Safety and feasibility of modified duct-to-mucosa pancreaticojejunostomy during pancreatoduodenectomy: A retrospective cohort study

BACKGROUND Pancreatoduodenectomy(PD)is the most effective surgical procedure to remove a pancreatic tumor,but the prevalent postoperative complications,including postoperative pancreatic fistula(POPF),can be life-threatening.Thus far,there is no consensus about the prevention of POPF.AIM To determine possible prognostic factors and investigate the clinical effects of modified duct-to-mucosa pancreaticojejunostomy(PJ)on POPF development.METHODS We retrospectively collected and analyzed the data of 215 patients who under-went PD between January 2017 and February 2022 in our surgery center.The risk factors for POPF were analyzed by univariate analysis and multivariate logistic regression analysis.Then,we stratified patients by anastomotic technique(end-to-side invagination PJ vs modified duct-to-mucosa PJ)to conduct a comparative study.RESULTS A total of 108 patients received traditional end-to-side invagination PJ,and 107 received modified duct-to-mucosa PJ.Overall,58.6%of patients had various complications,and 0.9%of patients died after PD.Univariate and multivariate logistic regression analyses showed that anastomotic approaches,main pancreatic duct(MPD)diameter and pancreatic texture were significantly associated with the incidence of POPF.Additionally,the POPF incidence and operation time in patients receiving modified duct-to-mucosa PJ were 11.2%and 283.4 min,respectively,which were significantly lower than those in patients receiving traditional end-to-side invagination PJ(27.8%and 333.2 minutes).CONCLUSION Anastomotic approach,MPD diameter and pancreatic texture are major risk factors for POPF development.Compared with traditional end-to-side invagination PJ,modified duct-to-mucosa PJ is a simpler and more efficient technique that results in a lower incidence of POPF.Further studies are needed to validate our findings and explore the clinical applicability of our technique for laparoscopic and robotic PD.

A new pancreaticojejunostomy technique: A battle against postoperative pancreatic fistula

AIM:To present a new technique of end-to-side, ductto-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and insertion of a silicone stent. METHODS:We present an end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and the insertion of a silicone stent. This technique was performed in thirty-two consecutive patients who underwent a pancreaticoduodenectomy procedure by the same surgical team, from January 2005 to March 2011. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity. RESULTS:There were 32 patients who underwent end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation. Thirteen of them were women and 19 were men. These data correspond to 40.6% and 59.4%, respectively. The mean age was 64.2 years, ranging from 55 to 82 years. The mean operative time was 310.2 ± 40.0 min, and was defined as the time period from the intubation up to the extubation of the patient. Also, the mean time needed to perform the pancreaticojejunostomy was 22.7 min, ranging from 18 to 25 min. Postoperatively, one patient developed a low output pancreatic fistula, three patients developed surgical site infection, and one patient developed pneumonia. The rate of overall morbidity was 15.6%. There was no 30-d postoperative mortality. CONCLUSION:This modification appears to be a significantly safe approach to the pancreaticojejunostomy without adversely affecting operative time.

Matched-pair analysis of postoperative morbidity and mortality for pancreaticogastrostomy and pancreaticojejunostomy using mattress sutures in soft pancreatic tissue remnants

BACKGROUND:After pancreaticoduodenectomy,the incidence of postoperative pancreatic fistula remains high,especially in patients with 'soft' pancreatic tissue remnants.No 'gold standard' surgical technique for pancreaticoenteric anastomosis has been established.This study aimed to compare the postoperative morbidity and mortality of pancreaticogastrostomy and pancreaticojejunostomy for 'soft' pancreatic tissue remnants using modified mattress sutures.METHODS:Seventy-five patients who had undergone pancreaticogastrostomy and 75 who had undergone pancreaticojejunostomy after pancreaticoduodenectomy between 2002 and 2008 were retrospectively compared using matched-pair analysis.A modified mattress suture technique was used for the pancreaticoenteric anastomosis.Patients with an underlying 'hard' pancreatic tissue remnant,as in chronic pancreatitis,were excluded.Both groups were homogeneous for age,gender,and underlying disease.Postoperative morbidity,mortality,and preoperative and operative data were analyzed.RESULTS:There were no significant differences between the groups for the incidence of postoperative pancreatic fistula (10.7% in both).Postoperative morbidity and mortality,median operation time,median length of hospital stay,intraoperative blood loss,and the amount of intraoperatively transfused erythrocyte concentrates also did not significantly differ between the groups.Patient age >65 years (P=0.017),operation time >350minutes (P=0.001),and intraoperative transfusion of erythrocyte concentrates (P=0.038) were identified as risk factors for postoperative morbidity.CONCLUSIONS:Our results showed no significant differences between the groups in the pancreaticogastrostomy and pancreaticojejunostomy anastomosis techniques using mattress sutures for 'soft' pancreatic tissue remnants.In our experience,the mattress sutures are safe and simple to use,and pancreaticogastrostomy in particular is feasible and easy to learn,with good endoscopic accessibility to the anastomosis region.However,the location of the anastomosis and the surgical technique need to be individually evaluated to further reduce the incidence of postoperative pancreatic fistula.

