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Pancreatoduodenectomy may be a difficult operation, not only during the resectional part of the procedure, but also during reconstruction. Usually, these problems are due to local conditions of the organs/tissues, such as small diameter of the common bile duct or pancreatic duct, friable soft pancreas, vascular anomalies, etc. Reconstruction may al...
Context in source publication
Context 1
... retaining the gallbladder after PD is not the usual practice, this approach allows a cholecystojejunos- tomy [23] to be performed to establish biliary-intestinal continuity, provided that the cystic duct enters the bile duct sufficiently high enough to preserve retrograde flow of bile from hepatic duct to gallbladder ( fig. 5) ...
Citations
... Normal anatomy present in 55-79% patients, other patients will have aberrant or anomalous vascular anomaly .These anomalies may contribute to the surgical difculties during Pancreatico duodenectomy [4][5][6]. Some vascular anomalies may also interfere with resection and reconstruction of the digestive tract during PD, Others (e.g., replaced left hepatic artery (RLHA), accessory left hepatic artery (AHA)) may not [7,8]. Michel's described Hepatic artery and its anomalies were based on anatomy of 200 cadaver livers. ...
Background: Safe Whipple's procedure needs proper knowledge about Anatomy to avoid injuries . Normal vascular anatomy(celiac and hepatic) can be found in only 50–70% of individuals. Good knowledge about aberrant vascular anatomy is required to avoid unnecessary complications. Case presentation: An elderly man presented with history of obstructive jaundice due to Periampullary carcinoma with abnormal CHA and left hepatic artery morphology was discovered after MD CT (Pancreatic protocol).After ERCP Stenting for cholangitis we have proceeded for Whipple's procedure Despite the anomalous origin and anterior course of replaced Comm Conclusion: on hepatic artery, Classical Whipple's with preservation of replaced Common hepatic artery and regional lymphadenectomy with no major intra and post-operative problems was conducted by superior mesenteric artery rst approach. Prior to major hepato- pancreaticobiliary surgery, a thorough examination of a contrast enhanced computerized tomography scan is required to understand vascular anatomy, recognize anomalous vessels, and understand their signicance. Nevertheless, if the abnormal vessel anatomy like replaced Common hepatic artery are identied during surgery, a careful dissection of the anomalous vessel is essential to identify all vascular relationships and avoid irreversible injury.
... The course of these vascular anomalies varied according to their origin. Some vascular abnormalities (e.g., replaced right hepatic artery (RRHA)) may demand change in surgical approach and may also interfere with resection and reconstruction of the digestive tract during pancreaticoduodenectomy whereas others (e.g., replaced left hepatic artery (RLHA), accessory hepatic artery (AHA)) may not [7,8]. Hepatic artery and its anomalies were described into 10 most common variants by Michels [6] based on anatomy of 200 cadaver livers. ...
Background
During pancreaticoduodenectomy proper dissection of local vessels is required. Normal coeliac and hepatic arterial anatomy can be found in only 50–70% of individuals. Good knowledge about aberrant vascular anatomies is necessary to avoid unnecessary complications.
Case presentation
An elderly gentleman presented to us with history of jaundice. Periampullary carcinoma with abnormal right and left hepatic artery morphology was discovered after a contrast enhanced computerized tomography scan.
Conclusion
Despite the anomalous origin and anterior course of replaced right hepatic artery, Classical pancreatoduodenectomy with preservation of replaced right hepatic artery and regional lymphadenectomy with no major intra and post-operative problems was conducted by superior mesenteric artery first approach. Prior to major hepato-pancreatobiliary surgery, a thorough examination of a contrast enhanced computerized tomography scan is required to understand vascular anatomy, recognize anomalous vessels, and understand their significance. Nevertheless, if the abnormal vessel anatomy like replaced right hepatic artery are identified during surgery, a careful dissection of the anomalous vessel is essential to identify all vascular relationships and avoid irreversible injury.
... PJ is the commonly preferred anastomosis method. Many techniques have been proposed for the reconstruction of pancreatic digestive continuity to prevent complications after PD. [10][11][12] PG anastomosis has an excellent blood supply, less tension in the anastomosis, and a thick stomach wall, which facilitate the establishment of a sound anastomosis [13]. Furthermore, the acid milieu of the stomach and the absence of enterokinase protect the anastomosis from autodigestion by inactivating the pancreatic proenzymes [14]. ...
Background:
The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved. The present study aimed to clarify the impact of individualized pancreaticoenteric anastomosis and management to postoperative pancreatic fistula.
