[The outcomes of different pancreatodigestive anastomoses in pancreatoduodenectomy].

AIM: To compare early results after pancreaticoduodenectomy depending on variant of pancreatico-digestive anastomosis. MATERIAL AND METHODS: It was analyzed early results of 207 pancreaticoduodenectomies for cancer which were performed for the period 2010-2014. Pancreatointestinal and pancreatogastric anastomoses were applied in 165 and 42 patients respectively. RESULTS: Complications were observed in 73 (44.2%) and 18 (38.3%) patients after pancreatointestinal and pancreatogastric anastomoses respectively. Six patients died after pancreatointestinal anastomosis. At the same time there were no deaths in the group of pancreatogastric anastomosis. Differences were significant. Postoperative hospital-stay was similar in both groups.

Continuous versus interrupted suture techniques of pancreaticojejunostomy after pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) has traditionally been a source of significant morbidity and potential mortality after pancreaticoduodenectomy (PD). Both patient-derived and technical factors contribute to pancreatic anastomotic failure. The continuous suture duct-to-mucosa pancreaticojejunostomy (PJ) described previously is associated with a low rate of POPF. The aim of the present study was to observe whether the new technique would effectively reduce the POPF rate in comparison with conventional interrupted suture duct-to-mucosa PJ. METHODS: Data on 255 consecutive patients, who underwent the two methods of PJ after standard PD by one group of surgeons between 2006 and 2013, were collected retrospectively from a prospective database. The primary end point was the POPF rate. The risk factors of POPF were investigated by using univariate and multivariate analyses. RESULTS: A total of 120 patients received continuous suture PJ and 135 underwent interrupted suture PJ. Rate of POPF for the entire cohort was 12.5%. There were 9 fistulas (7.5%) in the continuous anastomosis group and 23 fistulas (17%) in the interrupted anastomosis group (P = 0.022). The rates of major complications (Clavien grades 3-5) were less in the continuous anastomosis group (5%) compared with the interrupted anastomosis group (13.3%) (P = 0.023). The greatest risk factor for a POPF was pancreatic duct diameter: POPF developed in only 3 patients (3.6%) with large pancreatic ducts (≥ 3 mm) and in 29 patients (16.9%) with small pancreatic ducts (<3 mm). There were four postoperative (in-hospital) deaths (both in the interrupted anastomosis group); two of which had POPF as the proximate cause of death, followed by bleeding and sepsis. CONCLUSIONS: The continuous suture duct-to-mucosa PJ effectively reduces the POPF rate after PD in comparison with interrupted anastomosis. The results confirm increased POPF rates in patients with pancreatic duct diameter <3 mm compared with pancreatic duct diameter ≥ 3 mm.

Pancreatoduodenectomy--current status of surgical and perioperative techniques in Germany.

BACKGROUND: Pancreatoduodenectomy in Germany is performed by a broad range of hospitals. A diversity of operative techniques is employed as no guidelines exist for intra- and perioperative management. We carried out a national survey to determine the de facto German standards for pancreatoduodenectomy, assess quality assurance measures, and identify relevant issues for further investigation. METHODS: A questionnaire evaluating major outcome variables, case load, preferred surgical procedures, and perioperative management during pancreatoduodenectomy was developed and sent to 211 German hospitals performing >12 pancreatoduodenectomies per year (requirement for certification as a pancreas center). Statistical analysis was carried out using the Fisher Exact, Mann-Whitney U, and Spearman tests. RESULTS: The final response rate was 86 % (182/211). The preferred technique and de facto German standard for pancreatoduodenectomy was pylorus-preserving pancreatoduodenectomy with pancreatojejunostomy carried out via duct-to-mucosa anastomosis with interrupted sutures using PDS 4.0. The minority of German pancreas centers were certified (18-48 %). The certification rate increased with higher capacity levels and case load (P < 0.05); however, significant correlations between the fistula rate and hospital case load, hospital capacity level, or hospital certification status were not seen. CONCLUSION: This study revealed a distinct variety of management strategies for pancreatic surgery and available evidence-based data was not necessarily translated into clinical practice. The limited certification rate represented a shortcoming of quality assurance. The data emphasize the need for further trials to answer the questions whether hospital certifications and omission of drains improve outcome after pancreatoduodenectomy and for the establishment of guidelines for pancreatoduodenectomy.

[The pancreaticogastroanastomosis by pancreatoduodenal resection].

