant' (CR) POPF. This study identified variables associated with the two International Study Group on Pancreatic Surgery definitions to identify which variables are more strongly associated with CR-POPF. METHODS A systematic review identified all studies reporting risk factors for POPF (using both International Study Group on Pancreatic Fistula definitions) following pancreatoduodenectomy. The primary outcome was factors associated with CR-POPF. Meta-analyses (random effects models) of pre-, intra- and post-operative factors associated with POPF in more than two studies were included. RESULTS Among 52 774 patients All-POPF (n = 69 studies) and CR-POPF (n = 53 studies) affected 27% (95% confidence interval (CI95% ) 23-30) and 19% (CI95% 17-22), respectively. Of the 176 factors, 24 and 17 were associated with All- and CR-POPF, respectively. Absence of pre-operative pancreatitis, presence of renal disease, no pre-operative neoadjuvant therapy, use of post-operative somatostatin analogues, absence of associated venous or arterial resection were associated with CR-POPF but not All-POPF. CONCLUSION In conclusion this study demonstrates wide variation in reported rates of POPF and that several risk factors associated with CR-POPF are not used within risk prediction models. Data from this study can be used to shape future studies, research and audit across ethnic and geographic boundaries in POPF following pancreatoduodenectomy.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, Newcastle-Upon-Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle-Upon-Tyne, UK
| | - James R Bundred
- Department of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aaron Lin
- Department of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Halle-Smith
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Rupaly Pande
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Keith J Roberts
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Clinical Surgery, Edinburgh Royal Infirmary, Edinburgh, UK
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8
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Eshmuminov D, Schneider MA, Tschuor C, Raptis DA, Kambakamba P, Muller X, Lesurtel M, Clavien PA. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB (Oxford) 2018; 20:992-1003. [PMID: 29807807 DOI: 10.1016/j.hpb.2018.04.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/09/2018] [Accepted: 04/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2016, the International Study Group of Pancreatic Fistula (ISGPS) proposed an updated definition for postoperative pancreatic fistula (POPF). Pancreas texture (PT) is an established risk factor of POPF. The definition of soft vs. hard texture, however, remains elusive. METHODS A systematic search was performed to identify PT definitions and a meta-analysis linking POPF to PT using the updated ISGPS definition. RESULTS 122 studies including 22 376 patients were identified. Definition criteria for PT varied among studies and most classified PT in hard and soft based on intraoperative subjective assessment. The total POPF rate (pooled grades B and C) after pancreatoduodenectomy was 14.5% (n = 10 395) and 15.5% (n = 3767) after distal pancreatectomy. In pancreatoduodenectomy, POPF rate was higher in soft compared to hard pancreas (RR, 4.4, 3.3 to 6.1; p < 0.001; n = 6393), where PT grouped as soft and hard. No data were available for intermediate PT. CONCLUSION The reported POPF rates may be used in planning future prospective studies. A widely accepted definition of PT is lacking and a correlation with the risk of POPF is based on subjective evaluation, which is still acceptable. Classification of PT into 2-groups is more reasonable than classification into 3-groups.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel A Schneider
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Raptis
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Patryk Kambakamba
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, University of Lyon, Lyon, France
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
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Interrupted versus Continuous Suturing for Vesicourethral Anastomosis During Radical Prostatectomy: A Systematic Review and Meta-analysis. Eur Urol Focus 2018; 5:980-991. [PMID: 29907547 DOI: 10.1016/j.euf.2018.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/28/2018] [Accepted: 05/16/2018] [Indexed: 12/18/2022]
Abstract
CONTEXT Vesicourethral anastomosis (VUA) is a crucial step during radical prostatectomy (RP). Generally, either a continuous (CS) or an interrupted suture (IS) is used. However, there is no clear evidence if one technique is superior to the other. OBJECTIVE This study aimed to provide a systematic overview and comparison between IS and CS for the VUA during RP. EVIDENCE ACQUISITION The study was conducting according to the PRISMA guidelines. A systematic data base search (Pubmed, Embase, and Central) was performed. Outcomes included catheterization time, extravasation, anastomotic time, length of hospital stay, continence, and development of strictures. EVIDENCE SYNTHESIS A total of 2021 studies were retrieved, of which nine studies (1475 patients) were included in analysis. Results showed a shorter catheterization time (2.06 d; 95% confidence interval [CI]: 0.56-3.57; p=0.007), anastomotic time (6.39min; 95% CI: 3.68-9.10; p<0.001), and a lower rate of extravasation (odds ratio [OR]: 2.36; 95% CI: 1.26-4.43; p<0.007) in favor of CS. There were no differences between groups concerning length of hospital stay (0.40 d; 95% CI: -1.41-2.20; p=0.670) or continence at 3 mo (OR: 1.09; 95% CI: 0.83-1.44; p=0.540), 6 mo (OR: 1.04; 95% CI: 0.67-1.61; p=0.870) or 12 mo (OR: 1.43; 95% CI: 0.92-2.24; p=0.110), respectively. The incidence of urethral strictures was not different between the techniques (OR: 1.00; 95% CI: 0.42-2.40; p=1.000). The quality of evidence according to Grading of Recommendations Assessment, Development and Evaluation tool was rated as low. CONCLUSIONS This meta-analysis showed advantages of CS for catheterization time, anastomotic time, and rate of extravasation without compromising other parameters. Although CS seems to offer favorable results, its technical challenge in open RP and the generally low quality of data makes a clear recommendation impossible. PATIENT SUMMARY Continuous and interrupted suturing are safe suture techniques for the vesicourethral anastomosis during radical prostatectomy. The choice of the suture technique should be based on surgeon's experience and technical approach. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42017076126.