Methods:
Data from 529 consecutive pancreaticoduodenectomies were retrospectively analysed from the Hepatobiliary and Pancreatic Surgery Unit I, Peking Cancer Hospital. The pancreaticoenteric anastomosis was determined based on the pancreatic texture and diameter of the main pancreatic duct. The amylase value of the drainage fluid was dynamically monitored postoperatively on days 3, 5 and 7. A low speed intermittent irrigation was performed in selected patients. Intraoperative and postoperative results were collected and compared between the pancreaticogastrostomy (PG) group and pancreaticojejunostomy (PJ) group.
Results:
From 2010 to 2019, 529 consecutive patients underwent pancreaticoduodenectomy. Pancreaticogastrostomy was performed in 364 patients; pancreaticojejunostomy was performed in 150 patients respectively. The clinically relevant pancreatic fistula (CR-POPF) was 9.8% and mortality was zero. The soft pancreas, diameter of main pancreatic duct≤3 mm, BMI ≥ 25, operation time > 330 min and pancreaticogastrostomy was correlated with postoperative pancreatic fistula significantly. The CR-POPF of PJ was significantly higher than that of PG in soft pancreas patients; the operation time of PJ was shorter than that of PG significantly in hard pancreas patients. Intraoperative blood loss and operation time of PG was less than that of PJ significantly in normal pancreatic duct patients (p < 0.05).
Conclusions:
Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and pancreatic duct diameter. The appropriate anastomosis and postoperative management could prevent mortality.
... PF was observed in 18 (75%) of the patients with soft pancreatic tissue. Statistical significance was found between the texture of pancreatic tissue and PF (p <0.001).When the literature is reviewed, it is seen that these two factors have been evaluated as significant risk factors 24 . Soft residual pancreatic tissue and narrow duct size have been accepted as a potent PF risk factor 25 . ...
... To reduce the risk of PJ anastomotic leak, the pancreatic duct ligation without anastomosis is preferred in some patients However, since the external fistula rate was on average 50%, this method was abandoned 24,30 . In the studies that the pancreatic duct was blocked with biological substances, the results were reported as quite successful. ...
Aim:
Pancreatic fistula (PF) and anastomotic leakage are significant complications of the pancreaticoduodenectomy (PD). The PF is considered as the root cause of other major complications of PD. The aim of the study was to investigate the risk factors underlying PF that occurred after PD and the effects of the PF on postoperative morbidity.
Material and methods:
In this study, fifty patients who underwent classic PD were evaluated, retrospectively. Patients were divided into two groups as patients with PF and patients without PF. The following demographical, clinical and operative parameters were collected to evaluate the PF; age, gender, preoperative biochemical parameters, resection type, duration of the operation, patient's comorbidities, amount of perioperative transfusion, localization of the tumour, texture of the residual pancreas, type of the anastomosis and the diameter of the pancreatic duct.
Results:
A statistically significant relation was found between the texture of the remnant pancreatic parenchyma and PF (p<0.001). A significant relation was determined between PF and preoperative ALP, GGT, AST, ALT, hemoglobin levels and length of the hospitalization (p<0.05). In this study, we found that mortality, abdominal bleeding, bile leakage, intra-abdominal abscess were associated with reoperation and prolonged hospitalization.
Conclusion:
The lack of internationally accepted definition of a fistula is an important issue. Preoperative high ALP, ALT, AST, GGT values, low hemoglobin values and soft texture of remnant pancreatic tissue were found to be related with PF that occurs after PD. Residual pancreatic tissue has been shown as an independent risk factor.
Key words:
ISPGF, Pancreaticoduodenectomy, Pancreatic fistula, Risk factors.
... PJ is the commonly preferred anastomosis method. Many techniques have been proposed for the reconstruction of pancreatic digestive continuity to prevent complications after PD [10][11][12] . PG anastomosis has an excellent blood supply, less tension in the anastomosis, and a thick stomach wall, which facilitate the establishment of a sound anastomosis [13] . ...
Background: The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved. The present study aimed to clarify the impact of individualized pancreaticoenteric anastomosis and management to postoperative pancreatic fistula.
Methods: Data from 529 consecutive pancreaticoduodenectomies were retrospectively analysed from the Hepatobiliary and Pancreatic Surgery Unit I, Peking Cancer Hospital. The pancreaticoenteric anastomosis was determined based on the pancreatic texture and diameter of the main pancreatic duct. The amylase value of the drainage fluid was dynamically monitored postoperatively on days 3, 5 and 7. A low speed intermittent irrigation was performed in selected patients. Intraoperative and postoperative results were collected and compared between the pancreaticogastrostomy (PG) group and pancreaticojejunostomy (PJ) group.