Prevention of pancreatic leakage after pancreaticoduodenectomy by modified Child pancreaticojejunostomy

BACKGROUND: Pancreatic leakage after pancreaticoduodenectomy is associated with a morbidity and mortality. Different techniques have been used to make a safe anastomosis to the left pancreatic remnant. METHODS: We performed 'modified Child pancreatico jejunostomy' for 31 patients, by which end-to-end pancreaticojejunal anastomosis was made with a two-layer polypropylene continuous running suture. RESULTS: In the patients who underwent pancreaticojejunostomy, the average operative time was 14.2 minutes. There was no pancreaticoenterostomy leakage in all patients, and no deaths occurred. CONCLUSIONS: In pancreaticojejunostomy, pancreatic anastomosis is time-saving and free from complications. Thus it is an improvement of pancreaticojejunostomy.

An end-to-side suspender pancreaticojejunostomy: A new invagination pancreaticojejunostomy

Background: Postoperative pancreatic fistula(POPF) is a severe complication of the pancreaticoduodenectomy(PD). Recently, we introduced a method of suspender pancreaticojejunostomy(PJ) to the PD. In this study, we retrospectively analyzed various risk factors for complications after PD. We also introduced and assessed the suspender PJ to demonstrate its advantages.Methods: Data from 335 patients with various periampullary lesions, who underwent the Whipple procedure(classic Whipple procedure or pylorus-preserving) PD by either traditional end-to-side invagination PJ or suspender PJ, were analyzed. The correlation between either perioperative or postoperative complications and corresponding PD approaches was evaluated by univariate analysis.Results: A total of 147 patients received the traditional end-to-side invagination PJ, and 188 patients were given the suspender PJ. Overall, 51.9% patients had various complications after PD. The mortality rate was 2.4%. The POPF incidence in patients who received the suspender PJ was 5.3%, which was significantly lower than those who received the traditional end-to-side invagination PJ(18.4%)(P < 0.001).Univariate analysis showed that PJ approach and the pancreas texture were significantly associated with the POPF incidence rate(P < 0.01). POPF was a risk factor for both postoperative abdominal cavity infection(OR = 8.34, 95% CI: 3.99–17.42, P < 0.001) and abdominal cavity hemorrhage(OR = 4.86, 95% CI:1.92–12.33, P = 0.001).Conclusions: Our study showed that the impact of the pancreas texture was a major risk factor for pancreatic leakage after a PD. The suspender PJ can be easily accomplished and widely applied and can effectively decrease the impact of the pancreas texture on pancreatic fistula after a PD and leads to a lower POPF incidence rate.

Total closure of pancreatic section for end-to-side pancreaticojejunostomy decreases incidence of pancreatic fistula in pancreaticoduodenectomy

BACKGROUND： Postoperative pancreatic fistula （POPF） is a serious complication and results in prolonged hospitalization and high mortality. The present study aimed to evaluate the safety and effectiveness of total closure of pancreatic section for end-to-side pancreaticojejunostomy in pancreaticoduodenectomy （PD）. METHODS： This was a prospective randomized clinical trial comparing the outcomes of PD between patients who un- derwent total closure of pancreatic section for end-to-side pancreaticojejunostomy （Group A） vs those who underwent conventional pancreaticojejunostomy （Group B）. The primary endpoint was the incidence of pancreatic fistula. Secondary endpoints were morbidity and mortality rates. RESULTS： One hundred twenty-three patients were included in this study. The POPF rate was significantly lower in Group A than that in Group B （4.8% vs 16.7%, P〈0.05）. About 38.3% patients in Group B developed one or more complications; this rate was 14.3% in Group A （P〈0.01）. The wound/abdomi- nal infection rate was also much higher in Group B than that in Group A （20.0% vs 6.3%, P〈0.05）. Furthermore, the average hospital stays of the two groups were 18 days in Group A, and 24 days in Group B, respectively （P〈0.001）. However, there was no difference in the probability of mortality, biliary leakage,delayed gastric emptying, and pulmonary infection between the two groups. CONCLUSION： Total closure of pancreatic section for end-to- side pancreaticojejunostomy is a safe and effective method for pancreaticojejunostomy in PD.