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Kang JS, Han Y, Kim H, Kwon W, Kim SW, Jang JY. Prevention of pancreatic fistula using polyethylene glycolic acid mesh reinforcement around pancreatojejunostomy: the propensity score-matched analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:169-175. [PMID: 28054751 DOI: 10.1002/jhbp.428] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Several small-scale studies have shown that wrapping polyethylene glycolic acid (PGA) mesh around the anastomotic site reinforced pancreaticojejunostomy following pancreatoduodenectomy (PD) with favorable outcomes. This study investigated the efficacy of PGA mesh for reducing postoperative pancreatic fistula (POPF) and evaluated other risk factors for POPF. METHODS This study enrolled 464 consecutive patients who underwent PD performed by one surgeon between 2006 and 2015, including a PGA group of 281 patients (60.6%) and a control group of 183 patients (39.4%). All pancreatico-enteric anastomoses were performed using double-layered, duct-to-mucosa, end-to-side pancreaticojejunostomy. RESULTS Mean patient age was 63.1 years. The rates of overall (27.0% vs. 37.2%, P = 0.024) and clinically relevant (Grades B, C; 13.9% vs. 24.0%, P = 0.006) POPF were significantly lower in the PGA than in the control group. Following propensity score matching, the rates of clinically relevant POPF (12.6% vs. 22.4%, P = 0.024) and complications (40.2% vs. 63.8%, P < 0.001) remained significantly lower in the PGA group. Multivariate analysis showed that non-pancreatic disease, greater blood loss, higher body mass index, and non-application of PGA mesh were significantly associated with the development of clinically relevant POPF. CONCLUSIONS PGA mesh reinforcement of pancreaticojejunostomy may prevent POPF as well as reducing overall abdominal complications after PD.
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Affiliation(s)
- Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Korea
| | - Hongbeom Kim
- Department of Surgery, Dongguk University College of Medicine, Ilsan, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Korea
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11
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Jin S, Shi XJ, Wang SY, Zhang P, Lv GY, Du XH, Wang GY. Drainage fluid and serum amylase levels accurately predict development of postoperative pancreatic fistula. World J Gastroenterol 2017; 23:6357-6364. [PMID: 28974903 PMCID: PMC5603503 DOI: 10.3748/wjg.v23.i34.6357] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/04/2017] [Accepted: 05/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate potential biomarkers for predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD).
METHODS We prospectively recruited 83 patients to this study. All patients underwent PD (Child’s procedure) at the Division of Hepatobiliary and Pancreas Surgery at the First Bethune Hospital of Jilin University between June 2011 and April 2015. Data pertaining to demographic variables, clinical characteristics, texture of pancreas, surgical approach, histopathological results, white blood cell count, amylase and choline levels in the serum, pancreatic/gastric drainage fluid, and choline and amylase levels in abdominal drainage fluid were included in the analysis. Potential correlations between these parameters and postoperative complications such as, POPF, acute pancreatitis, hemorrhage, delayed gastric emptying, and biliary fistula, were assessed.
RESULTS Twenty-eight out of the 83 (33.7%) patients developed POPF. The severity of POPF was classified as Grade A in 8 (28%) patients, grade B in 16 (58%), and grade C in 4 (14%), according to the pancreatic fistula criteria. On univariate and multivariate logistic regression analyses, higher amylase level in the abdominal drainage fluid on postoperative day (POD)1 and higher serum amylase levels on POD4 showed a significant correlation with POPF (P < 0.05). On receiver operating characteristic curve analysis, amylase cut-off level of 2365.5 U/L in the abdominal drainage fluid was associated with a 78.6% sensitivity and 80% specificity [area under the curve (AUC): 0.844; P = 0.009]. A cut-off serum amylase level of 44.2 U/L was associated with a 78.6% sensitivity and 70.9% specificity (AUC: 0.784; P = 0.05).
CONCLUSION Amylase level in the abdominal drainage fluid on POD1 and serum amylase level on POD4 represent novel biomarkers associated with POPF development.