Results: From 2010 to 2019, 529 consecutive patients underwent pancreaticoduodenectomy. Pancreaticogastrostomy was performed in 364 patients; pancreaticojejunostomy was performed in 150 patients respectively. The clinically relevant pancreatic fistula (CR-POPF) was 9.8% and mortality was zero. The soft pancreas, diameter of main pancreatic duct≤3mm, BMI≥25, operation time>330min and pancreaticogastrostomy was correlated with postoperative pancreatic fistula significantly. The CR-POPF of PJ was significantly higher than that of PG in soft pancreas patients; the operation time of PJ was shorter than that of PG significantly in hard pancreas patients. Intraoperative blood loss and operation time of PG was less than that of PJ significantly in normal pancreatic duct patients (p<0.05).
Conclusions: Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and pancreatic duct diameter. The appropriate anastomosis and postoperative management could prevent mortality.
... In 1978, Pylorus-preserving pancreaticoduodenectomy (PPPD) was described by Longmire and Traverso [1,2]. Today, PPPD became more preferred than the standard Whipple intervention in periampullary malignity [3]. Besides providing a cure as much as the standard Whipple procedure, PPPD is also reported to have many advantages over Whipple surgery in terms of quality of life in the postoperative period [1,4]. ...
Aim: The most important complication that develops after pancreaticoduodenectomy is anastomosis leak and pancreatic fistula. Pancreatic fistula is thought to be the cause of major complications such as intra-abdominal abscess. The relationship between the development of fistula after pancreaticoduodenectomy and intraoperative risk factors (resection type, pancreatic anastomosis type, pancreatic duct diameter and pancreatic stump structure), along with the effect of pancreatic fistula on morbidity were investigated.Methods: Forty-one patients who had undergone pancreaticoduodenectomy due to periampullary region tumors were included in this study. Patients were divided into two groups as with and without pancreatic fistula, and compared in terms of demographics, preoperative serum bilirubin and serum albumin values, and intraoperative risks (resection type, pancreatic anastomosis type, pancreatic duct diameter and pancreatic stump structure). In addition, the groups were evaluated for the development of post-operative complications. Results: When both groups were compared in terms of intraoperative risk factors (resection type, pancreatic anastomosis type, pancreatic duct diameter and pancreatic stump structure), similar results were obtained for biochemical parameters (P=0.719, 0.599, 0.250, 0.906, respectively). A statistically significant association was found between the occurrence of pancreatic fistula and delay of gastric emptying (P=0.028). No significant relationship was detected between intraabdominal collection-abscess, intraabdominal hemorrhage, wound infection parameters and pancreatic fistula (P=0.204, 0.950, 0.116, respectively).Conclusion: No factors were found to be solely associated with the development of pancreatic fistula following pancreaticoduodenectomy; however, it was concluded that pancreaticoenteric anastomosis technique and the consistency of pancreatic stump may be closely and significantly related.
... It was reported that soft pancreatic parenchyma and the diameter of main pancreatic duct less than 3 mm were risk factors for pancreatic leakage [31,32]. To prevent these complications, various methods during the preoperative, intraoperative, and postoperative periods have been proposed, especially surgical techniques [33,34]. For example, it is reported that the application of the novel embeddedness-like pancreaticojejunostomy anastomosis technique in PD was effective and could reduce the incidence of pancreatic fistula [35]. ...
Background:
Postoperative complications, especially postoperative pancreatic fistulas, remain the major concern following pancreaticoduodenectomy (PD). Mesh-reinforced pancreatic anastomoses, including pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), are a new effective technique in PD. This study was conducted to analyze the safety and efficacy of this new technique and to compare the results of mesh-reinforced PJ vs PG.
Methods:
A total of 110 patients who underwent PD between August 2005 and January 2016 were eligible in this study. Perioperative and postoperative data of patients with a mesh-reinforced technique were analyzed. Data were also grouped according to the procedure performed: mesh-reinforced PJ and mesh-reinforced PG.
Results:
Among patients undergoing PD with the mesh-reinforced technique, 42 had postoperative complications, and the comprehensive complication index (CCI) was 32.7 ± 2.5. Only 10% of patients had pancreatic fistula; three were grade A, six were grade B, and two were grade C. Biliary fistula occurred in only 8.2% of patients. Patients undergoing mesh-reinforced PG showed a significantly lower rate of CCI than did mesh-reinforced PJ patients (27.0 ± 2.1 vs 37.0 ± 3.9, p < 0.05). The mesh-reinforced PG was also favored over mesh-reinforced PJ because of significant differences in intra-abdominal fluid collection (5.9% vs 18.6%, p < 0.05) and delayed gastric emptying (3.9% vs 15.3%, p < 0.05).