Effect of six-stitch pancreaticojejunostomy on pancreatic fistula:A propensity score-matched comparative cohort study

Background:Clinically relevant postoperative pancreatic fistula(CR-POPF)is the most common and severe complication after pancreaticoduodenectomy(PD).Despite the development of numerous anastomotic surgical techniques to minimize CR-POPF,more than 30%of patients who undergo PD develop CR-POPF.Herein,we propose a novel pancreaticojejunostomy(PJ)technique and evaluate its efficacy and safety compared to traditional PJ.Methods:This retrospective study enrolled 164 consecutive patients who underwent PJ after PD between January 2012 and June 2017.Of them,78(47.6%)underwent traditional PJ and 86(52.4%)underwent sixstitch PJ.The primary outcome was CR-POPF at 1-month follow-up defined according to the revised 2016 International Study Group on Pancreatic Fistula definition.To adjust for baseline differences and selection bias,patients were matched by propensity scores,which left 63 patients with traditional PJ and 63 with six-stitch PJ.Results:Compared to patients who underwent traditional PJ(mean age 56.2±9.4 years),patients who underwent six-stitch PJ(mean age 57.4±11.4 years)had a lower CR-POPF rate.The risk of CR-POPF among patients who underwent six-stitch PJ was decreased by 81.7%after adjustment for age,sex,body mass index,and disease severity compared to patients who underwent traditional PJ.Additionally,the surgery time was reduced from 29 min for traditional PJ to 15 min for six-stitch PJ(P<0.001).Adverse effects such as abdominal fluid collection,abdominal bleeding,and wound infection were similar between two groups.Conclusion:Six-stitch PJ may be an effective and efficient PJ technique for patients who undergo PD surgery.

Mattress sutures for the modification of end-to-end dunking pancreaticojejunostomy

Despite the improvement of surgical techniques,the rate of anastomotic failure of pancreaticojejunostomy remains high(30%-50%).Here we describe the use of vertical mattress sutures in the modification of dunking pancreaticojejunal anastomosis.In 7 patients who used this technique,neither anastomotic failure nor any major postsurgical complication developed.This technique is an easy,safe,and promising for the performance of pancreaticojejunostomy.

Modified binding pancreaticogastrostomy vs modified Blumgart pancreaticojejunostomy after laparoscopic pancreaticoduodenectomy for pancreatic or periampullary tumors

BACKGROUND Laparoscopic pancreaticoenteric anastomosis is one of the technically challenging steps of minimally invasive pancreaticoduodenectomy(PD),especially during the learning curve.Despite multiple randomized controlled trials and meta-analyses,the type of pancreatico-enteric anastomosis as a risk factor for post-pancreatectomy complications is debatable.Also,the ideal technique of pancreatic reconstruction during the learning curve of laparoscopic PD has not been well studied.AIM To compare the short-term outcomes of modified binding pancreaticogastrostomy(PG)and Blumgart pancreaticojejunostomy(PJ)during learning curve of laparoscopic PD.METHODS The first 25 patients with resectable pancreatic or periampullary tumors who underwent laparoscopic PD with modified binding PG or modified Blumgart PJ between January 2015 and May 2020 were retrospectively analyzed to compare perioperative outcomes during the same learning curve.A single layer of the fullthickness purse-string suture was placed around the posterior gastrotomy in the modified binding PG.In the modified Blumgart technique,only a single transpancreatic horizontal mattress suture was placed on either side of the pancreatic duct(total two sutures)to secure the pancreatic parenchyma to the jejunum.Also,on the ventral surface,the knot is tied on the jejunal wall without going through the pancreatic parenchyma.Post pancreatectomy complications are graded as per the RESULTS During the study period,modified binding PG was performed in 27 patients and modified Blumgart PJ in 29 patients.The demographic and clinical parameters of the first 25 patients included in both groups were comparable.Lower end cholangiocarcinoma and ampullary adenocarcinoma were the primary indications for laparoscopic PD in both groups(32/50,64%).The median operative time for pancreatic reconstruction was significantly lower in the binding PG group(42 vs 58 min,P=0.01).The clinically relevant(Grade B/C)postoperative pancreatic fistula(POPF)was significantly more in the modified PJ group(28%vs 4%,P=0.04).In contrast,intraluminal postpancreatectomy hemorrhage(PPH)was more in the binding PG group(32%vs 4%,P=0.02).There was no significant difference in the incidence of delayed gastric emptying between the two groups.CONCLUSION During the learning curve of laparoscopic PD,modified binding PG reduces POPF but is associated with increased intraluminal PPH compared to PJ using the modified Blumgart technique.