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Affiliation(s)
- Shuo Jin
- School of Clinical Medicine, Tsinghua University, Beijing 100084, China
- Department of Hepatobiliary and Pancreatic Surgery, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing 100084, China
| | - Xiao-Ju Shi
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Si-Yuan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-yang Hospital Affiliated to Capital Medical University, Beijing 100020, China
| | - Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Yue Lv
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Xiao-Hong Du
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guang-Yi Wang
- Department of Hepatobiliary and Pancreatic Surgery, Bethune First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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Papalampros A, Niehaus K, Moris D, Fard-Aghaie M, Stavrou G, Margonis AG, Angelou A, Oldhafer K. A safe and feasible “clock-face” duct-to-mucosa pancreaticojejunostomy with a very low incidence of anastomotic failure: A single center experience of 248 patients. J Visc Surg 2016; 153:425-431. [PMID: 27256902 DOI: 10.1016/j.jviscsurg.2016.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Papalampros A, Niehaus K, Moris D, Fard-Aghaie M, Stavrou G, Margonis AG, Angelou A, Oldhafer K. Une technique d’anastomose pancréaticojéjunale en cadran (de montre) faisable et sûre avec un taux de fistules anastomotiques très faible. Expérience monocentrique à propos de 248 patients. JOURNAL DE CHIRURGIE VISCÉRALE 2016; 153:440-446. [DOI: 10.1016/j.jchirv.2016.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2025]
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Yao G, Fan Y, Zhai J. Continuous suturing with two anterior layers reduces post-operative complications and hospitalization time in pancreaticoenterostomy. BMC Gastroenterol 2016; 16:69. [PMID: 27401981 PMCID: PMC4940953 DOI: 10.1186/s12876-016-0482-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 06/17/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Most complications after pancreaticoduodenectomy (PD) were relation to pancreaticoenterostomy. We improved a new method of pancreaticoenterostomy that included the continuous suturing of the jejunum and the stump of the pancreas end-to-side with one layer posteriorly and two layers anteriorly. To evaluate the safety and efficiency of this new method, we introduced this retrospectively compared trial. METHODS We compared 45 patients who had undergone pancreaticoduodenectomy with either the regular interrupted suturing method or the new continuous mattress suturing method in our hospital from September 2011 to March 2014. RESULTS Although the total operation times were not reduced, the suturing time for the pancreaticoenterostomies in the continuous suture group (11.3 ± 1.8 min) was greatly reduced compared with that for the interrupted suture group (14.1 ± 2.9 min, p = 0.045). Importantly, the continuous mattress suturing method significantly decreased short-term post-operative complications, including pancreatic leakage (p = 0.042). Furthermore, shorter hospitalization times were observed in the continuous mattress suture group (12.3 ± 5.0 d) than in the interrupted suture group (24.2 ± 11.6 d, p = 0.000). CONCLUSIONS Continuous mattress suturing is a safe and effective pancreaticoenterostomy method that leads to reduced complications and hospitalization times.
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Affiliation(s)
- Guoliang Yao
- Department of General Surgery, The First Affiliated Hospital of Henan University of Science and Technology, 24 Jinghua Road, Luoyang, 471003, People's Republic of China
| | - Yonggang Fan
- Department of General Surgery, The First Affiliated Hospital of Henan University of Science and Technology, 24 Jinghua Road, Luoyang, 471003, People's Republic of China
| | - Jingming Zhai
- Department of General Surgery, The First Affiliated Hospital of Henan University of Science and Technology, 24 Jinghua Road, Luoyang, 471003, People's Republic of China.
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Testini M, Piccinni G, Lissidini G, Gurrado A, Tedeschi M, Franco IF, Di Meo G, Pasculli A, De Luca GM, Ribezzi M, Falconi M. Surgical management of the pancreatic stump following pancreato-duodenectomy. J Visc Surg 2016; 153:193-202. [PMID: 27130693 DOI: 10.1016/j.jviscsurg.2016.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.
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Affiliation(s)
- M Testini
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy.
| | - G Piccinni
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G Lissidini
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - A Gurrado
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Tedeschi
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - I F Franco
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G Di Meo
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - A Pasculli
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - G M De Luca
- Endocrine, Digestive, and Emergency Surgery Unit, Department of Biomedical Sciences and Human Oncology, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Ribezzi
- Anesthesiology Unit, Department of Emergency Surgery and Organs Transplantation, University Medical School of Bari, Policlinico, Piazza Giulio Cesare 11, 70121 Bari, Italy
| | - M Falconi
- Pancreatic Surgery Unit, San Raffaele Hospital IRCCS, University Vita e Salute, Milan, Italy
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Halloran CM, Platt K, Gerard A, Polydoros F, O'Reilly DA, Gomez D, Smith A, Neoptolemos JP, Soonwalla Z, Taylor M, Blazeby JM, Ghaneh P. PANasta Trial; Cattell Warren versus Blumgart techniques of panreatico-jejunostomy following pancreato-duodenectomy: Study protocol for a randomized controlled trial. Trials 2016; 17:30. [PMID: 26772736 PMCID: PMC4714471 DOI: 10.1186/s13063-015-1144-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 12/23/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Failure of the pancreatic remnant anastomosis to heal following pancreato-duodenectomy is a major cause of significant and life-threatening complications, notably a post-operative pancreatic fistula. Recently, non-randomized trials have shown superiority of a most intuitive anastomosis (Blumgart technique), which involves both a duct-to-mucosa and a full-thickness pancreatic "U" stitch, in effect a mattress stitch, over a standard duct-mucosa technique (Cattell-Warren). The aim of this study is to examine if these findings remain within a randomized setting. METHODS/DESIGN The PANasta trial is a randomized, double-blinded multi-center study, whose primary aim is to assess whether a Blumgart pancreatic anastomosis (trial intervention) is superior to a Cattell-Warren pancreatic anastomosis (control intervention), in terms of pancreatic fistula rates. Patients with suspected malignancy of the pancreatic head, in whom a pancreato-duodenectomy is recommended, would be recruited from several UK specialist regional centers. The hypothesis to be tested is that a Blumgart anastomosis will reduce fistula rate from 20 to 10 %. Subjects will be stratified by research site, pancreatic consistency and diameter of pancreatic duct; giving a sample size of 253 per group. The primary outcome measure is fistula rate at the pancreatico-jejunostomy. Secondary outcome measures are: entry into adjuvant therapy, mortality, surgical complications, non-surgical complications, hospital stay, cancer-specific quality of life and health economic assessments. Enrolled patients will undergo pancreatic resection and be randomized immediately prior to pancreatic reconstruction. The operation note will only record "anastomosis constructed as per PANasta trial randomization," thus the other members of the trial team and patient are blinded. An inbuilt internal pilot study will assess the ability to randomize patients, while the construction of an operative manual and review of operative photographs will maintain standardization of techniques. DISCUSSION The PANasta trial will be the first multi-center randomized controlled trial (RCT) comparing two types of duct-to-mucosa pancreatic anastomosis with surgical quality assurance. TRIAL REGISTRATION ISRCTN52263879 . Date of registration 15 January 2015.
