External Negative Pressure Drainage of the Pancreatic Duct in Pancreatogastrostomy Following Pylorus-Preserving Pancreaticoduodenectomy—Feasibility and Technique

Background: Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreaticoduodenectomy. There is no consensus on the best technique to protect the pancreato-enteric anastomosis and reduce the rate of POPF. This study investigated the feasibility and efficiency of external suction drainage of the pancreatic duct to improve the healing of pancreaticogastrostomy.Methods: Between July 2019 and June 2021, 21 consecutive patients undergoing elective pancreaticoduodenectomy were included. In all patients we performed a pancreaticogastrostomy and inserted a negative pressure drainage into the pancreatic duct. The length and diameter of the pancreatic duct were measured and the texture of the pancreas was evaluated. The daily secretion volume and the lipase value via pancreatic duct drainage were documented. The occurrence of POPF was evaluated.Results: None of the patients had drainage-related complications. In 4 patients we registered a dislocation of the drainage from the pancreas duct into the stomach. 17/21 Patients showed no signs of POPF. A biochemical leak was measured in one patient. Furthermore, 2 patients had a POPF grade B. In one patient, POPF grade C required reoperation and resection of the remnant pancreas. All 4 cases of POPF met the risk criteria soft pancreas, high volume and high lipase value in the duct drainage.Conclusion: The insertion of the pancreatic duct drainage was feasible and caused no drainage-related morbidity. POPF-rate was moderate in the risk population of soft pancreas and small duct.

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The efficacy of polyglycolic acid felt reinforcement in preventing postoperative pancreatic fistula after pancreaticojejunostomy in patients with main pancreatic duct less than 3 mm in diameter and soft pancreas undergoing pancreatoduodenectomy (PLANET-PJ trial): study protocol for a multicentre randomized phase III trial in Japan and Korea

Trials ◽

10.1186/s13063-019-3595-x ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Kazuto Shibuya ◽

Jin-Young Jang ◽

Sohei Satoi ◽

Masayuki Sho ◽

Suguru Yamada ◽

...

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Study Protocol ◽

Main Pancreatic Duct ◽

Polyglycolic Acid ◽

Postoperative Pancreatic Fistula ◽

Phase Iii ◽

Phase Iii Trial ◽

Soft Pancreas

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Comparison Between Dunking (Invagination) Pancreaticojejunoanastomosis and Double Layer Duct to Mucosa Anastomosis After Cephalic Duodenopancreatectomy-Whipple Procedure for Pancreatic Cephalic Carcinoma

PRILOZI ◽

10.2478/prilozi-2020-0044 ◽

2020 ◽

Vol 41 (3) ◽

pp. 39-47

Author(s):

Aleksandar Shumkovski ◽

Ljubomir Ognjenovic ◽

Stojan Gjoshev

Keyword(s):

Overall Survival ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Double Layer ◽