The 10 year experience of pancreatoduodenal resection, consisting of 63 operations was analyzed by the authors. The reconstructive stage of the operation included pancreaticojejunoanastomosis in 20 patients and pancreaticogastroanastomosis in the original modification in 43 patients. The method included the tamponization of the pancreatic stump with the mucosa layer of the gastric back wall. The suggested way of the pancreaticogastrostomy proved to shorten the operative time without increasing the postoperative morbidity and mortality rates.

Surgical Outcomes of Distal Pancreatectomy in Elderly Patients.

BACKGROUND: The extent to which age impacts surgical outcomes remains poorly characterized. This study aims to evaluate the impact of age on 30-day outcomes in patients after distal pancreatectomy. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), distal pancreatectomy patients were identified and age-stratified, groups A (≤75 years) and B (>75 years). Outcomes included 30-day mortality, morbidity, readmissions, operative time (min), and hospital length of stay (LOS, days). RESULTS: Of 3042 total patients identified, 1686 (55.4%) were women. A total of 2649 patients (87.1%) were in group A. Overall, both groups had similar baseline characteristics with the exception of the following: diabetes mellitus (24.8% vs. 30.0%, P = .03), smoking (19.3% vs. 4.8%, P < .001), congestive heart failure (.5% vs. 1.8%, P = .010), hypertension (HTN) (47.9% vs. 72.5%, P < .001), bleeding disorders (3.1% vs. 5.3%, P = .036), the American Society of Anesthesiologists (ASA) (III-V) scores (67.6% vs. 85.5%, P < .001), and body mass index (29.2 [±6.7] vs. 27.4 [±5.6], P = .001).Deep surgical site infection was higher in group A (12.1% vs. 6.6%, P = .001), while acute renal failure (ARF) and postoperative myocardial infarction (MI) were higher in group B. 30-day readmissions were higher in group A (17.4% vs. 12.2%, P = .011) despite no statistically significant difference in LOS (7.10 [±6.36] vs. 7.30 [±4.93] days, P = .553) or overall morbidity (29.4% vs. 28.8%, P = .859). CONCLUSION(S): Those undergoing distal pancreatectomy experienced similar overall morbidity and mortality outcomes regardless of age. However, those older than 75 years had more cardiovascular risk factors, which may have contributed to their higher rates of postoperative ARF and MI.

Factors affecting morbidity and mortality in pancreatic injuries.

PURPOSE: Difficulties in the detection of pancreatic damage result in morbidity and mortality in cases of pancreatic trauma. This study was performed to determine factors affecting morbidity and mortality in pancreatic trauma. METHODS: The records of 33 patients who underwent surgery for pancreatic trauma between January 2004 and December 2013 were analyzed retrospectively. RESULTS: The types of injury were penetrating injury and blunt abdominal trauma in 75.8 and 24.2 % of all cases, respectively. Injuries were classified as stage 1 in 6 cases (18.2 %), stage 2 in 18 cases (54.5 %), stage 3 in 5 cases (15.2 %), and stage 4 in 4 cases (12.1 %). The average injury severity scale (ISS) value was 25.70 ± 9:33. Six patients (18.2 %) had isolated pancreatic injury, 27 (81.2 %) had additional intraabdominal organ injuries and 10 patients (30.3 %) had extraabdominal organ injuries. The mean length of hospital stay was 13.24 ± 9 days. Various complications were observed in eight patients (24.2 %) and mortality occurred in three (9.1 %). Complications were more frequent in patients with high pancreatic damage scores (p = 0.024), additional organ injuries (p = 0.05), and blunt trauma (p = 0.026). Pancreatic injury score was associated with morbidity, while the presence of major vascular injury was associated with mortality. CONCLUSIONS: Complications were significantly more common in injuries with higher pancreatic damage scores, additional organ injuries, and blunt abdominal trauma. Pancreatic injury score was associated with morbidity, while the presence of major vascular injury was associated with mortality.

The clinical results of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy in consecutive 55 cases.