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Affiliation(s)
- Christopher M Halloran
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, The Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Kellie Platt
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Abbie Gerard
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Fotis Polydoros
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Derek A O'Reilly
- Department of Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, UK. Derek.O'
| | - Dhanwant Gomez
- Queen's Medical Center, Derby Road, Nottingham, NG7 2UH, UK.
| | - Andrew Smith
- Department of Pancreatic Surgery, Abdominal Medicine and Surgery CSU, St James's University Hospital, 3rd Floor Bexley Wing, Leeds, LS9 7TF, UK.
| | - John P Neoptolemos
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Zahir Soonwalla
- Churchill Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford, OX3 7LJ, UK.
| | - Mark Taylor
- Mater Hospital, Belfast Health and Social care Trust, Crumlin Rd, Belfast, BT12 6AB, UK.
| | - Jane M Blazeby
- Bristol Center for Surgical Research, School of Social and Community Medicine, University of Bristol, BS8 2PS and University Hospitals Bristol NHS Foundation Trust, Bristol, BS2 8HW, UK.
| | - Paula Ghaneh
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
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Assessing surgical quality: comparison of general and procedure-specific morbidity estimation models for the risk adjustment of pancreaticoduodenectomy outcomes. World J Surg 2015; 38:2412-21. [PMID: 24705780 DOI: 10.1007/s00268-014-2554-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of outcomes to evaluate surgical quality implies the need for detailed risk adjustment. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a generally applicable risk adjustment model suitable for pancreatic surgery. A pancreaticoduodenectomy (PD)-specific intraoperative pancreatic risk assessment (IPRA) estimates the risk of postoperative pancreatic fistula (POPF) and associated morbidity based on factors that are not incorporated into POSSUM. OBJECTIVE The aim of the study was to compare the risk estimations of POSSUM and IPRA in patients undergoing PD. METHODS An observational single-center cohort study was conducted including 195 patients undergoing PD in 2008-2010. POSSUM and IPRA data were recorded prospectively. Incidence and severity of postoperative morbidity was recorded according to established definitions. The cohort was grouped by POSSUM and IPRA risk groups. The estimated and observed outcomes and morbidity profiles of POSSUM and IPRA were scrutinized. RESULTS POSSUM-estimated risk (62 %) corresponded with observed total morbidity (65 %). Severe morbidity was 17 % and in-hospital-mortality 3.1 %. Individual and grouped POSSUM risk estimates did not reveal associations with incidence (p = 0.637) or severity (p = 0.321) of total morbidity or POPF. The IPRA model identified patients with high POPF risk (p < 0.001), but was even associated with incidence (p < 0.001) and severity (p < 0.001) of total morbidity. CONCLUSION The risk factors defined by a PD-specific model were significantly stronger predictive indicators for the incidence and severity of postoperative morbidity than the factors incorporated in POSSUM. If available, reliable procedure-specific risk factors should be utilized in the risk adjustment of surgical outcomes. For pancreatic surgery, generally applicable tools such as POSSUM still have to prove their relevance.
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Wei J, Liu X, Wu J, Xu W, Zhou J, Lu Z, Chen J, Guo F, Gao W, Li Q, Jiang K, Dai C, Miao Y. Modified One-layer Duct-to-mucosa Pancreaticojejunostomy Reduces Pancreatic Fistula After Pancreaticoduodenectomy. Int Surg 2015; 103:10.9738/INTSURG-D-15-00094.1. [PMID: 26037262 DOI: 10.9738/intsurg-d-15-00094.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) is a major source of morbidity after pancreaticoduodenectomy (PD). The purpose of this retrospective study comparing one-layer pancreaticojejunostomy (PJ) with two-layer PJ after PD was to evaluate whether the one-layer duct-to-mucosa PJ after PD can reduce the incidence of POPF.A total of 194 consecutive patients who underwent PD by one surgeon (Y. Miao) from January 2011 to February 2014 were included in this study. Among those patients, 104 underwent one-layer PJ (one-layer group) and 90 patients underwent two-layer PJ (two-layer group), respectively. Preoperative clinicopathologic features, intraoperative parameters, postoperative morbidity with focus on POPF, were compared between the two groups.The overall incidence of POPF was 19.6% (38/194), and clinically relevant grade B/C POPF rates were 8.6% (16/194) and 3.1% (6/194), respectively. There were no differences in patients' demographics and operation related factors between the two groups. However, the incidence of POPF in the one-layer group was significantly lower than in two-layer group (13.5% [14/104 patients] and 26.7% [24/90 patients] respectively; p=0.021). The median postoperative hospital stay was also significantly lower in the one-layer group compared to the two-layer group (13 days vs. 15 days, p=0.035). One patient in two-layer group died due to postoperative hemorrhage.One-layer duct-to-mucosa pancreaticojejunostomy is a simple and easy technique for pancreaticojejunal anastomosis after PD, and can reduce the POPF rate in comparison to the two-layer technique.