One-half layer pancreaticojejunostomy with the rear wall of the pancreas reinforced:A valuable anastomosis technique

BACKGROUND Postoperative pancreatic fistula(POPF)is one of the most common and serious complications after pancreaticoduodenectomy(PD).To effectively reduce the incidence of POPF,we designed a new type of pancreaticojejunostomy(PJ),which was termed one-half layer PJ with the rear wall of the pancreas reinforced.AIM To explore the clinical application value of this new technique.METHODS We compared 62 patients who had undergone PD by either the traditional ductto-mucosa anastomoses or the new one-half layer PJ with the rear wall of the pancreas reinforced method at our hospital from May 2015 to September 2019.All 62 patients were operated by the same surgeon experienced in both procedures.We retrospectively analyzed patient characteristics,perioperative outcomes,and surgical results.RESULTS There was no significant difference between the two groups in basic information except the postoperative hospital stays,14.7±5.4 d in the traditional duct-tomucosa anastomoses group and 12.0±4.2 d in the one-half layer PJ group(P=0.042).In terms of postoperative complications,the one-half layer PJ group had a lower rate of POPF than the traditional group.The overall number of cases with POPF was 8(24.2%)in the traditional group and 2(6.9%)in the one-half layer group(P=0.017).Additionally,the rate of grades B and C POPF was lower in the one-half layer group(3.4%)compared with that(12.1%)in the traditional group(P=0.010).One patient died due to hemorrhage caused by severe pancreatic fistula in the traditional group.CONCLUSION One-half layer PJ with the rear wall of the pancreas reinforced is a safe and feasible procedure that can successfully reduce the rate of POPF.It may be a promising technique for PJ after PD.

‘Short’pancreaticojejunostomy might be a valid option for treatment of chronic pancreatitis in many cases

BACKGROUND The Partington-Rochelle pancreaticojejunostomy(PJ)is an essential management option for patients with chronic pancreatitis(CP)associated with intractable pain and a dilated pancreatic duct(PD).Wide ductotomy and long PJ(L-PJ)have been advocated as the standard of care to ensure full PD decompression.However,the role of short PJ(S-PJ)in a uniformly dilated PD has not yet been evaluated.AIM To evaluate the possible advantages and disadvantages of S-PJ and L-PJ and to interpret the perspective of S-PJ in the treatment of CP.METHODS A retrospective review of prospectively collected cohort data was conducted on surgically treated CP patients subjected to side-to-side PJ.The length of the PJ was adapted to anatomical alterations in PD.A comparison was made of S-PJ(<50 mm)for uniformly dilated PD and L-PJ(50-100 mm)in the setting of multiple PD strictures,calcifications and dilatations.We hypothesized that S-PJ and L-PJ ensure comparable clinical outcomes.The primary outcomes were pain relief and quality of life(QOL);the secondary outcomes were perioperative characteristics,body weight,patients’satisfaction with treatment,and readmission rate due to CP.RESULTS Overall,91 patients underwent side-to-side PJ for CP,including S-PJ in 46 patients and L-PJ in 45 patients.S-PJ resulted in better perioperative outcomes:Significantly shorter operative time(107.5 min vs 134 min),lower need for intraoperative(0%vs 15.6%)and total(2.2%vs 31.1%)blood transfusions,and lower rate of perioperative complications(6.5%vs 17.8%).We noted no significant difference in pain relief,improvement in QOL,body weight gain,patients’satisfaction with surgical treatment,or readmission rate due to CP.CONCLUSION Based on our data,in the setting of a uniformly dilated PD,S-PJ provides adequate decompression of the PD.As the clinical outcomes following S-PJ are not inferior to those of L-PJ,S-PJ should be preferred as a surgical option in the case of a uniformly dilated PD.