Conclusions:
PD with the mesh-reinforced technique was a safe and effective method of decreasing postoperative pancreatic fistula. Compared with mesh-reinforced PJ, mesh-reinforced PG did not show significant differences in the rates of pancreatic fistula or biliary fistula. However, CCI, intra-abdominal fluid collection, and delayed gastric emptying were significantly reduced in patients with mesh-reinforced PG.
... Anatomik yerleşim yeri özelliklerinden dolayı erken belirti verdiklerinden dolayı pankreas başı kanserinin aksine prognozu daha iyidir ve tanı anında hastaların büyük çoğunluğunda tümör cerrahi olarak çıkarılabilmektedir (14). Ampulla vateri tümörü dahil PBT'inde standart pankreatikoduodenektomi tedavi şekli olarak kabul edilmekle beraber günümüzde pilor koruyucu pankreatikoduodenektomi genel prosedür haline gelmeye başlamıştır (15). Bizim serimizde de literatür ile uyumlu olarak hastaların büyük çoğunluğu 60 yaş üzerindeydi ve bu hastaların %81.9'unun operasyona uygun olduğu gözlendi. ...
... As it is very evident that the major concern of a pancreaticoenteric anastomosis is post operative pancreatic leak, various techniques have been used historically to stop the leakage including: ligation of the duct of pancreas [40], closure of the duct using rubber or fibrin glue application [41], fibrin glue around the pancreaticojejunal anastomosis [42] and various modifications on anastomosing techniques, among them Roux-en-Y reconstruction with pancreaticojejunostomy [43] and pancreaticogastrostomy [44] are the common anastomotic variants. To minimize leak rates many technical variations of pancreaticojejunostomy have been suggested, few are tabulated below (Table 1). ...
Background and aims: The foundation of the pancreatojejunostomy was popularized in 1935 by Whipple and colleagues. Despite significant progress in the surgical technique and perioperative management, morbidity of this procedure remains to be considerably high. Post operative pancreatic fistula (POPF) has been one of the major factors for morbidity and even mortality following pancreaticoduodenectomy and pancreaticoenteric anastomosis. This review will focus on various techniques, their modifications, shortcomings and complication in the management of pancreaticoenteric anastomosis.
... As it is very evident that the major concern of a pancreaticoenteric anastomosis is post operative pancreatic leak, various techniques have been used historically to stop the leakage including: ligation of the duct of pancreas [40], closure of the duct using rubber or fibrin glue application [41], fibrin glue around the pancreaticojejunal anastomosis [42] and various modifications on anastomosing techniques, among them Roux-en-Y reconstruction with pancreaticojejunostomy [43] and pancreaticogastrostomy [44] are the common anastomotic variants. To minimize leak rates many technical variations of pancreaticojejunostomy have been suggested, few are tabulated below (Table 1). ...
Background and aims: The foundation of the pancreatojejunostomy was popularized in
1935 by Whipple and colleagues. Despite significant progress in the surgical technique and perioperative management, morbidity of this procedure remains to be considerably high. Post operative pancreatic fistula (POPF) has been one of the major factors for morbidity and even mortality following pancreaticoduodenectomy and pancreaticoenteric anastomosis. This review will focus on various techniques, their modifications, shortcomings and complication in the management of pancreaticoenteric anastomosis.
Material and methods: A search of various surgical guidelines, prospective randomized
controlled trials, systemic Meta analysis, and case series was performed with regards to surgical techniques and complication in the management of a pancreaticoenteric anastomosis.
Discussion: The major concern of a pancreaticojejunostomy (PJ) is post operative pancreatic leak. Various techniques have been used historically to stop the leakage. Even with the modifications these methods have similar complication rates, so the next factor that should be considered while choosing a PJ method would be related to the individual operator’s experience. A pancreaticogastrostomy is the other alternative that was introduced into practice relatively recently and the advent of the laparoscopic and robotic technologies in surgery has provided a newer domain to pancreatic surgery.
Conclusion: As post-operative pancreatic fistula (POPF) is a major source of morbidity and
mortality surgeons should continue to use the familiar anastomotic technique and interchange of these techniques during surgery will result in decrease incidence of pancreatic fistula when done by experienced surgeons.
