Reconstruction after pancreatoduodenectomy:Pancreatojejunostomy vs pancreatogastrostomy

Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy(PD) in order to decrease postoperative complications,mainly pancreatic fistulas(PF).In this work,we compare the two most frequent techniques of reconstruction after PD,pancreatojejunostomy(PJ) and pancreatogastrostomy(PG),in order to determine which of the two is better.A systematic review of the literature was performed,including major meta-analysis articles,clinical randomized trials,systematic reviews,and retrospective studies.A total of 64 articles were finally included.PJ and PG are usually responsible for most of the postoperative morbidity,mainly due to the onset of PF,being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia.The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG.PF,delayed gastric emptying and mortality were not different.Although there was heterogeneity between these studies,all were conducted in specialized centers by highly experienced surgeons,and the surgical care was likely to be similar for all the studies.The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa.Exocrine function appears to be worse after PG than after PJ,resulting in severe atrophic changes in the remnant pancreas.Depending on the type of PJ or PG used,the PF rate and other complications can also be different.The best method to deal with the pancreatic stump after PD remains questionable.The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles such as good exposure and visualization.In conclusion,up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD.

The reconstruction after pylorus preserving pancreatoduodenectomy: pancreatogastrostomy with Roux-en-Y reconstruction versus conventional Traverso type reconstruction

Objective: To compare the result of pancreatogastrostomy (PG) with Roux-en-Y reconstruction versus pancreatojejunostomy (PJ) with conventional Traverso-type reconstruction following pylorus-preserving pancreatectomy (PP- PD) in a retrospective study. PPPD has been accepted as a radical surgical treatment for malignant periampullary neoplasms. However, the reconstruction of this surgery is technically complicated. The leakage of pancreatic juice and the delayed gastric emptying are the major complications of PPPD and may be fatal. To solve these problems, we have performed PG with Roux-en-Y anastomosis. There are several techniques proposed the reconstruction after PPPD, however there have been no previous study describing the result of PG with Roux- en-Y anastomosis. Since 2002 we have perfor- med 32 cases of PPPD. They were divided into two groups according to the reconstruction procedures: PG with Roux-en-Y reconstruction (group PG-RY) (17 cases) and pancreatojejunostomy with Traverso-type reconstruction (group PJ-T) (15 cases). Results: Patient age, gender, and underlying disease were comparable among the groups. Two groups showed no differences in intraoperative bleeding amount, and the time of surgery. The occurrence of the pancreatic leakage was significantly reduced in the group PG-RY compared with the group PJ-T. There was no case of the delayed gastric emptying in the group PGRY. Conclusions: Pancreatogastrosotmy with Roux-en-Y anastomosis can reduce the occurrence of the pancreatic leakage and delayed gastric emptying following pylorus-preserving pancreatoduodenectomy.

Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.

Pancreatic Anastomosis Healing

Background: Pancreatoduodenectomy (PD) is a complex procedure with a relatively high risk of complications. There is an increasing trend showing that the success of pancreato-enteral anastomosis depends on surgical skill and the material used. Methods: We present four cases of pancreato-enteral anastomosis resected 37 - 114 days after primary surgery and the analysis of the healing process, i.e., morphology of the pancreatic parenchyma, pancreatic duct, and digestive tract mucosa, as well as the pancreatic reaction to the sewing material by microscopic morphometry. Results: Evidence of regeneration in the columnar-lined mucosa of main pancreatic ducts in all cases of pancreato-enterostomy was observed. The inflammatory foreign-body reaction around monofilament stitch was present without an evident infection. There were no microscopic signs of pancreatic duct damage. Total foreign body reaction varied between 138.1 μm and 207.3 μm. Conclusions: This observation supports the beneficial use of thin monofilament threads for pancreato-enteral anastomosis. There was no evidence of harmful action from gastric or intestinal juices on pancreatic remnant or the Wirsung duct.