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Affiliation(s)
- Jishu Wei
- b The first Affiliated Hospital of Nanjing Medical University
| | - Xinchun Liu
- c The first Affiliated Hospital of Nanjing Medical University
| | | | | | | | | | | | | | | | | | | | | | - Yi Miao
- f The first hospital affiliated of, Nanjing, Jiangsu, China
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A comparison of two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy. Gastroenterol Res Pract 2015; 2015:894292. [PMID: 25852753 PMCID: PMC4380088 DOI: 10.1155/2015/894292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 03/03/2015] [Indexed: 12/20/2022] Open
Abstract
Background. The aim of the study was to compare two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy. Methods. For effective prevention of the development of pancreatic leakage, we modified invagination technique that we term the "serous touch." We analysed the diameter of the main pancreatic duct, the texture of the remnant pancreas, the method of the reconstruction, pancreatic external drainage, anastomotic procedure time, histopathological examination, and postoperative complications. Results. Fifty-two patients underwent pancreatoduodenectomy with pancreatojejunostomy using "serous touch" technique (ST group) and 52 classic pancreatojejunostomy (C group). In the ST group one patient (1.9%) was diagnosed as grade B pancreatic fistula, and no patient experienced fistula grade A or C. In the C group 6 patients (11.5%) were diagnosed as fistula grade A, 1 (1.9%) patient as fistula grade B, and 1 (1.9%) patient as fistula grade C. There was a significant statistical difference in incidents of pancreatic fistula (P < 0.05) and no statistical difference in other postoperative complications or mortality in comparison group. Anastomosis time was statistically shorter in the ST group. Conclusions. "Serous touch" technique appeared to be easy, safe, associated with fewer incidences of pancreatic fistulas, and less time consuming in comparison with classical pancreatojejunostomy.
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Jin S, Shi XJ, Sun XD, Zhang P, Lv GY, Du XH, Wang SY, Wang GY. The gastric/pancreatic amylase ratio predicts postoperative pancreatic fistula with high sensitivity and specificity. Medicine (Baltimore) 2015; 94:e339. [PMID: 25621676 PMCID: PMC4602641 DOI: 10.1097/md.0000000000000339] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
This article aims to identify risk factors for postoperative pancreatic fistula (POPF) and evaluate the gastric/pancreatic amylase ratio (GPAR) on postoperative day (POD) 3 as a POPF predictor in patients who undergo pancreaticoduodenectomy (PD).POPF significantly contributes to mortality and morbidity in patients who undergo PD. Previously identified predictors for POPF often have low predictive accuracy. Therefore, accurate POPF predictors are needed.In this prospective cohort study, we measured the clinical and biochemical factors of 61 patients who underwent PD and diagnosed POPF according to the definition of the International Study Group of Pancreatic Fistula. We analyzed the association between POPF and various factors, identified POPF risk factors, and evaluated the predictive power of the GPAR on POD3 and the levels of serum and ascites amylase.Of the 61 patients, 21 developed POPF. The color of the pancreatic drain fluid, POD1 serum, POD1 median output of pancreatic drain fluid volume, and GPAR were significantly associated with POPF. The color of the pancreatic drain fluid and high GPAR were independent risk factors. Although serum and ascites amylase did not predict POPF accurately, the cutoff value was 1.24, and GPAR predicted POPF with high sensitivity and specificity.This is the first report demonstrating that high GPAR on POD3 is a risk factor for POPF and showing that GPAR is a more accurate predictor of POPF than the previously reported amylase markers.
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Affiliation(s)
- Shuo Jin
- From the Department of Hepatobiliary and Pancreatic Surgery (SJ, X-JS, X-DS, PZ, G-YL, X-HD, G-YW), Bethune First Hospital of Jilin University, Changchun 130021, Jilin; and Department of Surgery Intensive Care Unit (S-YW), Beijing Chao-yang Hospital Affiliated to Capital Medical University, Beijing, China
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Xu C, Yang X, Luo X, Shen F, Wu M, Tan W, Jiang X. "Wrapping the gastroduodenal artery stump" during pancreatoduodenectomy reduced the stump hemorrhage incidence after operation. Chin J Cancer Res 2014; 26:299-308. [PMID: 25035657 DOI: 10.3978/j.issn.1000-9604.2014.06.08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 06/05/2014] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE After pancreaticoduodenectomy (PD), the postoperative gastroduodenal artery stump (GDAS) hemorrhage is one of the most serious complications. The purpose of this study is to determine whether wrapping the GDAS during PD could decrease the postoperative GDAS hemorrhage incidence. METHODS A retrospective review involving 280 patients who underwent PD from 2005 to 2012 was performed. Wrapping the GDAS during PD was defined as "Wrapping the GDAS using the teres hepatis ligamentum during PD". A total of 140 patients accepted the "wrapping" procedure (wrapping group). The other 140 patients didn't apply the procedure (non-wrapping group). Age, sex, preoperative data, estimated intraoperative blood loss, postoperative complications, pathologic parameters and hospitalization time were compared between two groups. RESULTS There were no significant differences in patient characteristics between two groups. After wrapping, the incidence of postoperative GDAS bleeding decreased significantly (1/140 vs. 9/140, P=0.01). The rates of the other complications (such as intra-abdominal infection pancreatic fistula, billiary fistula, gastrointestinal bleeding, et al.) showed no significant differences. CONCLUSIONS Wrapping the GDAS during PD significantly reduced the postoperative GDAS hemorrhage incidence. And the "wrapping" had no obvious influence on other complications.
