Risk factors of pancreatic leakage after pancreaticoduodenectomy

AIM: To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage. METHODS: Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage. RESULTS: Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) devel-oped postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical signific-ance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P= 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy. CONCLUSION: Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.

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.

Choice of operative method for pancreaticojejunostomy and a multivariable study of pancreatic leakage in pancreaticoduodenectomy

BACKGROUND As one of the major abdominal operations,pancreaticoduodenectomy(PD)involves many organs.The operation is complex,and the scope of the operation is large,which can cause significant trauma in patients.The operation has a high rate of complications.Pancreatic leakage is the main complication after PD.When pancreatic leakage occurs after PD,it can often lead to abdominal bleeding and infection,threatening the lives of patients.One study found that pancreatic leakage was affected by many factors including the choice of pancreaticojejunostomy method which can be well controlled.AIM To investigate the choice of operative methods for pancreaticojejunostomy and to conduct a multivariate study of pancreatic leakage in PD.METHODS A total of 420 patients undergoing PD in our hospital from January 2014 to March 2019 were enrolled and divided into group A(n=198)and group B(n=222)according to the pancreatointestinal anastomosis method adopted during the operation.Duct-to-mucosa pancreatojejunostomy was performed in group A and bundled pancreaticojejunostomy was performed in group B.The operation time,intraoperative blood loss,and pancreatic leakage of the two groups were assessed.The occurrence of pancreatic leakage after the operation in different patients was analyzed.RESULTS The differences in operative time and intraoperative bleeding between groups A and B were not significant(P>0.05).In group A,the time of pancreatojejunostomy was 26.03±4.40 min and pancreatic duct diameter was 3.90±1.10 mm.These measurements were significantly higher than those in group B(P<0.05).The differences in the occurrence of pancreatic leakage,abdominal infection,abdominal hemorrhage and gastric retention between group A and group B were not significant(P>0.05).The rates of pancreatic leakage in patients with preoperative albumin<30 g/L,preoperative jaundice time≥8 wk,and pancreatic duct diameter<3 mm,were 23.33%,33.96%,and 19.01%,respectively.These were significantly higher than those in patients with preoperative albumin≥30 g/L,preoperative jaundice time<8 wk,and pancreatic duct diameter≥3 cm(P<0.05).Logistic regression analysis showed that preoperative albumin<30 g/L,preoperative jaundice time≥8 wk,and pancreatic duct diameter<3 mm were risk factors for pancreatic leakage after PD(odds ratio=2.038,2.416 and 2.670,P<0.05).CONCLUSION The pancreatointestinal anastomosis method during PD has no significant effect on the occurrence of pancreatic leakage.The main risk factors for pancreatic leakage include preoperative albumin,preoperative jaundice time,and pancreatic duct diameter.

Risk factors affecting pancreatic fistulas after pancreaticoduodenectomy

AIM: To analyze the risk factors of pancreatic leakage after pancreaticoduodenectomy.METHODS: We retrospectively reviewed 172 consecutive patients who had undergone pancreatico-duodenectomy at Inha University Hospital between April 1996 and March 2006. We analyzed the pancreatic fistula rate according to the clinical characteristics, the pathologic and laboratory findings, and the anastomotic methods.RESULTS: The incidence of developing pancreatic fistulas in patients older than 60 years of age was 21.7% (25/115), while the incidence was 8.8% (5/57) for younger patients; the difference was significant (P = 0.03). Patients with a dilated pancreatic duct had a lower rate of post-operative pancreatic fistulas than patients with a non-dilated duct (P = 0.001). Other factors, including clinical features, anastomotic methods, and pathologic diagnosis, did not show any statistical difference. CONCLUSION: Our study demonstrated that pancreatic fistulas are related to age and a dilated pancreatic duct. The surgeon must take these risk factors into consideration when performing a pancre-aticoduodenectomy.

Polypropylene mesh-reinforced pancreaticojejunostomy for periampullar neoplasm

AIM： To evaluate the effect of polypropylene mesh- reinforced pancreatojejunostomy on pancreatic leakage. METHODS： Seventeen consecutive patients with paraampullar malignancy received polyprolene meshreinforced pancreatodudeonectomy and the Child＇s method was used to rebuild the alimentary tract. RESULTS： The mean time of polyprolene mesh-reinforced pancreatojejunostomy was 22 rain. Anastomosis could endure 30-500 cm H20 pressure during operation. All patients recovered without pancreatic leakage. CONCLUSION： Polyprolene mesh-reinforced pancreatojejunostomy is a feasible and reliable procedure to prevent pancreatic leakage.

Novel and supplementary management of pancreatic fluid collections:Endoscopic ultrasound-guided drainage

AIM To compare efficacy and safety of endoscopic ultrasound (EUS)-guided and surgical drainage in pancreatic fluid collection management.METHODS Data were obtained retrospectively from January 2012 to December 2016.Patients with pancreatic fluid collection were performed EUS-guided or surgical procedure.Main outcome measures including clinical efficiency,complication,duration of procedures,hospital stay and cost were analyzed.RESULTS Thirty-six patients were enrolled into the study,including 14 in endoscopic group while 22 in the surgical group.Twelve (86%) patients were treated successfully by endoscopic approach while 21 (95%) patients benefited through surgical procedure.Endoscopic treatment had higher recurrence and complication rates than surgery,resulting in more re-interventions.Meanwhile,duration of procedure,hospital stay and cost were significantly lower in endoscopic group.CONCLUSION Both approaches were effective and safe.EUS-guided approach should be the first-line treatment in mild and simple cases,while surgical approach should be considered as priority in severe and complex cases.