Absorbable 3D-printed pancreaticojejunostomy device with a dual-layer drug coating for the prevention of postoperative local recurrence of pancreatic cancer

The high local recurrence rate of pancreatic cancer after surgery is one of the important risk factors affecting patient survival.The traditionally used silicone tube stent is not only complicated to operate but also lacks antitumor properties.The purpose of this study was to develop a dual-layer drug-coated pancreaticojejunostomy device.The coating consisted of two layers,an outer basic fibroblast growth factor(bFGF)coating layer and an inner nanoparticle albumin-bound paclitaxel(nab-PTX)coating layer with chitosan as the drug-carrying medium.Due to the diffusion barrier from the outer coating,the release of nab-PTX from the inner layer was delayed and slowed down.We studied the degradation rates,mechanical properties,surface morphologies,drug release kinetics,promoting the growth of fibroblasts and antitumor properties of the coated stents.It was found that 100 ng of bFGF and 50µg of nab-PTX were suitable drug concentrations that can effectively promote the growth of fibroblasts and inhibit pancreatic cancer cells.The results also confirmed that the dual-layer drug-coated pancreaticojejunostomy device showed good antitumor activity both in vitro and in vivo without obvious systemic toxicity.In addition,the device has a suitable degradation rate.In conclusion,this biodegradable dual-layer drug-coated pancreaticojejunostomy device can potentially inhibit the local recurrence of pancreatic cancer after surgery and promote the healing of pancreaticointestinal anastomosis.This device has great potential to treat pancreatic cancer in the future.

Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy： a meta-analysis

Background Postoperative pancreatic fistula remains one of the most common and troublesome complications following pancreaticoduodenectomy. No consensus exists regarding the optimal pancreaticojejunostomy reconstruction technique to reduce this complication. We aimed to perform a systematic review comparing two commonly used techniques of pancreaticojejunostomy reconstruction （duct-to-mucosa versus invagination）, by meta-analysis and assessment of evidence quality. Methods Databases searched including The Cochrane Library, Medline, PubMed, Embase, etc. Randomized controlled trials （RCTs） comparing duct-to-mucosa and invagination pancreaticojejunostomy were included. Outcomes of interest were pancreatic fistula rate, mortality, morbidity, reoperation and hospital stay. Pooled estimates were expressed as risk ratio （RR） or mean difference. Results From 321 identified abstracts, four RCTs （467 patients; duct-to-mucosa： 232; invagination： 235） were included. Pancreatic fistula rate （RR, 0.74; 95% confidence interval （C/）： 0.24-2.28; P=0.60）, mortality （RR, 1.18; 95% CI： 0.39- 3.54; P=0.77）, morbidity （RR, 0.91; 95% CI： 0.69-1.21; P=0.53）, reoperation （RR, 1.09; 95% CI： 0.54-2.22; P=-0.81） and hospital stay （mean difference, -1.78; 95% CI： -4.60-1.04; P=0.22） were similar between techniques. Conclusions Duct-to-mucosa and invagination pancreaticojejunostomy are comparable with regards to assessed parameters. High-quality, large-volume, multi-center RCTs with standard outcome definitions are required.

Meta-analysis of pancreaticoduodenectomy prospective controlled trials： pancreaticogastrostomy versus pancreaticojejunostomy reconstruction

Background Pancreaticogastrostomy （PG） has been proposed as an alternative to pancreaticojejunostomy （PJ）, assuming that postoperative complications are less frequent. The aim of this research was to compare the safety of PG with PJ reconstruction after pancreaticoduodenectomy.