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Affiliation(s)
- Chang Xu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Xinwei Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Xiangji Luo
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Mengchao Wu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Weifeng Tan
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Xiaoqing Jiang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
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Bugiantella W, Rondelli F, Mariani L, Longaroni M, Federici MT, Avenia N, Mariani E. Pancreatico-jejunal anastomosis with invaginating jenunal "J"-loop. Preliminary report of a new technique. Int J Surg 2014; 12 Suppl 1:S87-90. [PMID: 24879342 DOI: 10.1016/j.ijsu.2014.05.046] [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: 03/23/2014] [Accepted: 05/03/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The pancreatic anastomosis is the most demanding step after pancreaticoduodenectomy (PD) and the pancreatic fistula (PF) is the most dreaded complication. Many techniques have been investigated to assess the best way to deal with the pancreatic stump after PD and none of these has shown to be superior in terms of statistically significant reduction of PF rate. We report the preliminary experience of a new technique of pancreaticojejunostomy (PJ). METHODS Fifteen patients underwent PD for neoplasms with end-to-side PJ with dunking jejunal "J"-loop, between July 2011 and March 2014. The data about their post-operative outcomes were analyzed. RESULTS There were no intra-operative neither post-operative deaths. One patient had a grade A PF (6.7%). Total post-operative complications occurred in 6 patients (40%), major post-operative complications occurred in 3 patients (20%). CONCLUSION The new "sandwich" technique for dunking PJ after PD that we describe proved to be easy to perform and sure. It appears to be suitable for a dunking PJ when the diameter of the jejunum is too small than this of the pancreatic stump.
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Affiliation(s)
- Walter Bugiantella
- "San Matteo degli Infermi" Hospital, AUSL Umbria 2, Via Loreto, 06049 Spoleto, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100 Perugia, Italy; "San Giovanni" Bellinzona e Valli Regional Hospital, 6500 Bellinzona, Switzerland
| | - Lorenzo Mariani
- General Surgery, "San Giovanni Battista Hopsital", AUSL Umbria 2, Via M. Arcamone, 06034 Foligno, Italy
| | - Maurizio Longaroni
- General Surgery, "San Giovanni Battista Hopsital", AUSL Umbria 2, Via M. Arcamone, 06034 Foligno, Italy
| | - Maria Teresa Federici
- General Surgery, "San Giovanni Battista Hopsital", AUSL Umbria 2, Via M. Arcamone, 06034 Foligno, Italy
| | - Nicola Avenia
- University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100 Perugia, Italy; General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy
| | - Enrico Mariani
- General Surgery, "San Giovanni Battista Hopsital", AUSL Umbria 2, Via M. Arcamone, 06034 Foligno, Italy
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Chen YJ, Lai ECH, Lau WY, Chen XP. Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature. Int J Surg 2014; 12:706-11. [PMID: 24851718 DOI: 10.1016/j.ijsu.2014.05.060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/11/2014] [Accepted: 05/14/2014] [Indexed: 01/15/2023]
Abstract
Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.
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Affiliation(s)
- Yong-jun Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
| | - Eric C H Lai
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chaiwan, Hong Kong, China.
| | - Wan-Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.
| | - Xiao-ping Chen
- Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei Province, China.
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Cloyd JM, Kastenberg ZJ, Visser BC, Poultsides GA, Norton JA. Postoperative serum amylase predicts pancreatic fistula formation following pancreaticoduodenectomy. J Gastrointest Surg 2014; 18:348-53. [PMID: 23903930 DOI: 10.1007/s11605-013-2293-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/15/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Early identification of patients at risk for developing pancreatic fistula (PF) after pancreaticoduodenectomy (PD) may facilitate prevention or treatment strategies aimed at reducing its associated morbidity. MATERIALS AND METHODS A retrospective review of 176 consecutive PD performed between 2006 and 2011 was conducted in order to analyze the association between the serum amylase on postoperative day 1 (POD1) and the development of PF. RESULTS Serum amylase was recorded on POD1 in 146 of 176 PD cases (83.0 %). Twenty-seven patients (18.5 %) developed a postoperative PF: 6 type A, 19 type B, and 2 type C. Patients with a PF had a mean serum amylase on POD1 of 659 ± 581 compared to 246 ± 368 in those without a fistula (p < 0.001). On logistic regression, a serum amylase >140 U/L on POD1 was strongly associated with developing a PF (OR, 5.48; 95 % CI, 1.94-15.44). Sensitivity and specificity of a postoperative serum amylase >140 U/L was 81.5 and 55.5 %, respectively. Positive and negative predictive values were 29.3 and 93.0 %, respectively. CONCLUSION An elevated serum amylase on POD1 may be used, in addition to other prognostic factors, to help stratify risk for developing PF following PD.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, Stanford University, 300 Pasteur Dr, H3591, Stanford, CA, 94305, USA
