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Gastro- or Duodenojejunostomy Leaks After Pancreatoduodenectomy: Single Center Experience and Narrative Literature Review. J Gastrointest Surg 2021; 25:3130-3136. [PMID: 34131862 PMCID: PMC8654710 DOI: 10.1007/s11605-021-05058-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND METHODS Gastro- or duodenojejunostomy leaks after pancreatoduodenectomy is rare. This study aims to analyze the incidence, management, and outcome of gastro- or duodenojejunostomy leaks after pancreatoduodenectomy based on a single center experience from 2004 to 2020 with a narrative literature review. RESULTS Of a total of 1494 pancreatoduodenectomies, eight patients with gastrojejunostomy (n=1) or duodenojejunostomy (n=7) leak were identified from the institutional pancreatic database. All leaks were treated operatively. In two patients dismantling of the duodenojejunostomy, distal gastrectomy, and closure of the pyloric and jejunal side, a percutaneous endoscopic gastrostomy and a feeding jejunostomy ultimately had to be performed after an unsuccessful attempt of gastrojejunostomy and suture of the duodenojejunostomy, respectively. The literature search revealed three more studies specifically addressing this complication after pancreatoduodenectomy (36 patients of a total of 4739 pancreatoduodenectomies). Based on an analysis of the current study and the literature review, the overall incidence of gastro- or duodenojejunostomy leaks after pancreatoduodenectomy was 0.71 % (44/6233 pancreatoduodenectomies). The occurrence of a gastro- or duodenojejunostomy leak was associated with a concomitant postoperative pancreatic fistula in 50 % of the cases, an increased length of hospital stay, and a mortality rate of 15.9 %. Surgical treatment was performed in 84 % of the cases. CONCLUSION Gastro- or duodenojejunostomy leak is a rare complication after pancreatoduodenectomy. Prompt diagnosis and early repair is important. In most cases, a surgical intervention is necessary for a good outcome. Under salvage conditions, a bailout strategy may be to temporarily dismantle the gastro- or duodenojejunal anastomosis.
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Birhanu Y, Tesgera D, Biresaw Netsere H, Nuru N. Prevalence and factors associated with re-laparotomy among patients operated in Debre-Markos referral hospital, north west Ethiopia: Retrospective cross-sectional study. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2020. [DOI: 10.1016/j.ijans.2020.100249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Lessing Y, Pencovich N, Nevo N, Lubezky N, Goykhman Y, Nakache R, Lahat G, Klausner JM, Nachmany I. Early reoperation following pancreaticoduodenectomy: impact on morbidity, mortality, and long-term survival. World J Surg Oncol 2019; 17:26. [PMID: 30704497 PMCID: PMC6357503 DOI: 10.1186/s12957-019-1569-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/23/2019] [Indexed: 02/08/2023] Open
Abstract
Background Reoperation following PD is a surrogate marker for a complex post-operative course and may lead to devastating consequences. We evaluate the indications for early reoperation following PD and analyze its effect on short- and long-term outcome. Methods Four hundred and thirty-three patients that underwent PD between August 2006 and June 2016 were retrospectively analyzed. Results Forty-eight patients (11%; ROp group) underwent 60 reoperations within 60 days from PD. Forty-two patients underwent 1 reoperation, and 6 had up to 6 reoperations. The average time to first reoperation was 10.1 ± 13.4 days. The most common indications were anastomotic leaks (22 operations in 18 patients; 37.5% of ROp), followed by post-pancreatectomy hemorrhage (PPH) (14 reoperations in 12 patients; 25%), and wound complications in 10 (20.8%). Patients with cholangiocarcinoma had the highest reoperation rate (25%) followed by ductal adenocarcinoma (12.3%). Reoperation was associated with increased length of hospital stay and a high post-operative mortality of 18.7%, compared to 2.6% for the non-reoperated group. For those who survived the post-operative period, the overall and disease-free survival were not affected by reoperation. Conclusions Early reoperations following PD carries a dramatically increased mortality rate, but has no impact on long-term survival.
