Stent A pancreaticojejunostomy after pancreatoduodenectomy:Is it always necessary?

The establishment of a postoperative pancreatic fistula(POPF)is considered the most common and,concomitantly,the most serious complication associated with pancreaticoduodenectomy(PD).The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified.The stenting of the pancreatic duct,with the use of either internal or external stents,has been evaluated in this direction.In theory,it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF.The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF,after PD,by using PubMed and Reference Citation Analysis.In general,previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF;this is at the cost,however,of increased morbidity associated mainly with the stent removal.Certainly,the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract.Bearing in mind the scarcity of high-quality data on the subject,an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.

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.

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.

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.

Pancreatic fistula after pancreaticoduodenectomy:A comparison between the two pancreaticojejunostomy methods for approximating the pancreatic parenchyma to the jejunal seromuscular layer:Interrupted vs continuous stitches

AIM： The purpose of this study is to find a better operative technique by comparing interrupted stitches with continuous stitches for the outer layer of the pancreaticojejunostomy, i.e. the stitches between the stump parenchyma of the pancreas and the jejunal seromuscular layer, and other risk factors for the incidence of pancreatic leakage.METHODS： During the period January 1997 to October 2004, 133 patients have undergone the end-to-side and duct-to-mucosa pancreaticojejunostomy reconstruction after pancreaticoduodenectomy with interrupted suture for outer layer of the pancreaticojejunostomy and 170 patients with a continuous suture at our institution by one surgeon.RESULTS： There were no significant differences between the two groups in the diagnosis, texture of the pancreas, use of octreotide and pathologic stage. Pancreatic fistula occurred in 14 patients （11%） among the interrupted suture cases and in 10 （6%） among the continuous suture cases （P = 0.102）. Major pancreatic leakage developed in three interrupted suture patients （2%） and zero continuous suture patients （P = 0.026）. In multivariate analysis, soft pancreatic consistency （odds ratio, 5.5; 95% confidence interval 2.3-13.1） and common bile duct cancer （odds ratio, 3.7; 95%CI 1.6-8.5） were＇predictive of pancreatic leakage.CONCLUSION： Pancreatic texture and pathology are the most important factors in determining the fate of pancreaticojejunal anastomosis and our continuous suture method was performed with significantly decreased occurrence of major pancreatic fistula. In conclusion, the continuous suture method is more feasible and safer in performing duct-to-mucosa 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.

Experimental study on operative methods of pancreaticojejunostomy with reference to anastomotic patency and postoperative pancreatic exocrine function

AIM:To assess the patency of pancreaticoenterostomy and pancreatic exocrine function after three surgical methods. METHODS: A pig model of pancreatic ductal dilation was made by ligating the main pancreatic duct. After 4 wk ligation, a total of 36 piglets were divided randomly into four groups. The piglets in the control group underwent laparotomy only; the others were treated by three anastomoses: (1) end-to-end pancreaticojejunostomy invagination (EEPJ); (2) end-to-side duct-to- mucosa sutured anastomosis (ESPJ); or (3) binding pancreaticojejunostomy (BPJ). Anastomotic patency was assessed after 8 wk by body weight gain, intrapancreatic ductal pressure, pancreatic exocrine function secretin test, pancreatography, and macroscopic and histologic features of the anastomotic site. RESULTS: The EEPJ group had significantly slower weight gain than the ESPJ and BPJ groups on postoperative weeks 6 and 8 (P < 0.05). The animals in both the ESPJ and BPJ groups had a similar body weight gain.Intrapancreatic ductal pressure was similar in ESPJ and BPJ. However, pressure in EEPJ was significantly higher than that in ESPJ and BPJ (P < 0.05). All three functional parameters, the secretory volume, the flow rate of pancreatic juice, and bicarbonate concentration, were significantly higher in ESPJ and BPJ as compared to EEPJ (P < 0.05). However, the three parameters were similar in ESPJ and BPJ. Pancreatography performed after EEPJ revealed dilation and meandering of the main pancreatic duct, and the anastomotic site exhibited a variable degree of occlusion, and even blockage. Pancreatography of ESPJ and BPJ, however, showed normal ductal patency. Histopathology showed that the intestinal mucosa had fused with that of the pancreatic duct, with a gradual and continuous change from one to the other. For EEPJ, the portion of the pancreatic stump protruding into the jejunal lumen was largely replaced by cicatricial fibrous tissue. CONCLUSION: A mucosa-to-mucosa pancreatico- jejunostomy is the best choice for anastomotic patency when compared with EEPJ. BPJ can effectively maintain anastomotic patency and preserve pancreatic exocrine function as well as ESPJ.

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.

An easier method for performing a pancreaticojejunostomy for the soft pancreas using a fast-absorbable suture

AIM: To clarify the usefulness of a new method for performing a pancreaticojejunostomy by using a fast-absorbable suture material irradiated polyglactin 910, and a temporary stent tube for a narrow pancreatic duct with a soft pancreatic texture.METHODS: Among 63 consecutive patients with soft pancreas undergoing a pancreaticoduodenectomy from 2003 to 2006, 35 patients were treated with a new reconstructive method. Briefly, after the pancreatic transaction, a stent tube was inserted into the lumen of the pancreatic duct and ligated with it by a fast-absorbable suture. Another tip of the stent tube was introduced into the intestinal lumen at the jejunal limb, where a purse-string suture was made by another fast-absorbable suture to roughly fix the tube. The pancreaticojejunostomy was completed by ligating two fast-absorbable sutures to approximate the ductal end and the jejunal mucosa, and by adding a rough anastomosis between the pancreatic parenchyma and the seromuscular layer of the jejunum. The initial surgical results with this method were retrospectively compared with those of the 28 patients treated with conventional duct-to-mucosa anastomosis.RESULTS: The incidences of postoperative morbidity including pancreatic fistula were comparable between the two groups (new; 3%-17% vs conventional; 7%-14% according to the definitions). There was no mortality and re-admission. Late complications were also rarely seen.CONCLUSION: A pancreaticojejunostomy using an irradiated polyglactin 910 suture material and a temporary stent is easy to perform and is feasible even in cases with a narrow pancreatic duct and a normal soft pancreas.

