Does antecolic reconstruction for duodenojejunostomy improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? A systematic review and meta-analysis

AIM:To evaluate whether antecolic reconstruction for duodenojejunostomy (DJ) can decrease delayed gastric emptying (DGE) rate after pylorus-preserving pancreaticoduodenectomy (PPPD) through literature review and meta-analysis. METHODS:Articles published between January 1991 and April 2012 comparing antecolic and retrocolic reconstruction for DJ after PPPD were retrieved from the databases of MEDLINE (PubMed), EMBASE, OVID and Cochrane Library Central. The primary outcome of interest was DGE. Either fixed effects model or random effects model was used to assess the pooled effect based on the heterogeneity. RESULTS:Five articles were identified for inclusion:two randomized controlled trials and three non-randomized controlled trials. The meta-analysis revealed that antecolic reconstruction for DJ after PPPD was associated with a statistically significant decrease in the incidence of DGE [odds ratio (OR), 0.06; 95% CI, 0.02-0.17; P < 0.00 001] and intra-operative blood loss [mean difference (MD), -317.68; 95% CI, -416.67 to -218.70; P < 0.00 001]. There was no significant difference between the groups of antecolic and retrocolic reconstruction in operative time (MD, 25.23; 95% CI, -14.37 to 64.83; P = 0.21), postoperative mortality, overall morbidity (OR, 0.54; 95% CI, 0.20-1.46; P = 0.22) and length of postoperative hospital stay (MD, -9.08; 95% CI, -21.28 to 3.11; P = 0.14). CONCLUSION:Antecolic reconstruction for DJ can decrease the DGE rate after PPPD.

Stapled gastro/duodenojejunostomy shortens reconstruction time during pylorus-preserving pancreaticoduodenectomy

AIM:To investigate whether a stapled technique is superior to the conventional hand-sewn technique for gastro/duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy(PpPD).METHODS:In October 2010,we introduced a mechanical anastomotic technique of gastro-or duodenojejunostomy using staplers during PpPD.We compared clinical outcomes between 19 patients who underwent PpPD with a stapled gastro/duodenojejunostomy(stapled anastomosis group)and 19 patients who underwent PpPD with a conventional hand-sewn duodenojejunostomy(hand-sewn anastomosis group).RESULTS:The time required for reconstruction was significantly shorter in the stapled anastomosis group than in the hand-sewn anastomosis group(186.0±29.4 min vs 219.7±50.0 min,P=0.02).In addition,intraoperative blood loss was significantly less(391.0±212.0 mL vs 647.1±482.1 mL,P=0.03)and the time to oral intake was significantly shorter(5.4±1.7d vs 11.3±7.9 d,P=0.002)in the stapled anastomosis group than in the hand-sewn anastomosis group.There were no differences in the incidences of delayed gastric emptying and other postoperative complications between the groups.CONCLUSION:These results suggest that stapled gastro/duodenojejunostomy shortens reconstruction time during PpPD without affecting the incidence of delayed gastric emptying.

Laparoscopic duodenojejunostomy for malignant stenosis as a part of multimodal therapy:A case report

BACKGROUND Laparoscopic duodenojejunostomy(LDJ) has become the standard surgical procedure for superior mesenteric artery syndrome due to its sufficient outcome in terms of safety and symptom relief. However, there are only a few reports about LDJ for malignant stenosis and its indication remains uncertain.CASE SUMMARY A 77-year-old woman with a history of pancreatic cancer(PC) treated with distal pancreatectomy with en bloc resection of the transverse colon 7 mo ago was admitted for recurrent vomiting. Imaging upon admission revealed marked distention of the duodenum and a tumor around the duodenojejunal flexure. She was diagnosed with malignant stenosis caused by local recurrence of PC. LDJ was performed with an uneventful postoperative course, followed by chemotherapy which gave her 10 mo overall survival.CONCLUSION We think that LDJ is a valuable method for unresectable malignant stenosis around the duodenojejunal flexure as a part of multimodal therapy.

Duodenojejunostomy treatment of groove pancreatitis-induced stenosis and obstruction of the horizontal duodenum:A case report

BACKGROUND Groove pancreatitis(GP)is a rare condition affecting the pancreatic groove region within the dorsal-cranial part of the pancreatic head,duodenum,and common bile duct.As a rare form of chronic pancreatitis,GP poses a diagnostic and therapeutic challenge for clinicians.GP is frequently misdiagnosed or not considered;thus,the diagnosis is often delayed by weeks or months.The treatment of GP is complicated and often requires surgical intervention,especially pancreatoduodenectomy.CASE SUMMARY A 66-year-old man with a history of long-term drinking was admitted to the gastroenterology department of our hospital,complaining of vomiting and acid reflux.Upper gastrointestinal endoscopy showed luminal stenosis in the descending part of the duodenum.Abdominal computed tomography showed slight exudation in the descending and horizontal parts of the duodenum with broadening of the groove region,indicating local pancreatitis.The symptoms of intestinal obstruction were not relieved with conservative therapy,and insertion of an enteral feeding tube was not successful.Exploratory laparoscopy was performed and revealed a hard mass with scarring in the horizontal part of the duodenum and stenosis.Intraoperative frozen section analysis showed no evidence of malignancy,and side-to-side duodenojejunostomy was performed.Routine pathologic examination showed massive proliferation of fibrous tissue,hyaline change,and the proliferation of spindle cells.Based on the radiologic and pathologic characteristics,a diagnosis of GP was made.The patient presented with anastomotic obstruction postoperatively and took a long time to recover,requiring supportive therapy.CONCLUSION GP often involves the descending and horizontal parts of the duodenum and causes duodenal stenosis,impaired duodenal motility,and gastric emptying due to fibrosis.

