Preoperative pancreatic duct stenting in patients undergoing laparoscopic pancreatic surgery – a preliminary report

AbstractLaparoscopic surgery is becoming an approved technique in pancreatic surgery. It offers some advantages over an open approach due to shorter hospital stay and decreased complication rate. Regardless the technique the most significant problem of pancreatic surgery is postoperative pancreatic fistula. There are numerous methods attempted at reduction of its incidence. One of the possibilities is preoperative pancreatic duct stenting. It aims at decreasing the pressure in the pancreatic duct, which is supposed to facilitate pancreatic juice flow to the duodenum.The aim of the study was to determine the role of preoperative pancreatic duct stenting in pancreatic surgery.Material and methods. Nineteen patients undergoing laparoscopic pancreatic resection were enrolled into the study. Prior to the surgery, all of the patients were submitted for the Endoscopic Retrograde Choleangiopancreatography (ERCP) with pancreatic duct stenting. Following the subsequent laparoscopic pancreatic resection, all patients were monitored to detect the pancreatic fistula appearance. The pancreatic stent was removed 6‑8 weeks after the surgery.Results. With an exception of two patients, all other patients underwent successful ERCP with pancreatic duct stenting before the surgery. In one case the placement of the prosthesis failed due to a tortuous pancreatic duct. Five patients had an episode of acute pancreatitis including two severe courses as a complication of preoperative ERCP. One of the patient died due to severe GI bleeding 2 weeks after stenting. Among the procedures there were 15 distal pancreatectomies, two enucleations of the tumor localized in the uncinate process and in the body of the pancreas and one central pancreatectomy. The median time of surgery duration was 186 minutes (90‑300; ±56). No conversions to an open approach were necessary. Likewise, there was neither any major complications reported in a postoperative course nor incidence of pancreatic fistula in any of the patients undergoing surgery.Conclusions. Preoperative pancreatic duct stenting can decrease the incidence of pancreatic fistula. However, a number of serious complications exceed the potential benefit of this method.

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Robotic pancreatic resection. Personal experience with 105 cases

Revista do Colégio Brasileiro de Cirurgiões ◽

10.1590/0100-6991e-20202501 ◽

2020 ◽

Vol 47 ◽

Author(s):

MARCEL AUTRAN CESAR MACHADO ◽

MURILLO M LOBO FILHO ◽

BRUNO H MATTOS ◽

JOSÉ CELSO ARDENGH ◽

FÁBIO FERRARI MAKDISSI

Keyword(s):

Minimally Invasive ◽

Pancreatic Fistula ◽

Pancreatic Resection ◽

Pancreatic Surgery ◽

Uncinate Process ◽

Central Pancreatectomy ◽

Endocrine Insufficiency ◽

Resection Of The Pancreas ◽

Minimally Invasive Pancreatic Surgery ◽

Robotic Resection

ABSTRACT Objective: the first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, a new policy prompted us to systematically employ the robot in all minimally invasive pancreatic surgery. The aim of this paper is to review our experience with robotic pancreatic resection. Methods: all patients who underwent robotic pancreatic resection from March 2018 through December 2019 were identified. Descriptive data were collected. Preoperative variables included age, sex, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. Results: 105 patients underwent robotic pancreatectomy. Median age was 60.5 years old. Fifty-five patients were female. 51 patients underwent robotic pancreatoduodenectomies, 34 distal pancreatectomy. Morbidity was 23.8%, mainly related to postoperative pancreatic fistula and one death occurred (mortality of 0.9%). Three patients (2.8%) were converted to open surgery. Four patients had delayed gastric emptying and two presented bleeding. Twenty-four patients had pancreatic fistula that was treated conservatively with late removal of the pancreatic drain. No patient required percutaneous drainage, reintervention or hospital readmission. Conclusions: the robotic platform is useful for the reconstruction of the alimentary tract after pancreatoduodenectomy or after central pancreatectomy. It may increase the preservation of the spleen during distal pancreatectomies. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency. Robotic resection of the pancreas is safe and feasible for selected patients. It should be performed in specialized centers by surgeons with experience in both open and minimally invasive pancreatic surgery.