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.

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.

A standardized technique for safe pancreaticojejunostomy:Pair-Watch suturing technique

AIM:To prevent pancreatic leakage after pancreaticoje-junostomy,we designed a new standardized technique that we term the "Pair-Watch suturing technique".METHODS:Before anastomosis,we imagine the faces of a pair of watches on the jejunal hole and pancreatic duct.The first stitch was put between 9 o'clock of the pancreatic side and 3 o'clock of the jejunal side,and a total of 7 stitches were put on the posterior wall,followed by the 5 stitches on the anterior wall.Using this technique,twelve stitches can be sutured on the first layer anastomosis regardless of the caliber of the pancreatic duct.In all cases the amylase activity of the drain were measured.A postoperative pancreatic fistula was diagnosed using postoperative pancreatic fistula grading.RESULTS:From March 2007 to July 2008,29 consecutive cases underwent pancreaticojejunostomy using this technique.Pathologic examination results showed pancreatic carcinoma(n=14),intraductal papillary-mucinous neoplasm(n=10),intraductal papillary-mucinous carcinoma(n=1),carcinoma of ampulla of Vater(n=1),carcinoma of extrahepatic bile duct(n=1),metastasis of renal cell carcinoma(n=1),and duodenal carcinoma(n=1).Pancreaticojejunal anastomoses using this technique were all watertight during the surgical procedure.The mean diameter of main pancreatic duct was 3.4 mm(range 2-7 mm).Three patients were recognized as having an amylase level greater than 3 times the serum amylase level,but all of them were diagnosed as grade A postoperative pancreatic fistula grading and required no treatment.None of the cases developed complications such as hemorrhage,abdominal abscess,and pulmonary infection.There was no postoperative mortality.CONCLUSION:Our technique is less complicated than other methods and very secure,providing reliable anastomosis for any size of pancreatic duct.

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.

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.

改良Kakita胰肠吻合技术在胰十二指肠切除术中的应用

目的探讨改良Kakita胰肠吻合技术(pancreaticojejunostomy,PJ)在胰十二指肠切除术(pancreaticoduodenectomy,PD)中的应用效果。方法选取2018年5月至2022年6月期间于武汉大学中南医院等5家医院采用改良Kakita PJ进行PD的病人,其中将153例行开腹PJ的病人分为A组,将110例行微创PJ的病人分为B组。A组包括135例开腹胰十二指肠切除术,13例微创PD中转开腹以及5例微创PD小切口吻合病人;B组包括87例腹腔镜下胰十二指肠切除术以及23例机器人辅助胰十二指肠切除术病人。回顾性分析两组病人的围术期临床资料。结果263例PD均顺利完成。(1)A组:PJ时间中位数为9 min(7~15 min),术中出血量中位数为200 mL(50~1000 mL),18例(11.8%)术后并发症Clavien-Dindo分级≥3级,B、C级胰瘘14例(9.2%),胆漏8例(5.2%),B、C级腹腔内出血13例(8.5%),消化道出血1例(0.7%),腹腔内感染14例(9.2%),术后30 d内再次手术者8例(5.2%),术后90 d内死亡2例(1.3%),死亡病例均由胰瘘引起。(2)B组:PJ时间中位数为17 min(12~25 min),术中出血量中位数为60 mL(10~250 mL),7例(6.4%)术后并发症Clavien-Dindo分级≥3级,B、C级胰瘘5例(4.6%),胆漏5例(4.6%),B、C级腹腔内出血3例(2.7%),消化道出血1例(0.9%),腹腔内感染9例(8.2%),术后30 d内再次手术者3例(2.7%),术后90 d内死亡者1例(0.9%),死亡病例与胰瘘无关。结论改良Kakita PJ操作简便,易于开展,可在开腹以及微创PD中安全实施。

胰肠吻合及其改良对于术后胰瘘影响的研究现状

胰十二指肠切除术被认为是治疗十二指肠、远端胆管和胰头良恶性病变最有效的方式。术后胰瘘会对病人的生存率、预后造成重大影响。胰肠吻合作为术后胰瘘的危险因素之一,学者们从吻合方式、辅助材料等多方面进行改进,试图最大程度地降低术后胰瘘的发生。此文就胰肠吻合及其改良对于术后胰瘘的影响做一综述,为进一步降低术后胰瘘发生率提供相关理论借鉴。

机器人胰十二指肠切除术:手术步骤及技术要领

机器人微创化的发展一直是学科焦点,胰十二指肠切除术因其风险高、难度大而被誉为外科手术的“珠穆朗玛峰”。标准化的手术步骤和简单易行的操作技巧有助于机器人胰十二指肠切除术(robotic pancreaticoduodenectomy,RPD)的推广应用。本文结合中国人民解放军总医院第一医学中心大量RPD实操经验,将RPD归纳总结为18个手术步骤,并对环血管切除技术、重建吻合技术进行要点解析,以期推动机器人在胰腺外科的深入应用,促进RPD规范和应用标准的进一步建立。