Shark mouth pancreaticojejunostomy: a new enteric reconstruction procedure of pancreatic stump

Background:The enteric reconstruction procedure of pancreatic stump after pancreaticoduodenectomy remains to be the critical factor influencing the mortality and morbidity.No widely accepted surgical procedure for the pancreaticojejunostomy has been erected yet.We have developed a new technique of pancreaticojejunostomy named "shark mouth pancreaticojejunostomy." The aim of this study is to assess the efficacy of "shark mouth pancreaticojejunostomy."Methods:This is a prospective single-arm observational study to evaluate the clinical efficacy of "shark mouth pancreaticojejunostomy." Patients with diseases,in whom a pancreaticoduodenectomy is indicated,would be recruited from Peking University Third Hospital.The hypothesis to be tested is that a "shark mouth pancreaticojejunostomy" will reduce fistula rate from around 20% to less than 10%.A sample size of 120 patients will be needed.The primary endpoint is the incidence rate of postoperative pancreatic fistula (POPF).The secondary endpoints of the study are anastomosis time,postoperative hospital stay,and morbidities besides the POPF such as the hemorrhage.Enrolled patients will undergo pancreaticoduodenectomy and be followed up for 3 months.The relevant data will be monitored and recorded.Conclusions:The current trial will explore the therapeutic value of the newly raised pancreaticojejunostomy procedure as the "shark mouth pancreaticojejunostomy." Its theoretical base and pragmatic feature will promise high external validity.Trial registration:Clinical Trials.gov:NCT03366038;https://www.clinicaltrials.gov.

Effect of end-to-end invagination pancreaticojejunostomy with circle discontinuous U suture in pancreatic surgery

The aim of this paper is to summarize the methods of pancreaticojejunostomy in the pancreatic operation and to study the safety and feasibility of a new operative method called end-to-end invagination pancreaticojejunostomy with circle discontinuous U suture to prevent fistula of pancreaticojejunostomy.Eight-three patients with pancreaticoduodenectomy in the 3rd Hospital,Jilin University from 2001 January to 2006 April were reviewed.The incidences of pancreatic fistula with different types of pancreaticojejunostomy were compared.The overall incidence rate of pancreatic fistula was 26.5%(22/83).No pancreatic fistula occurred in end-to-end invagination pancreaticojejunostomy with circle discontinuous U suture.The incidence rate of the fistula following end-to-end invagination pancreaticojejunostomy with circle discontinuous U suture was significantly lower than that of traditional end-to-end pancreaticojejunostomy[40%,(10/25),P<0.01]and end-to-side pancreaticojejunostomy[27.3%,(12/44),P<0.05],but no significant difference(P>0.05)between traditional end-to-end pancreaticojejunostomy and end-to-side pancreaticojejunostomy was discovered.End-to-end invagination pancreaticojejunostomy with circle discontinuous U suture has a definite effect on avoiding pancreatic fistula following pancreaticojejunostomy and is worth being recommended.But the cases were limited,so this method would still need to be observed and confirmed further in the future.

Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases

AIM To evaluate the evolution, trends in surgical approaches a n d r e c o n s t r u c t i o n t e c h n i q u e s, a n d i m p o r t a n t lessons learned from performing 1000 consecutive pancreaticoduodenectomies(PDs) for periampullary tumors.METHODS This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period(1993-2002), middle period(2003-2012), and late period(2013-2017).RESULTS The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods.CONCLUSION Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

Combined invagination and duct-to-mucosa techniques with modifications:anew method of pancreaticojejunal anastomosis

BACKGROUND:Soft pancreatic texture and a small main pancreatic duct are thought to be the most significant risk factors for the occurrence of pancreatic fistula (PF),a common and serious complication after pancreaticoduodenectomy (PD).This is in part due to the technical difficulties of pancreaticojejunostomy (PJ) posed by a soft gland with a normal-sized duct.To deal with this problem,we developed a new anastomotic technique which combines the two most widely used techniques,namely,the invagination technique and the duct-to-mucosa technique,with a modification of the suture route and insertion of a temporary stent tube.METHODS:Between January 2003 and December 2009,ninetytwo consecutive patients underwent PD in which the new PJ technique was used.Charts and follow-up data of these patients were reviewed for operative details,early postoperative events,and outcomes at 6 months after the operation.PF was defined by the International Study Group on Pancreatic Fistula (ISGPF) guidelines and graded (A,B or C) according to the clinical procedures and outcome.RESULTS:In this group of 92 patients,there was only 1 early death from acute renal failure.PF was observed in 11 patients (12.0%),8 in grade A,1 in grade B,and 2 in grade C.For the 2 patients in grade C,PF was surgically managed.There were no early or late deaths attributable to PF.Six months after the operation,all of the patients were free of PJ-related symptoms except for 2,who were found to have steatorrhea.CONCLUSIONS:Our modified technique is simple and safe in PD.Present data suggest that this technique produces excellent early and medium-term results.

Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy

BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence. AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula. METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and longterm follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031;and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration. CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.