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.

Considerations on pancreatic exocrine function after pancreaticoduodenectomy

The pancreaticoduodenectomy(PD) procedure may lead to pancreatic exocrine and endocrine insufficiency.There are several types of reconstruction for this kind of operation.Pancreaticogastrostomy(PG) was introduced to reduce the rate of postoperative pancreatic fistula.Although some randomized control trials have shown no differences regarding pancreatic leakage between PG and pancreaticojejunostomy(PJ),recently some reports reveal benefits from the PG over the PJ.Some surgeons concern about the performing of the PG and inactivation of pancreatic enzymes being in contact with the gastric juice,and the detrimental results over the exocrine pancreatic function.The pancreatic exocrine function can be measured with direct and indirect tests.Direct tests have the highest sensitivity and specificity for detection of exocrine insufficiency but require tube placement.Among the tubeless indirect tests,the van de Kamer stool fat analysis remains the standard to diagnose fat malabsorption.The patient compliance and time consuming makes it not so suitable for its clinical use.Fecal immunoreactive elastase test is employed for screening of exocrine insufficiency,is not cumbersome,and has been used to study pancreatic function after resection.We analyze the FE1 levels in our patients after the PD with two types of reconstruction,PG and PJ,and we discuss some considerations about the pancreaticointestinal drainage method after pancreaticoduodenectomy.

Autoimmune pancreatitis: Functional and morphological recovery after steroid therapy

Autoimmune pancreatitis, a recently recognized type of chronic pancreatitis, is not rare in Japan, but reports of it elsewhere are relatively uncommon. We report the first preoperatively diagnosed case of autoimmune pancreatitis in Hungary, which responded well to steroid treatment and provided radiographic and functional evidence of this improvement. A 62-year-old female presented with a 4-month history of recurrent epigastric pain and a 5-kg weight loss. The oral glucose tolerance test （OGTT） indicated diabetes mellitus and the result of the fecal elastase test was abnormal. Ultrasonography （US） and the CT scan demonstrated a diffusely enlarged pancreas, and endoscopic retrograde cholangiopancreatography （ERCP） an irregular main pancreatic duct with long strictures in the head and tail. Autoimmune pancreatitis was diagnosed. The patient was started on 32 mg prednisolone daily, After 4 wk, the OGTT and faecal elastase test results had normalized. The repeated US and CT scan revealed a marked improvement of the diffuse pancreatic swelling, while on repeated ERCP, the main pancreatic duct narrowing was seen to be ameliorated. It is important to be aware of this disease and its diagnosis, because AIP can clinically resemble pancreatobiliary malignancies, or chronic or acute pancreatitis, However, in contrast with chronic pancreatitis, its symptoms and morphologic and laboratory alterations are completely reversed by oral steroid therapy.