Wilkie’s syndrome as a cause of anxiety-depressive disorder:A case report and review of literature

BACKGROUND Superior mesenteric artery syndrome is a disease with a complex diagnosis,and it is associated with complications that make it even harder to identify.Currently,a frequent association with psychiatric disorders has been noted.Despite numerous case reports and case series,the variability of the disease has not allowed the development of protocols regarding diagnosis and management.CASE SUMMARY A 33-year-old woman presented with abdominal pain,nausea,and bile vomiting over the last 15 mo,associated with a 15-kg weight loss over the last three months.After the onset of the symptoms,the patient was diagnosed with anxietydepressive disorder and treated appropriately.Standard examinations excluded an organic cause,and the cause of the symptoms was considered psychogenic.The persistence of symptoms,even under treatment,prompted a computer tomography angiography examination of the abdomen and pelvis.The examination identified emergence at a sharp angle of 13.7°of the superior mesenteric artery,with a reduced distance between the artery and the anterior wall of the aorta up to a maximum of 8 mm.A diagnosis of aortomesenteric clamp was established.Surgical treatment by laparoscopic duodenojejunostomy was performed.Postoperative evolution was marked by a patent anastomosis at 1 mo,with a 10-kg weight gain and improvement of the associated anxiety.CONCLUSION This case report underlines two major aspects.One aspect refers to the predisposition of patients with superior mesenteric artery syndrome to develop psychiatric disorders,with an excellent outcome when proper treatment is administered.The second aspect underlines the key role of a multidisciplinary approach and follow-up.

Pancreas preserving distal duodenectomy: A versatile operation for a range of infra-papillary pathologies

To investigate the range of pathologies treated by pancreas preserving distal duodenectomy (PPDD) and present the outcome of follow-up.METHODSNeoplastic lesions of the duodenum are treated conventionally by pancreaticoduodenectomy. Lesions distal to the major papilla may be suitable for a pancreas-preserving distal duodenectomy, potentially reducing morbidity and mortality. We present our experience with this procedure. Selective intraoperative duodenoscopy assessed the relationship of the papilla to the lesion. After duodenal mobilisation and confirmation of the site of the lesion, the duodenum was transected distal to the papilla and beyond the duodenojejunal flexure and a side-to-side duodeno-jejunal anastomosis was formed. Patients were identified from a prospectively maintained database and outcomes determined from digital health records with a dataset including demographics, co-morbidities, mode of presentation, preoperative imaging and assessment, nutritional support needs, technical operative details, blood transfusion requirements, length of stay, pathology including lymph node yield and lymph node involvement, length of follow-up, complications and outcomes. Related published literature was also reviewed.RESULTSTwenty-four patients had surgery with the intent of performing PPDD from 2003 to 2016. Nineteen underwent PPDD successfully. Two patients planned for PPDD proceeded to formal pancreaticoduodenectomy (PD) while three had unresectable disease. Median post-operative follow-up was 32 mo. Pathologies resected included duodenal adenocarcinoma (n = 6), adenomas (n = 5), gastrointestinal stromal tumours (n = 4) and lipoma, bleeding duodenal diverticulum, locally advanced colonic adenocarcinoma and extrinsic compression (n = 1 each). Median postoperative length of stay (LOS) was 8 d and morbidity was low [pain and nausea/vomiting (n = 2), anastomotic stricture (n = 1), pneumonia (n = 1), and overwhelming post-splenectomy sepsis (n = 1, asplenic patient)]. PPDD was associated with a significantly shorter LOS than a contemporaneous PD series [PPDD 8 (6-14) d vs PD 11 (10-16) d, median (IQR), P = 0.026]. The 30-d mortality was zero and 16 of 19 patients are alive to date. One patient died of recurrent duodenal adenocarcinoma 18 mo postoperatively and two died of unrelated disease (at 2 mo and at 8 years respectively).CONCLUSIONPPDD is a versatile operation that can provide definitive treatment for a range of duodenal pathologies including adenocarcinoma.

Superior mesenteric artery syndrome in a patient with Charcot Marie Tooth disease

The extrinsic compression of the third part of the duodenum as it passes through the aorto-mesenteric angle is known as the superior mesenteric artery syndrome(SMAS).This syndrome is a rare mechanical cause of upper intestinal obstruction,with a reported incidence of between 0.2% and 0.78%.Clinical manifestations of SMAS may be chronic or acute;chronic symptoms include intermittent gastric pain,fullness and occasional episodes of postprandial vomiting,while acute symptoms include incoercible vomiting,oral intolerance,mainly epigastric abdominal distension and abdominal pain.Surgery is recommended only when initial conservative treatment fails.Here,we report what appears to be the third published case of SMAS associated with hereditary motor and sensory neuropathy or Charcot Marie Tooth disease.

Superior Mesenteric Artery Syndrome: First Chadian Observation

Introduction: The extrinsic compression of the third portion of the duodenum between the superior mesenteric artery and the aorta defines superior mesenteric artery syndrome. It determines an acute or chronic high intestinal obstruction pattern. We report the first observed case in Chad. Observation: HH was a 19 year-old woman with abdominal pain and intermittent postprandial vomiting since she was 5 years old. During last 11 months, post-prandial vomiting was more frequent, and non resolved after medical treatment. Unquantified weight loss was reported. Body mass index at hospitalization was 9.8. An injected abdominal scan demonstrated significant gastroduodenal distension, upstream of a stenosis of the third duodenal portion. Aorto-mesenteric space and angle were reduced. At laparotomy internal derivation by duodenojejunostomy was done. Postoperative situation was uneventful. Conclusion: Superior mesenteric artery syndrome determines an acute or chronic intestinal obstruction. Injected abdominal scan is fundamental for diagnosis. The treatment is firstly conservative but the need of surgery is common.