Main Pancreatic Duct ◽

Pancreatic Head ◽

Postoperative Pancreatic Fistula ◽

Postoperative Reflux ◽

Soft Pancreas ◽

Significant Difference

AbstractIntroduction: Pancreatic cancer is malignancy with poor prognosis for quality of life and overall survival. The incidence is variant, 7.7/100,000 in Europe, 7.6/100,000 in the USA, 2.2/100.000 in Africa. The only real benefit for cure is surgery, duodenopancreatectomy. The key points for this procedure are radicality, low morbidity and low mortality, the follow up and the expected overall survival. The benchmark of the procedure is the pancreaticojejunoanastomosis, with its main pitfall, postoperative pancreatic fistula B or C. Subsequently, the manner of creation of pancreaticojejunoanastomosis defines the safety, thus the postoperative morbidity and mortality. Finally, this issue remarkably depends on the surgeon and the surgical technique creating the anastomosis. We used 2 techniques with interrupted sutures, dunking anastomosis and duct-to-mucosa double layer technique. The objective of the study was to compare these 2 suturing techniques we applied, and the aim was to reveal the risk benefit rationale for dunking either duct to mucosa anastomosis.Material and method: In our last series of 25 patients suffering pancreatic head carcinoma we performed a standard dodenopancreatectomy. After the preoperative diagnosis and staging with US, CICT, tumor markers, they underwent surgery. Invagination-dunking anastomosis was performed in 15, whereas, duct-to-mucosa, double layer anastomosis was performed in 10. In the first group with dunking anastomosis, we had 6 patients with soft pancreas and 8 with narrow main pancreatic duct, less than 3 mm. In the duct-to-mucosa group there were 5 patients with soft pancreas and 4 with narrow main pancreatic duct. All other stages of surgery were unified, so the only difference in the procedure remained on the pancreatojejunoanastomosis. The onset of the postoperative pancreatic fistula was estimated with revelation of 3 fold serum level of alfa amylases from the third postoperative day in the drain liquid.Results: In the duct to mucosa group there wasn’t a clinically relevant postoperative pancreatic fistula, while in the dunking anastomosis group we had 4 postoperative pancreatic fistula B, 26 %. One of these 4 patients experienced intraabdominal collection – abscess, conservatively managed with lavation through the drain. Comparing the groups, there was no significant difference between the groups concerning the appearance of postoperative pancreatic fistula: p>0.05, p=0.125. From all 25 patients, in 21 patients biliary stent was installed preoperatively to resolve the preoperative jaundice. All 21 suffered preoperative and postoperative reflux cholangitis, extending the intra-hospital stay.Conclusion: So far, there have been many trials referring to opposite results while comparing these 2 techniques in creation of the pancreticojejunoanastomosis. In our study, the duct to mucosa anastomosis prevailed as a technique, proving its risk benefit rationale. However, further large randomized clinical studies have to be conducted to clarify which of these procedures would be the prime objective in the choice of the surgeon while creating pancreatojejunoanastomosis.

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Intermittent negative pressure external drainage of the pancreatic duct reduces pancreatic fistula after pancreaticojejunostomy in the patients with soft pancreas

Pancreatology ◽

10.1016/j.pan.2013.07.252 ◽

2013 ◽

Vol 13 (4) ◽

pp. S67

Author(s):

Noritaka Minagawa ◽

Toshihisa Tamura ◽

Yasuhisa Mori ◽

Norihiro Sato ◽

Kazunori Shibao ◽

...

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Negative Pressure ◽

External Drainage ◽

Soft Pancreas

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Laparoscopic pancreaticoduodenectomy reduces incidence of clinically relevant postoperative pancreatic fistula in soft pancreas with a smaller than 2 mm pancreatic duct

Surgical Endoscopy ◽

10.1007/s00464-020-08226-8 ◽

2021 ◽

Author(s):

Seung Soo Hong ◽

Jae Uk Chong ◽

Ho Kyoung Hwang ◽

Woo Jung Lee ◽

Chang Moo Kang

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Postoperative Pancreatic Fistula ◽

Laparoscopic Pancreaticoduodenectomy ◽

Soft Pancreas

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The Individualized Selection of Pancreaticoenteric Anastomosis in Pancreaticoduodenectomy

10.21203/rs.3.rs-30580/v1 ◽

2020 ◽

Author(s):

Ke-Min Jin ◽

Wei Liu ◽

Kun Wang ◽

Quan Bao ◽

Hong-Wei Wang ◽

...

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Operation Time ◽

Postoperative Management ◽

Postoperative Pancreatic Fistula ◽

Drainage Fluid ◽

Soft Pancreas ◽

Pancreatic Texture ◽

The Impact

Abstract Background: The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved. The present study aimed to clarify the impact of individualized pancreaticoenteric anastomosis and management to postoperative pancreatic fistula.Methods: Data from 529 consecutive pancreaticoduodenectomies were retrospectively analysed from the Hepatobiliary and Pancreatic Surgery Unit I, Peking Cancer Hospital. The pancreaticoenteric anastomosis was determined based on the pancreatic texture and diameter of the main pancreatic duct. The amylase value of the drainage fluid was dynamically monitored postoperatively on days 3, 5 and 7. A low speed intermittent irrigation was performed in selected patients. Intraoperative and postoperative results were collected and compared between the pancreaticogastrostomy (PG) group and pancreaticojejunostomy (PJ) group.Results: From 2010 to 2019, 529 consecutive patients underwent pancreaticoduodenectomy. Pancreaticogastrostomy was performed in 364 patients; pancreaticojejunostomy was performed in 150 patients respectively. The clinically relevant pancreatic fistula (CR-POPF) was 9.8% and mortality was zero. The soft pancreas, diameter of main pancreatic duct≤3mm, BMI≥25, operation time>330min and pancreaticogastrostomy was correlated with postoperative pancreatic fistula significantly. The CR-POPF of PJ was significantly higher than that of PG in soft pancreas patients; the operation time of PJ was shorter than that of PG significantly in hard pancreas patients. Intraoperative blood loss and operation time of PG was less than that of PJ significantly in normal pancreatic duct patients (p<0.05).Conclusions: Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and pancreatic duct diameter. The appropriate anastomosis and postoperative management could prevent mortality.