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Binziad S, Salem AAS, Amira G, Mourad F, Ibrahim AK, Manim TMA. Impact of reconstruction methods and pathological factors on survival after pancreaticoduodenectomy. South Asian J Cancer 2014; 2:160-8. [PMID: 24455609 PMCID: PMC3889193 DOI: 10.4103/2278-330x.114145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Surgery remains the mainstay of therapy for pancreatic head (PH) and periampullary carcinoma (PC) and provides the only chance of cure. Improvements of surgical technique, increased surgical experience and advances in anesthesia, intensive care and parenteral nutrition have substantially decreased surgical complications and increased survival. We evaluate the effects of reconstruction type, complications and pathological factors on survival and quality of life. Materials and Methods: This is a prospective study to evaluate the impact of various reconstruction methods of the pancreatic remnant after pancreaticoduodenectomy and the pathological characteristics of PC patients over 3.5 years. Patient characteristics and descriptive analysis in the three variable methods either with or without stent were compared with Chi-square test. Multivariate analysis was performed with the logistic regression analysis test and multinomial logistic regression analysis test. Survival rate was analyzed by use Kaplan-Meier test. Results: Forty-one consecutive patients with PC were enrolled. There were 23 men (56.1%) and 18 women (43.9%), with a median age of 56 years (16 to 70 years). There were 24 cases of PH cancer, eight cases of PC, four cases of distal CBD cancer and five cases of duodenal carcinoma. Nine patients underwent duct-to-mucosa pancreatico jejunostomy (PJ), 17 patients underwent telescoping pancreatico jejunostomy (PJ) and 15 patients pancreaticogastrostomy (PG). The pancreatic duct was stented in 30 patients while in 11 patients, the duct was not stented. The PJ duct-to-mucosa caused significantly less leakage, but longer operative and reconstructive times. Telescoping PJ was associated with the shortest hospital stay. There were 5 postoperative mortalities, while postoperative morbidities included pancreatic fistula-6 patients, delayed gastric emptying in-11, GI fistula-3, wound infection-12, burst abdomen-6 and pulmonary infection-2. Factors that predisposed to development of pancreatic leakage included male gender, preoperative albumin < 30g/dl, pre-operative hemoglobin < 10g/dl and non PJ-duct to mucosa type of reconstruction. The ampullary cancers presented at an earlier stage and had a better prognosis than pancreatic cancer and cholangiocarcinoma. Early stage (I and II), negative surgical margin, well and moderate differentiation and absence of lymph node involvement significantly predicted for longer survival. Conclusions: PJ duct-to-mucosa anastomosis was safe, caused least pancreatic leakage and least blood loss compared with the other methods of reconstruction and was associated with early return back to home and prolonged disease free and overall survival.
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Affiliation(s)
- Salah Binziad
- Department of Surgical Oncology, Assiut University, Assiut, Egypt
| | - Ahmed A S Salem
- South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Gamal Amira
- National Cancer Institute, Cairo University, Giza, Egypt
| | - Farouk Mourad
- Department of General Surgery, Assiut University, Assiut, Egypt
| | - Ahmed K Ibrahim
- Department of Public Health and Community Medicine, Assiut, Egypt
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Wang M, Zhu F, Wang X, Tian R, Shi C, Shen M, Xu M, Han J, Luo N, Qin R. A Modified Technique of End-to-End Pancreaticojejunostomy With Transpancreatic Interlocking Mattress Sutures. J Surg Oncol 2013; 107:783-788. [DOI: 10.1002/jso.23319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Jiang C, Wang M, Xu Q, Wu X, Yu D, Ding Y. A modified technique for end-to-side pancreaticojejunostomy by purse-string suture. J Surg Oncol 2011; 104:852-6. [PMID: 21713776 DOI: 10.1002/jso.21978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Accepted: 04/22/2011] [Indexed: 12/24/2022]
Affiliation(s)
- Chunping Jiang
- Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical College, Nanjing, China
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Ball CG, Howard TJ. Does the type of pancreaticojejunostomy after Whipple alter the leak rate? Adv Surg 2010; 44:131-48. [PMID: 20919519 DOI: 10.1016/j.yasu.2010.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis 46202, USA
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Measurement of pancreatic fat by magnetic resonance imaging: predicting the occurrence of pancreatic fistula after pancreatoduodenectomy. Ann Surg 2010; 251:932-6. [PMID: 20395858 DOI: 10.1097/sla.0b013e3181d65483] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether patients who develop a pancreatic fistula after pancreatoduodenectomy are more likely to have higher pancreatic fat levels than matched controls and if so, to investigate whether preoperative dual gradient-echo magnetic resonance (MR) imaging can be used to measure pancreatic fat and predict the development of postoperative pancreatic fistula. SUMMARY BACKGROUND DATA Pancreatic fistula is a major complication and its most frequently reported risk factors tend to be anatomic features of the pancreatic remnant, such as a soft pancreatic texture. METHODS Between January 2007 and September 2007, a total of 96 cases of pancreatoduodenectomy were performed at Seoul National University Hospital. Of total, 20 patients (20.8%) who developed a pancreatic fistula were carefully matched for multiple parameters including age, gender, pancreatic pathology, surgeon, and type of operation with 20 control patients who did not develop a pancreatic fistula. In the pancreatic fistula group, 9 patients (45%) had a grade A fistula and 11 (55%) grade B fistula. Degrees of pancreatic fatty infiltration and fibrosis were assessed quantitatively. In-phase and opposed-phase images were obtained by dual-gradient-echo MR imaging. Percentage decreases in pancreatic signal intensity on opposed-phase images relative to those on in-phase images were calculated and defined as relative signal intensity decreases (RSID). RESULTS More patients in the pancreatic fistula group had a soft pancreatic texture or a smaller pancreatic duct and total fat and RSID were significantly higher. In soft pancreatic texture group, intralobular, interlobular, and total fat were significantly elevated. Furthermore, pancreatic fat levels were found to be correlated positively with RSID (P=0.013). RSID was correlated with total pancreatic fat and when an RSID criterion more than 7.032 was used, pancreatic fistula could be predicted as 72.7% sensitivity and 75.9% specificity. CONCLUSION Our findings suggest that increased pancreatic fat is a risk factor of postoperative pancreatic fistula. Preoperative measurements of pancreatic fat by MRI offer a noninvasive predicting the occurrence of pancreatic fistula.
