Prospective study of short-term complications following pancreatoduodenectomy based on international definitions.

BACKGROUND AND AIM: Though, the morbidity following pancreatoduodenectomy remains high the mortality rate has reduced to < 5% in many high volume centres. The aim of this prospective study was to quantify the complications following pylorus preserving pancreatoduodenectomy using international definitions and to prove that pylorus preservation and retrocolic duodenojejunostomy are not associated with increased incidence of delayed gastric emptying. METHODS: This was a prospective observational study at a single GI surgery referral unit, conducted from January 2010 to December 2012. Patients who underwent pylorus preserving pancreatoduodenectomy for various indications were included; barring those who underwent major surgical procedures along with pancreatoduodenectomy. RESULTS: 76 patients (M:F = 37:39) underwent pylorus preserving pancreatoduodenectomy during the study period; with median age 52 yrs (range: 29-83) and hospital stay 11 days (range: 8-50). Overall mortality and significant morbidity were 7.89% and 12.5%, respectively. Four patients each (5.26%) developed significant delayed gastric emptying (DGE) and pancreatic fistula. Presence of comorbidity (p = 0.019; odds ratio: 3.16) and periampullary tumours (p = 0.011; odds ratio: 7.91) were identified as risk factors for the development of complications. Pancreatic juice amylase levels in chronic pancreatitis were very low (p < 0.005). CONCLUSION: Pylorus preserving pancreatoduodenectomy can be performed with very low mortality and morbidity at high volume centres. DGE is not significantly increased with pylorus preservation and retrocolic duodenojejunostomy, and is often secondary to post-op complications. The International Study Group of Pancreatic Fistula (ISGPF) definition may miss pancreatic fistula in chronic pancreatitis.

Postoperative pharyngocutaneous fistula: treated by sternocleidomastoid flap repair and cricopharyngeus myotomy.

INTRODUCTION: Pharyngoesophagocutaneous fistula (PEF) is one of the rare but serious complications of antero-lateral approach to cervical spine surgery. Because of its rarity, the true incidence of PEF is not clear. But, retrospective analysis of large series of cervical spine surgery reports 0-1.62 % incidence (Cloward in Surg 69:175-182, 1971; Elerkay et al. in J Neurosurg Spine 90(Suppl 1):35-41, 1999). Proximity to the vertebral column and thin walls makes the upper digestive tract vulnerable to injury in cervical trauma, surgical or nonsurgical. Presentation in early postoperative period is not rare and carries high morbidity and mortality (Jones and Ginsberg in Ann Thorac Surg 53(3):534-543, 1992). Various procedures for these fistulae such as simple closure, muscle flap interposition, esophageal diversion and jejunal interposition are reported. Some authors also advise removal of prosthetic plates and posterior stabilization, besides the repair of fistulae in a staged manner (Orlando et al. in Spine 28(15):E290-E295, 2003). METHODS: Two similar cases of pharyngeal fistulae with similar etiology and clinical scenario are presented here, which were managed successfully with initial control of sepsis followed by delayed definitive repair with sternocleidomastoid muscle flap interposition and cricopharyngeus myotomy without removal of prosthetic plates. RESULTS: Postoperatively, both patients showed no evidence of any wound complications or collections until the seventh day. A contrast swallow study on seventh day showed no leak following which soft diet was started. Both patients were not having any difficulty in swallowing or aspiration. On 1-year follow-up, both patients were having no difficulty in swallowing, no episodes of aspiration and no recurrence of fistula. CONCLUSION: This case series highlights the importance of cricopharyngeus myotomy for treating PEF and the improved results with the prosthesis kept undisturbed.