Wrapping the stump of the gastroduodenal artery using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a center's preliminary experience.

BACKGROUND: The present study aims to assess the preliminary outcomes of the effectiveness of wrapping the ligamentum teres hepatis (LTH) around the gastroduodenal artery stump for the prevention of erosion hemorrhage after laparoscopic pancreaticoduodenectomy (LPD). METHODS: We reviewed 247 patients who had undergone LPD between January 2016 and April 2019. The patients were divided into two groups according to whether LTH wrapped the stump of the gastroduodenal artery: group A (119 patients) who underwent the LTH wrapping procedure, and group B (128 patients) who did not undergo the procedure. The perioperative data from the two groups were reviewed to assess the effectiveness of the LTH procedure for the prevention of postpancreatectomy hemorrhage (PPH) and other complications. RESULTS: No differences were observed in the clinical characteristics between the two groups. The data from 247 patients were acceptable for analysis: 119 patients underwent wrapping, and 128 patients did not. The incidence of clinically relevant pancreatic fistula (8.4% vs 3.9%), biliary fistula (2.5% vs 1.6%), intra-abdominal infection (10.1% vs 3.9%) and delayed gastric emptying (13.4% vs 16.4%) showed no significant difference between group A and group B. The 90-day mortality and 90-day reoperation rates (0.8% vs 0.8% and 5.0% vs 3.1%) were also similar between group A and group B. Furthermore, postpancreatectomy hemorrhage of Grade B and C occurred in 0 patients (0.0%) in the wrapping group, which was significantly less frequent than the occurrence in the nonwrapping group (7 patients; 5.5%, P = 0.02). CONCLUSIONS: Wrapping the LTH around the gastroduodenal artery stump after LPD does not reduce the incidence of clinically relevant pancreatic fistula, biliary fistula or delayed gastric emptying. However, this procedure has a trend of reducing the rate of PPH of Grade B and C after LPD and is simple to perform.

[The Pedicled Teres Hepatis Ligament Flap Wrap Around the Gastroduodenal Artery Stump to Prevent Postoperative Hemorrhage after Laparoscopic Pancreatoduodenectomy (with Video)].

OBJECTIVE: To explore the feasibility and safety of teres hepatis ligament flap plasty around the gastroduodenal artery (GDA) stump to prevent postoperative hemorrhage after laparoscopic pancreatoduodenectomy (LPD). METHODS: A total of 108 patients with GDA stump wrapped by pedicled teres hepatis ligament after LPD in our center were included for analysis from March 2018 to March 2019. After completion of LPD, teres hepatis ligament was dissected from the ventral abdominal cephalad along the ventral attachment, and the teres hepatis ligament was separated from the falciform ligament by ultrasonic scalpel or Ligasure. At the junction to the liver, the teres hepatis ligament is freed from the ventral hepatic surface. The junction between liver and teres hepatis ligament should not be cut off to ensure blood supply. Division of the GDA was performed using a Prolene 4-0 suture stitch or two clamps as a standard (see the Video 1 in Supplemental Contents, http://ykxb.scu.edu.cn/article/doi/10.12182/20200760602). The pedicled teres hepatis ligament then was used to completely cover the skeletonized GDA stump, and part of the common hepatic artery and the proper hepatic artery. The mobilized ligament can be transposed without tension. RESULTS: A total of 108 patients completed the procedure of GDA stump wrapped with pedicled teres hepatis ligament during LPD. There were no complications caused by GDA stump after operation. The main steps to wrap the GDA stump took an average of 10 min. Clinically relevant postoperative pancreatic fistula (CR-POPF) occurred in 8 cases (7.4%) (including 6 cases of grade B pancreatic fistula and 2 cases of grade C pancreatic fistula), and intra-abdominal infection in 8 cases (7.4%), including 3 cases (2.8%) of intra-abdominal abscess, postoperative gastrointestinal ulcer bleeding occurred in 2 cases (1.9%), and no intra-abdominal hemorrhage occurred. CONCLUSION: It is a safe and feasible procedure of wrapping GDA stump with pedicled teres hepatis ligament to prevent postoperative hemorrhage after LPD. The procedure is easy to perform without relevant additional surgical trauma or prolongation of the operation time.

"Wrapping the gastroduodenal artery stump" during pancreatoduodenectomy reduced the stump hemorrhage incidence after operation.

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.

Ligamentum teres hepatis wrapping of the gastroduodenal artery stump for protection in total laparoscopic pancreaticoduodenectomy: a single-center experience.

OBJECTIVE: Hemorrhage from the stump of the gastroduodenal artery (GDA) is a significant postoperative risk with pancreaticoduodenectomy (PD). Studies have shown that wrapping the GDA stump using the omentum or the falciform ligament can help prevent bleeding. We aimed to determine whether wrapping the GDA stump with the ligamentum teres hepatis (LTH) would reduce postoperative PD hemorrhage. METHODS: We retrospectively reviewed data for 148 patients who underwent laparoscopic pancreatoduodenectomy (LPD) at our hospital from November 2015 to September 2021. We compared perioperative data from 63 LPD patients without wrapping of the GDA (unwrapped group) and 85 whose GDA stumps were wrapped (wrapped group). RESULTS: There were no significant differences in the groups' baseline characteristics. The postoperative GDA stump bleeding incidence was significantly lower in the wrapped group than that in the unwrapped group (7.9% vs. 0, respectively). There was also no significant difference in the incidence of other complications (intra-abdominal infection, postoperative pancreatic fistula (POPF), biliary fistula, and gastrointestinal bleeding). CONCLUSION: Using the LTH to wrap the GDA stump during LPD can reduce bleeding from the GDA stump but not the incidence of other complications.

Unusual case of digestive bleeding nine months after a cephalic pancreaticoduodenectomy (CPD).

INTRODUCTION: Post-pancreaticoduodenectomy hemorrhage is mostly due to the gastroduodenal artery stump erosion. The diagnosis of arterial bleeding is done by digestive endoscopy, selective angiography or video capsule endoscopy. On failure of etiological research, surgery is the last resort despite its technical difficulties. CASE PRESENTATION: A 63 years-old woman was admitted in surgery, nine months after cephalic pancreaticoduodenectomy for a pain of the right hypochondria combined with a pneumoperitoneum, after a 3rd episode of hemorrhage. Exploratory laparotomy is performed after a third hemorrhagic episode and failure of etiological research. Bleeding from the gastroduodenal artery stump was discovered and successfully treated. DISCUSSION: Post-pancreaticoduodenectomy hemorrhage can occur very late. In these cases, a secondary arterial erosion obstructed by left hemi-liver should not be excluded. In these cases, despite the technical risks, surgery is required. CONCLUSION: The failure of the means used for diagnostic must lead to the surgery right away, despite operating risk.