Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy:A review of the literature and critical reappraisal of the implicated pathomechanism

Pylorus-preserving pancreaticoduodenectomy （PPPD） is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying （DGE） comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/IVledline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy （PD） vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported （but not yet tested in largescale studies） modification, that is, PPPD with antecolic duodenojejunostomy.

Use of isolated Roux loop for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy

AIM: To evaluate the efficacy of the isolated Roux loop technique in decreasing the frequency of pancreaticojejunal anastomosis failure. METHODS: We retrospectively reviewed 88 consecutive patients who underwent pancreaticoduodenectomy (standard or pylorus-preserving). Single jejunal loop was used in 42 patients (SL group) while isolated Roux loop was used in 46 patients (RL group). Demographic characteristics (age, gender) and perioperative results (major/minor complications, mortality, hospital stay) were compared between the two groups. RESULTS: Mortality was almost equal in both groups and overall mortality was 2.27%. Leak rate from the pancreaticojejunal anastomosis and hospital stay were lower in the RL group without significant difference. Morbidity was 39.1% in the RL group, insignificantly higherthan the SL group. Operative time was almost 30 min longer in the RL group. CONCLUSION: The isolated Roux loop, although an equally safe alternative, does not present advantages over the traditional use of a single jejunal loop. Randomized controlled studies are required to further clarify its efficacy.

Laparoscopic pancreaticoduodenectomy: a descriptive and comparative review

Laparoscopic pancreaticoduodenectomy（LPD） is an extremely challenging surgery. First described in 1994, it has been slow to gain in popularity. Recently, however, we have seen an increase in the number of centers performing this operation, including our own institution, as well as an increase in the quantity of published data. The purpose of this review is to describe the current status of LPD as described in the literature. We performed a literature search in the Pub Med database using Me SH terms ＂laparoscopy＂ and ＂pancreaticoduodenectomy＂. We then identified articles in the English language with over 20 patients that focused on LPD only. Review articles were excluded and only one article per institution was used for descriptive analysis in order to avoid overlap. There were a total of eight articles meeting review criteria, consisting of 492 patients. On descriptive analysis we found that percent of LPD due to high-grade malignancy averaged 47% over all articles. Average operative time was 452 minutes, blood loss 369 cc＇s, pancreatic leak rate 15%, delayed gastric emptying 8.6%, length of hospital stay 9.4 days, and short term mortality 2.3%. Comparison studies between open pancreaticoduodenectomy（OPD） and LPD suggested decreased blood loss, longer operative time, similar post-operative complication rate, decreased pain, and shorter hospital length of stay for LPD. There was also increased number of lymph nodes harvested and similar margin free resections with LPD in the majority of studies. LPD is a safe surgery, providing many of the advantages typically associated with laparoscopic procedures. We expect this operation to continue to gain in popularity as well as be offered in increasingly more complex cases. In future studies, it will be beneficial to look further at the oncologic outcome data of LPD including survival.

Is bactibilia a predictor of poor outcome of pancreaticoduodenectomy?

BACKGROUND:Although bile infection has been proposed to increase infective complications following pancreaticoduodenectomy,its association with infective complications and non-infective complications like pancreatic fistula is still controversial.METHODS:Seventy-six patients who had undergone pancreaticoduodenectomy between July 2007 and December 2008 were included in a prospective database and their data analyzed.In all patients intraoperative bile from the bile duct was cultured.Preoperative,intra-operative,and post-operative variables were recorded and analyzed.RESULTS:Bile culture showed positive growth in 35 patients and negative growth in 41.Twenty patients in the positive group underwent ERCP and stenting.The patients with a positive bile culture had a higher incidence of infective complications including intra-abdominal abscess (n=8),wound infection (n=27),bacteremia (n=10),and renal insufficiency (n=9).There was no increase in the rate of non-infective complications of pancreaticoduodenectomy including pancreatic fistula (n=7),delayed gastric emptying (n=9),and post-operative hemorrhage (n=3).The hospital stay was significantly prolonged in the patients with a positive bile culture (P=0.0002).CONCLUSIONS:Pre-operative biliary drainage is significantly associated with bile infection,and bile infection increases the overall rates of infective complications and renal insufficiency.Because of the high incidence of complications is associated with infected bile,routine intra-operative bile culture is recommended in patients undergoing pancreaticoduodenectomy.Pre-operative prophylaxis is dependent on sensitivity of cases to perioperative antibiotics and intraoperative bile culture report.Because of its significant association with infected bile,biliary stenting should be used in strictly selected cases.

Pancreatic cancer surgery: past, present, and future

The history of pancreatic cancer surgery, though fraught with failure and setbacks, is punctuated by periods of incremental progress dependent upon the state of the art and the mettle of the surgeons daring enough to attempt it. Surgical anesthesia and the aseptic techniques developed during the latter half of the 19 th century were instrumental in establishing a viable setting for pancreatic surgery to develop. Together, they allowed for bolder interventions and improved survival through the postoperative period. Surgical management began with palliative procedures to address biliary obstruction in advanced disease. By the turn of the century, surgical pioneers such as Alessandro Codivilla and Walther Kausch were demonstrating the technical feasibility of pancreatic head resections and applying principles learned from palliation to perform complicated anatomical reconstructions. Allen O. Whipple, the namesake of the pancreaticoduodenectomy（PD）, was the first to take a systematic approach to refining the procedure. Perhaps his greatest contribution was sparking a renewed interest in the surgical management of periampullary cancers and engendering a community of surgeons who advanced the field through their collective efforts. Though the work of Whipple and his contemporaries legitimized PD as an accepted surgical option, it was the establishment of high-volume centers of excellence and a multidisciplinary approach in the later decades of the 20^th century that made it a viable surgical option. Today, pancreatic surgeons are experimenting with minimally invasive surgical techniques, expanding indications for resection, and investigating new methods for screening and early detection. In the future, the effective management of pancreatic cancer will depend upon our ability to reliably detect the earliest cancers and precursor lesions to allow for truly curative resections.