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Affiliation(s)
- Yonatan Lessing
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel.
| | - Niv Pencovich
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Nadav Nevo
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Nir Lubezky
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Yaacov Goykhman
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Richard Nakache
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Guy Lahat
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Joseph M Klausner
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
| | - Ido Nachmany
- Department of General Surgery B, Division of General Surgery, Tel-Aviv Sourasky, Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., 64239, Tel-Aviv, Israel
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Abstract
BACKGROUND Pancreatic resection is associated with a high incidence of postoperative complications, some of which require reoperation. AIMS To analyze the incidence of and risk factors for reoperation following pancreatectomy. METHODS Pre- and postoperative information and procedure characteristics of 15,549 patients having undergone pancreatectomy in 435 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014 were analyzed. RESULTS A total of 773 (5.0%) patients required reoperation within 30 days of their index pancreatectomy. Patients requiring reoperation were more likely to be younger (mean ± standard deviation, 62.6 ± 13.2 vs. 64.1 ± 12.2 years, p < 0.001), male (60 vs. 49%, p < 0.001), to have respiratory comorbidities, lower preoperative serum albumin (3.7 ± 0.68 vs. 3.8 ± 0.62 mg/dl, p < 0.001), higher total bilirubin (1.7 ± 2.7 vs. 1.5 ± 2.4 mg/dl, p = 0.02), and higher American Society of Anesthesiologists (ASA) class than those who did not undergo reoperation. Other factors associated with increased incidence of reoperation included longer mean operative duration at the index procedure, postoperative transfusion requirement, wound complications, and cardiorespiratory, renal, thromboembolic, and infectious events. Multivariate regression analysis identified male sex, preoperative serum albumin <3.5 mg/dl, ASA class of 3 or 4, pancreaticoduodenectomy, and total pancreatectomy as the strongest predictors for reoperation after index pancreatic resection. Complication and readmission rates were significantly higher for those undergoing reoperation. CONCLUSION Patient characteristics and procedural factors contribute to reoperation after pancreatectomy in this largest and most diverse sample to date. Further investigation to identify perioperative strategies for mitigating this risk is required to improve the safety of pancreatic resection.
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Blouhos K, Boulas KA, Tsalis K, Hatzigeorgiadis A. Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions? World J Gastrointest Surg 2015; 7:190-195. [PMID: 26425267 PMCID: PMC4582236 DOI: 10.4240/wjgs.v7.i9.190] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/21/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth II or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes: (1) entrapment, compression and kinking by postoperative adhesions; (2) internal herniation, volvulus and intussusception; (3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop; (4) cancer recurrence; and (5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluid-filled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes: (1) adhesiolysis and reconstruction for benign causes; and (2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.
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Penumadu P, Barreto SG, Goel M, Shrikhande SV. Pancreatoduodenectomy - preventing complications. Indian J Surg Oncol 2015; 6:6-15. [PMID: 25937757 PMCID: PMC4412861 DOI: 10.1007/s13193-013-0286-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/30/2013] [Indexed: 02/07/2023] Open
Abstract
Increased awareness of periampullary & pancreatic head cancers, and the accompanying improved outcomes following pancreatoduodenectomy (PD), has possibly led to an increase in patients seeking treatment for the same. While there has definitely been a reduction in morbidity rates following PD in the last few decades, this decline has not mirrored the drastic fall in mortality. Amongst the foremost in the factors responsible for this reduction in mortality is the standardization of surgical technique and development of dedicated teams to manage all aspects of this demanding procedure. This review intends to provide the reader with an overview of major complications following this major surgery and measures to prevent them based on the authors' experience.