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Impact of a 7.5-Fr Pancreatic Stent for Preventing Pancreatic Fistula after Pancreaticoduodenectomy

Digestive Surgery ◽

10.1159/000520462 ◽

2021 ◽

Vol 38 (5-6) ◽

pp. 361-367

Author(s):

Tomohiro Iguchi ◽

Takashi Motomura ◽

Hideaki Uchiyama ◽

Norifumi Iseda ◽

Rintaro Yoshida ◽

...

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Postoperative Pancreatic Fistula ◽

Pancreatic Stent ◽

Factors Associated ◽

Soft Pancreas ◽

Pancreatic Duct Stent ◽

Pancreatic Texture ◽

Male Sex

Introduction: Pancreatic duct stents are widely used to reduce the incidence of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD); however, small stents may cause adverse effects, such as occlusion. Recently, we have tried placing a 7.5-Fr pancreatic duct stent to achieve more effective exocrine output from the pancreas; however, the association between pancreatic duct stent size and POPF remains unknown. Methods: Sixty-five patients with soft pancreatic texture who underwent PD were retrospectively analyzed. After dividing the pancreas, a pancreatic duct stent (stent size 4.0 in 29 patients, 5.0 in 18, and 7.5 Fr in 18) was placed in the main pancreatic duct. Results: Twenty-five of 65 patients with soft pancreatic texture (38.5%) developed POPF. POPF became less frequent as the pancreatic duct stent size increased (p = 0.003). The factors associated with POPF development were a 7.5-Fr pancreatic duct stent (p = 0.005), 5.0-Fr pancreatic duct stent (p = 0.031), and male sex (p = 0.008). Pancreatic duct stent size and pancreatic duct diameter did not differ between the POPF and non-POPF groups. Discussion/Conclusions: In patients with a soft pancreas, the placement of a 7.5-Fr pancreatic duct stent may reduce the incidence of POPF.

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Risk Factors for Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) after Distal Pancreatectomy: A Single Center Retrospective Study

Canadian Journal of Gastroenterology and Hepatology ◽

10.1155/2021/8874504 ◽

2021 ◽

Vol 2021 ◽

pp. 1-10

Author(s):

Gao Qing Wang ◽

Dipesh Kumar Yadav ◽

Wei Jiang ◽

Yong Fei Hua ◽

Cai De Lu

Keyword(s):

Risk Factors ◽

Retrospective Study ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Distal Pancreatectomy ◽

Main Pancreatic Duct ◽

Surgical Complication ◽

Univariate Analysis ◽

Postoperative Pancreatic Fistula ◽

Soft Pancreas

Objectives. Clinically relevant postoperative pancreatic fistula (CR-POPF) is the considerable contributor to major complications after pancreatectomy. The purpose of this study was to evaluate the potential risk factor contributing to CR-POPF following distal pancreatectomy (DP) and discuss the risk factors of pancreatic fistula in order to interpret the clinical importance. Methods. In this retrospective study, 263 patients who underwent DP at Ningbo Medical Center Li Huili Hospital between January 2011 and January 2020 were reviewed in accordance with relevant guidelines and regulations. Patients’ demographics and clinical parameters were evaluated using univariate and multivariate analyses to identify the risk factors contributing to CR-POPF. P < 0.05 was considered statistically significant. Results. In all of the 263 patients with DP, pancreatic fistula was the most common surgical complication (19.0%). The univariate analysis of 18 factors showed that the patients with a malignant tumor, soft pancreas, and patient without ligation of the main pancreatic duct were more likely to develop pancreatic fistula. However, on multivariate analysis, the soft texture of the pancreas (OR = 2.381, 95% CI = 1.271–4.460, P = 0.001 ) and the ligation of the main pancreatic duct (OR = 0.388, 95% CI = 0.207–0.726, P = 0.002 ) were only an independent influencing factor for CR-POPF. Conclusions. As a conclusion, pancreatic fistula was the most common surgical complication after DP. The soft texture of the pancreas and the absence of ligation of the main pancreatic duct can increase the risk of CR-POPF.