OBJECTIVES: Pancreatic anastomotic leakage remains a major troublesome complication after pancreaticoduodenectomy. Thus, various technical modifications regarding the pancreatic anastomosis after pancreaticoduodenectomy have been attempted to minimize anastomotic leakage. We have performed duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa (layer-to-layer pancreaticojejunostomy) and obtained extremely favorable results. METHODS: During 1999 to 2006, 55 patients (27 women and 28 men) underwent duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa after pancreaticoduodenectomy. The mean age was 64.6 years (range, 33-84 years). RESULTS: Median postoperative hospital stay was 32.8 days. Morbidity rate due to early postoperative complication was 9.1% (pneumothorax in 1, pulmonary embolism in 1, gastric ulcer in 1, and wound infection in 2), with no pancreatic anastomotic leakage. CONCLUSIONS: There was low complication rate and no pancreatic anastomotic leakage in consecutive 55 patients who underwent pancreaticoduodenectomy. We consider that duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa is extremely safe, reliable, and favorable for the anastomosis after pancreaticoduodenectomy.

Frey procedure for surgical management of chronic pancreatitis in children.

BACKGROUND: The authors adopted the Frey procedure for the surgical management of chronic pancreatitis after one of their patients had recurrent disease in the head of the gland after a longitudinal pancreaticojejunostomy (LPJ or modified Puestow procedure). This is the first description of its use in children. METHODS: A retrospective chart review was performed of all children undergoing a drainage or resection procedure for chronic pancreatitis from 1995 to 2002. RESULTS: Eleven children (6 boys, 5 girls, ages 8 to 18 years) underwent either the LPJ (3) or Frey (8) procedure. Etiologies included: idiopathic (5), familial (2), congenital anomaly of the major papilla (1), pancreatic head mass (1), short bowel syndrome (1), and pancreatic divisum (1). Before surgical therapy, patients had been symptomatic 2.3 years (range, 1 month to 6 years) and had been hospitalized for pancreatitis 4 times (range, 1 to 10). Four patients did not respond to endoscopic stenting, and 5 had a pancreatic pseudocyst. Patients were followed up in clinic an average of 2.5 years, with total time elapsed since surgery averaging 4.6 years. Eight of 11 patients experienced excellent or good results subsequent to surgical intervention. CONCLUSIONS: The Frey procedure is effective for children who have not responded to conservative management of chronic pancreatitis and may prevent recurrent disease in the head of the gland.

Management of blunt pancreatic injury in children.

BACKGROUND AND METHODS: Controversy persists regarding the management of pancreatic transection. Over the past 10 years, 51 patients admitted to the Children's Hospital of Pittsburgh sustained blunt pancreatic injuries. We reviewed their medical records to clarify the optimal management strategy and to define distinguishing characteristics, if any, of patients with pancreatic transection. RESULTS: Patients who sustained pancreatic transection had a significantly higher Injury Severity Score, length of stay, serum amylase, and serum lipase, than those patients who sustained pancreatic contusion. Patients who underwent laparotomy within 48 hours of injury for pancreatic transection had a significantly shorter length of stay than those who underwent laparotomy more than 48 hours after injury. CONCLUSION: Serum amylase greater than 200 and serum lipase greater than 1,800 may be useful clinical markers for major pancreatic ductal injury when combined with physical examination. Early operative intervention for pancreatic transection results in shorter length of stay and fewer complications.

Resultados inmediatos y alejados de la anastomosis pancreatogástrica / Early and long term result of the pancreaticogastrostomies

Experiencias recientes muestran que la morbilidad de la pancreatoyeyunoanastomosis por duodenopancreatectomía cefálica no ha disminuído con el tiempo, lo cual obliga a investigar métodos alternativos de anastomosis. Entre 1988 y 1994 fueron realizadas 35 anastomosis pancreatogástricas; 31 luego de duodenopancreatectomía cefálica, 3 luego de pancreatectomía izquierda y una pancreatogastroanastomosis longitudinal. Según las condiciones del páncreas se realizaron en la duodenopancreatectomía 12 anastomosis a boca total en un plano, 5 anastomosis ductomucosas y en 14 casos se insertó el muñón pancreático. Se registró sólo una fístula pancreática de 70 ml diarios que curó espontáneamente. Falleció un enfermo por hemorragia masiva del muñón pancreático y 3 por causas no relacionadas directamente con la anastomosis. En el seguimiento, 10 de 19 enfermos controlados más de 6 meses requirieron tratamiento enzimático por insuficiencia exocrina, incluyendo 2 casos que habían recibido una sutura ductomucosa. Se concluye que la anastomosis pancreatogástrica es una técnica de baja morbilidad (23 por ciento), con una mortalidad del 79 por ciento pero cuyas complicaciones son graves debido a la ubicación del muñón pancreático. La sutura ductomucosa no parece ofrecer ventajas en cuanto a la preservación de la función exocrina