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Affiliation(s)
- Prasanth Penumadu
- />Department of Gastrointestinal Surgical Oncology, Tata Memorial Center, Mumbai, India
| | - Savio G. Barreto
- />Department of Gastrointestinal Surgical Oncology, Tata Memorial Center, Mumbai, India
- />GI Surgery, GI Oncology & Bariatric Surgery, Medanta Institute of Hepatobiliary & Digestive Sciences, Medanta, The Medicity, Gurgaon, India
| | - Mahesh Goel
- />Department of Gastrointestinal Surgical Oncology, Tata Memorial Center, Mumbai, India
| | - Shailesh V. Shrikhande
- />Department of Gastrointestinal Surgical Oncology, Tata Memorial Center, Mumbai, India
- />Department of Surgical Oncology, Convener, GI Disease Management Group, Tata Memorial Centre, Ernest Borges Marg, Parel, Mumbai, 400012 India
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Pancreaticojejuno-jejunostomy during reconstruction of the afferent loop in surgery of radiation-induced afferent loop obstruction following pancreaticoduodenectomy with Roux-en-Y reconstruction. Updates Surg 2013; 66:51-7. [PMID: 24254381 DOI: 10.1007/s13304-013-0238-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 11/11/2013] [Indexed: 12/19/2022]
Abstract
Radiation-induced afferent loop obstruction is a rare complication following pancreaticoduodenectomy and adjuvant radiotherapy. As in the setting of Roux-en-Y reconstruction endoscopic approaches are limited, surgery of this complication becomes inevitable. This study provides a new classification/management system of the radiation-induced obstruction of the afferent loop based on the extent and location of radiation injury, and describes the Pancreaticojejuno-jejunostomy, a novel technique to avoid revision of the pancreatic anastomosis during reconstruction of the afferent loop. Data were analyzed from nine patients who developed radiation-induced afferent loop obstruction after pancreaticoduodenectomy with single Roux limb reconstruction. One patient had type I obstruction and treated with by-pass surgery, seven patients had type II obstruction and treated with reconstruction including revision of the hepaticojejunostomy and Pancreaticojejuno-jejunostomy, and one patient had type III obstruction and treated with reconstruction including revision of the hepaticojejunostomy and the pancreatic anastomosis. Reconstruction along with Pancreaticojejuno-jejunostomy performed in six patients with type II radiation-induced afferent loop obstruction; reconstruction was not feasible for one patient. The median operative time was 149 min. No intraoperative complication was observed. By performing Pancreaticojejuno-jejunostomy we managed efficiently to convert a pancreatic anastomosis to an enteric anastomosis as one case of Grade B pancreatic fistula and no case of Pancreaticojejuno-jejunostomy stricture were observed, regarding short- and long-term results, respectively. The above technique may have a useful application in the surgical management of the radiation-induced afferent loop obstruction when endoscopy fails and by-pass surgery is inappropriate.
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Blouhos K, Boulas KA, Salpigktidis II, Konstantinidou A, Ioannidis K, Hatzigeorgiadis A. Total Reconstruction of the Afferent Loop for Treatment of Radiation-Induced Afferent Loop Obstruction with Segmental Involvement after Pancreaticoduodenectomy with Roux-en-Y Reconstruction. Case Rep Oncol 2013; 6:424-9. [PMID: 24019782 PMCID: PMC3764962 DOI: 10.1159/000354576] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
As the literature on afferent loop obstruction (ALO) after pancreaticoduodenectomy (PD) is very limited, standardized rules for its management do not exist. Herein, we report the case of a 65-year-old male patient with chronic ALO who had undergone PD with single Roux-en-Y limb reconstruction and adjuvant chemoradiation therapy for pancreatic head adenocarcinoma 2 years earlier. The patient was brought to the operating room with the diagnosis of radiation enteritis of the afferent loop with segmental involvement and concurrent hepaticojejunostomy (HJ) and pancreaticojejunostomy (PJ) stricture. Complete mobilization of the afferent loop, removal of the affected segment and reconstruction were performed. Reconstruction of the afferent loop was a one-way option for the surgeons because the Roux-en-Y reconstruction limited endoscopic access to the afferent loop, and the segmental radiation injury of the afferent loop ruled out bypass surgery. However, mobilization of the affected segment through a field of dense adhesions and revision of the HJ and PJ were technically demanding.
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