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Prospective randomized pilot trial comparing closed suction drainage and gravity drainage of the pancreatic duct in pancreaticojejunostomy. ACTA ACUST UNITED AC 2010; 16:837-43. [PMID: 19730769 DOI: 10.1007/s00534-009-0171-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 08/04/2009] [Indexed: 01/14/2023]
Abstract
BACKGROUND Pancreaticojejunal anastomotic leakage remains a major complication after pancreatoduodenectomy, and various means of preventing pancreatic leakage have been studied over the past few decades. The purpose of this study was to determine whether closed suction drainage provided a better option than gravity drainage in pancreaticojejunostomy. METHODS Between 2004 and 2006, a total of 110 patients who underwent pancreaticojejunostomy at our institute were enrolled in this prospective randomized pilot study. Fifty-five patients were allocated to the closed suction drainage (CD) group and 55 to the gravity drainage (GD) group. In each patient a polyethylene pediatric feeding tube was inserted into the remnant pancreatic duct across a duct-to-mucosa type pancreaticojejunostomy and totally externalized. The tube was then connected to the aspiration bag of a Jackson-Pratt drain to generate negative pressure or to a bile bag for natural drainage. Pancreatic fistulas were defined and graded as A, B, or C according to the international study group for pancreatic fistulas (ISGPF) criteria. RESULTS No differences were found between the GD and CD groups in age, sex distribution, or diagnosis. A pancreatic fistula occurred in 24 patients (43.6%) in the GD group and in 14 (25.5%) in the CD group (P = 0.045). In the GD group, grade B and C fistula occurred in 6 patients (10.9%), whereas in the CD group, this occurred in 5 patients (9.1%). CONCLUSION In this study, temporary external drainage of the pancreatic duct with closed suction drainage significantly reduced the incidence of grade A pancreatic fistula. A follow-up randomized prospective multicenter study has been initiated.
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Abstract
Pancreatic fistula, the most dreaded complication of pancreatoduodenectomy occurs with an incidence ranging from 4-30% in literature reports; the incidence varies considerably according to the definition of fistula used. This literature review describes various methods proposed over the last decade to decrease the incidence and severity of pancreatic fistula including techniques of pancreatico-jejunal and pancreatico-gastric anastomoses, deliberate avoidance of pancreatico-enteric anastomosis, and the prophylactic role of somatostatin analogues.
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Affiliation(s)
- F Paye
- Service de chirurgie digestive, hôpital Saint-Antoine, UPMC Paris-06, 75012 Paris, France.
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Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump. Pancreas 2009; 38:e177-82. [PMID: 19730152 DOI: 10.1097/mpa.0b013e3181b57705] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the impact of the length of the isolated jejunal loop and the type of pancreaticojejunostomy on pancreatic leakage after pancreaticoduodenectomy. METHODS One hundred thirty-two consecutive patients who underwent a pancreaticoduodenectomy were studied according to the length of the isolated jejunal loop (short loop, 20-25 cm vs long loop, 40-50 cm) and the type of pancreaticojejunostomy (invagination vs duct to mucosa). RESULTS The use of the long isolated jejunal loop was associated with a significantly lower pancreatic leakage rate compared with the use of a short isolated jejunal loop (4.34% vs 14.2%, P < 0.05). In addition, the use of duct-to-mucosa technique was associated with significantly lower incidence of postoperative pancreatic fistula compared with the invagination technique (4.2% vs 14.5%, P < 0.05). Finally, patients with a short isolated jejunal loop compared with patients with a long loop had increased morbidity (50.7% vs 27.5%, P < 0.05) and prolonged hospital stay (16.3 +/- 1.9 days vs 10.2 +/- 2.3 days, P < 0.05). Overall mortality rate was 1.5%. CONCLUSIONS The use of a long isolated jejunal loop and a duct-to-mucosa pancreaticojejunostomy is associated with decreased pancreatic leakage rate after pancreaticoduodenectomy.
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Chen XP, Qiu FZ, Zhang ZW, Chen YF, Huang ZY, Zhang WG. A new simple and safe technique of end-to-end invaginated pancreaticojejunostomy with transpancreatic U-sutures—early postoperative outcomes in consecutive 88 cases. Langenbecks Arch Surg 2009; 394:739-44. [DOI: 10.1007/s00423-009-0487-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 03/13/2009] [Indexed: 11/30/2022]
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Lee SE, Hwang DW, Lim CS, Jang JY, Kim SW. Pancreas-Sparing Total Duodenectomy. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.76.4.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Seung Eun Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dae Wook Hwang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Sup Lim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Pancreatic injuries are rare, with penetrating mechanisms being causative in majority of cases. They can create major diagnostic and therapeutic challenges and require multiple diagnostic modalities, including multislice high-definition computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, ultrasonography, and at times, surgery and direct visualization of the pancreas. Pancreatic trauma is frequently associated with duodenal and other severe vascular and visceral injuries. Mortality is high and usually related to the concomitant vascular injury. Surgical management of pancreatic and pancreatic-duodenal trauma is challenging, and multiple surgical approaches and techniques have been described, up to and including pancreatic damage control and later resection and reconstruction. Wide surgical drainage is a key to any surgical trauma technique and access for enteral nutrition, or occasionally parenteral nutrition, are important adjuncts. Morbidity associated with pancreatic trauma is high and can be quite severe. Treatment of pancreatic trauma-related complications often requires a combination of interventional, endoscopic, and surgical approaches.
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Affiliation(s)
- Stanislaw Peter Stawicki
- Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - C. William Schwab
- Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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