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Pancreatic fistulae following pancreatic resection. Analysis of causes and prevention methods

Reports of Vinnytsia National Medical University ◽

10.31393/reports-vnmedical-2018-22(4)-11 ◽

2018 ◽

Vol 22 (4) ◽

pp. 640-646

Author(s):

K.G. Valikhnovska

Keyword(s):

Risk Factors ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Pancreatic Resection ◽

Pancreatic Head ◽

Preoperative Period ◽

External Drainage ◽

Distal Pancreatic Resection ◽

Glycemic Level ◽

Prevention Methods

The causes of pancreatic fistula were analyzed in 503 patients aged from 22 to 81who underwent pancreaticoduodenectomy for pancreatic and periampullary tumors. The said patients were operated on during the period from 2008 to 2017. The aim of this study is to improve the outcomes of pancreatic resection based on a retrospective analysis of the risk factors of postoperative pancreatic fistulae and the development of a range of measures to prevent the above complication. The influence of factors on the risk of pancreatic fistula was investigated by Pearson method (χ2). The factors contributing to the occurrence of pancreatic fistulae included type of resection (Whipple pancreaticoduodenectomy, pylorus preserving pancreaticoduodenectomy; χ2=8.616,1, p=0.0033, p<0.01), kind of pathology (cancer of the pancreatic head, χ2=7.658,1, p=0.0057, p<0.01), type of pancreaticojejunostomy (invaginative pancreatic duct-jejunostomy; χ2=12.75,1, p<0.001), technique for drainage of the major pancreatic duct (pancreaticojejunostomy on external drainage, χ2=44.01,1, p<0.0001), resection of venous vessels following distal pancreatic resection (χ2=8.350,1, p=0.0039, p<0.01), glycemic level in the preoperative period (P=0.0344,U=15061), the presence of concomitant diseases in patients (χ2=15.62,1, p=0.0001, p<0.001). Preoperative glycemic level and the presence of concomitant diseases in patients are factors that can be influenced to prevent the onset of pancreatic fistula in the postoperative period in patients who are scheduled for pancreatic resection. Prevention of this complication involves the correction of glycemic level and treatment of concomitant pathology in patients in the preoperative period.

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Internal pancreatic duct stent does not decrease pancreatic fistula rate after pancreatic resection: a meta-analysis

The American Journal of Surgery ◽

10.1016/j.amjsurg.2012.07.039 ◽

2013 ◽

Vol 205 (6) ◽

pp. 718-725 ◽

Cited By ~ 29

Author(s):

Yu Zhou ◽

Quanbo Zhou ◽

Zhihua Li ◽

Rufu Chen

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Pancreatic Resection ◽

Meta Analysis ◽

Pancreatic Duct Stent ◽

Fistula Rate ◽

Pancreatic Fistula Rate

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LAPAROSCOPIC PANCREATIC RESECTION. FROM ENUCLEATION TO PANCREATODUODENECTOMY. 11-YEAR EXPERIENCE

Arquivos de Gastroenterologia ◽

10.1590/s0004-28032013000200038 ◽

2013 ◽

Vol 50 (3) ◽

pp. 214-218 ◽

Cited By ~ 13

Author(s):

Marcel Autran Cesar MACHADO ◽

Rodrigo Canada Trofo SURJAN ◽

Suzan Menasce GOLDMAN ◽

Jose Celso ARDENGH ◽

Fabio Ferrari MAKDISSI

Keyword(s):

Blood Transfusion ◽

Pancreatic Resection ◽

Operative Time ◽

Uncinate Process ◽

Central Pancreatectomy ◽

Endocrine Insufficiency ◽

Laparoscopic Pancreatoduodenectomy ◽

Laparoscopic Pancreatic Resection ◽

Resection Of The Pancreas ◽

Totally Laparoscopic

Context Our experience with laparoscopic pancreatic resection began in 2001. During initial experience, laparoscopy was reserved for selected cases. With increasing experience more complex laparoscopic procedures such as central pancreatectomy and pancreatoduodenectomies were performed. Objectives The aim of this paper is to review our personal experience with laparoscopic pancreatic resection over 11-year period. Methods All patients who underwent laparoscopic pancreatic resection from 2001 through 2012 were reviewed. Preoperative data included age, gender, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. Diagnosis, tumor size, margin status were determined from final pathology reports. Results Since 2001, 96 patients underwent laparoscopic pancreatectomy. Median age was 55 years old. 60 patients were female and 36 male. Of these, 88 (91.6%) were performed totally laparoscopic; 4 (4.2%) needed hand-assistance, 1 robotic assistance. Three patients were converted. Four patients needed blood transfusion. Operative time varied according type of operation. Mortality was nil but morbidity was high, mainly due to pancreatic fistula (28.1%). Sixty-one patients underwent distal pancreatectomy, 18 underwent pancreatic enucleation, 7 pylorus-preserving pancreatoduodenectomies, 5 uncinate process resection, 3 central and 2 total pancreatectomies. Conclusions Laparoscopic resection of the pancreas is a reality. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency that could be detrimental to the patient's quality of life. Laparoscopic pancreatoduodenectomy is a safe operation but should be performed in specialized centers by highly skilled laparoscopic surgeons.

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Pancreaticogastrostomy Prevents Postoperative Pancreatic Fistula of Portal Annular Pancreas During Pancreaticoduodenectomy

International Surgery ◽

10.9738/intsurg-d-16-00044.1 ◽

2016 ◽

Vol 101 (11-12) ◽

pp. 550-553

Author(s):

Ippei Matsumoto ◽

Keiko Kamei ◽

Shumpei Satoi ◽

Takuya Nakai ◽

Yoshifumi Takeyama

Keyword(s):

Portal Vein ◽

Pancreatic Fistula ◽

Dorsal Surface ◽

Uncinate Process ◽

Postoperative Pancreatic Fistula ◽

The Body ◽

Annular Pancreas ◽

Exocrine Function ◽

Portal Annular Pancreas ◽

Increased Risk

Portal annular pancreas (PAP) is an asymptomatic congenital pancreatic anomaly in which the uncinate process of the pancreas extends and fuses to the dorsal surface of the body of the pancreas by surrounding the portal vein and or the superior mesenteric vein. During pancreaticoduonectomy (PD), the presence of PAP significantly increased risk for postoperative pancreatic fistula (POPF) because specific management of 2 pancreatic resection planes with 1 or 2 pancreatic ducts is required for pancreatico-intestinal reconstruction. To reduce the risk of POPF, a shift of the resection plain to the left for 1 anastomosis is recommended. We report a case of PAP that was successfully performed PD with pancreaticogastrostomy (PG). PG was conducted with invagination of the 2 resected pancreatic planes together into the stomach to minimize resected volume of the pancreas. A 78-year-old male patient with PAP underwent PD due to a duodenal adenocarcinoma. Intraoperatively, the uncinate process extended extensively behind the portal vein and fused with the dorsal surface of the pancreatic body above the splenic vein. For pancreatico-intestinal reconstruction, PG was performed with invagination of the 2 resected pancreatic planes together into the stomach. The postoperative course was uneventful, and he was discharged on postoperative day 12. Endocrine and exocrine function of the pancreas were maintained well at 10 months after surgery. PG is one of the useful choices for patients with PAP to prevent POPF while maintaining the pancreatic endocrine and exocrine function after PD.

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A case of treatment of pancreatic fistula after distal pancreatectomy for pancreatic-tail cancer with pancreas divisum by endoscopic transampullary pancreatic duct stenting

Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association) ◽

10.3919/jjsa.73.2657 ◽

2012 ◽

Vol 73 (10) ◽

pp. 2657-2662

Author(s):

Tatsuya ORIMO ◽

Shirou NAKANO ◽

Mitsuhiro INAGAKI ◽

Hiromitsu AKABANE ◽

Naoyuki YANAGIDA ◽

...

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Distal Pancreatectomy ◽

Pancreas Divisum ◽

Pancreatic Tail ◽

Pancreatic Duct Stenting ◽

Pancréas Divisum

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Validation of Mucosal Sutureless Pancreatojejunostomy after Pancreatoduodenectomy

The American Surgeon ◽

10.1177/000313481408000222 ◽

2014 ◽

Vol 80 (2) ◽

pp. 149-154 ◽

Cited By ~ 1

Author(s):

Yoichi Ishizaki ◽

Jiro Yoshimoto ◽

Hiroyuki Sugo ◽

Hiroshi Imamura ◽

Seiji Kawasaki

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Postoperative Mortality ◽

International Study ◽

Study Group ◽

International Study Group ◽

Duct Diameter ◽

Pancreatic Duct Stenting ◽

Clinically Significant ◽

Low Rate

Although duct-to-mucosa pancreatojejunostomy has been considered safer than other techniques, this procedure is particularly difficult when the pancreatic duct is small. It has therefore become increasingly necessary to develop a simple mucosal sutureless pancreatojejunostomy technique to replace the conventional hand-sewing one. Two hundred fourteen patients who underwent mucosal sutureless pancreatojejunostomy were classified into two groups: those with a normal pancreatic duct diameter (less than 3 mm, n = 97) and those with a dilated pancreatic duct (3 mm or greater, n = 117). The rate of clinically significant pancreatic fistula (Grade B or C by the International Study Group on Pancreatic Fistula definition) among the patients as a whole was 8 per cent. The overall incidence of pancreatic fistula was significantly higher in the patients with a pancreatic duct diameter of less than 3 mm than in those with a pancreatic duct diameter of 3 mm or greater. However, the incidence of clinically significant pancreatic fistula did not differ between the groups (less than 3 mm, 11%; 3 mm or greater, 5%; P = 0.09). Grade C pancreatic fistula developed in one patient with a pancreatic duct diameter of less than 3 mm and in two with a pancreatic duct diameter 3 mm or greater. Although two patients required reoperation, all of the fistulas were cured and the postoperative mortality rate related to pancreatoduodenectomy was zero. Mucosal sutureless pancreatojejunostomy combined with pancreatic duct stenting is associated with a low rate of clinically significant pancreatic fistula even in patients with a small pancreatic duct diameter less than 3 mm.

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