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Quantification of Pancreatic Stiffness on Intraoperative Ultrasound Elastography and Evaluation of its Relationship With Postoperative Pancreatic Fistula

International Surgery ◽

10.9738/intsurg-d-14-00040.1 ◽

2015 ◽

Vol 100 (3) ◽

pp. 497-502 ◽

Cited By ~ 19

Author(s):

Masahide Hatano ◽

Jota Watanabe ◽

Fumiki Kushihata ◽

Taiji Tohyama ◽

Taira Kuroda ◽

...

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Pancreatic Resection ◽

Main Pancreatic Duct ◽

Intraoperative Ultrasound ◽

Postoperative Pancreatic Fistula ◽

Ultrasound Elastography ◽

Exocrine Gland ◽

Soft Pancreas ◽

Elastic Ratio

“Soft pancreas” has often been reported as a predictive factor for postoperative pancreatic fistula (POPF) after pancreatectomy. However, pancreatic stiffness is judged subjectively by surgeons, without objective criteria. In the present study, pancreatic stiffness was quantified using intraoperative ultrasound elastography, and its relevance to POPF and histopathology was investigated. Forty-one patients (pancreatoduodenectomy, 30; distal pancreatectomy, 11) who underwent intraoperative elastography during pancreatectomy were included. The elastic ratio was determined at the pancreatic resection site (just above the portal vein) and at the remnant pancreas (head or tail). Correlations between the incidence of POPF and patient characteristics, operative variables, and the elastic ratio were examined. In addition, the relationship between the elastic ratio and the percentage of the exocrine gland at the resection stump was investigated. For pancreatoduodenectomy patients, main pancreatic duct diameter < 3.2 mm and elastic ratio < 2.09 were significant risk factors for POPF. In addition, the elastic ratio, but not main pancreatic duct diameter, was significantly associated with the percentage of exocrine gland area at the pancreatic resection stump. Pancreatic stiffness can be quantified using intraoperative elastography. Elastography can be used to diagnose “soft pancreas” and may thus be useful in predicting the occurrence of POPF.

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Risk Factors for Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) after Distal Pancreatectomy: A Single Center Experience

10.1101/2020.05.04.20090241 ◽

2020 ◽

Author(s):

Gao Qing Wang ◽

Dipesh Kumar Yadav ◽

Wei Jiang ◽

Yong Fei Hua ◽

Cai De Lu

Keyword(s):

Risk Factors ◽

Multivariate Analysis ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Distal Pancreatectomy ◽

Main Pancreatic Duct ◽

Surgical Complication ◽

Univariate Analysis ◽

Postoperative Pancreatic Fistula ◽

Soft Pancreas

AbstractClinically relevant postoperative pancreatic fistula (CR-POPF) is the considerable contributor to major complications after pancreatectomy. The purpose of this study was to evaluate the potential risk factor contributing to CR-POPF following distal pancreatectomy (DP) and discussed the risk factors of pancreatic fistula in order to interpret the clinical importance. All the patients who underwent DP in between January 2011 and January 2020 were reviewed retrospectively in accordance with relevant guidelines and regulations. The univariate and multivariate analysis was performed was performed to test an independent risk factors for pancreatic fistula. P<0.05 was considered statistically significant. In all of the 263 patients with DP, pancreatic fistula was the most common surgical complication 19.0%. The univariate analysis of 18 factors showed that the patients with a malignant tumor, soft pancreas, and patient without ligation of the main pancreatic duct are more likely to develop pancreatic fistula. However, on multivariate analysis the soft texture of the pancreas (OR= 2.381, P= 0.001) and the ligation of main pancreatic duct (OR= 0.388, P= 0.002) were only an independent influencing factor for CR-POPF. As a conclusion, pancreatic fistula was the most common surgical complication after DP, and the texture of pancreas and ligation of main pancreatic duct can influence an incidence of CR-POPF.

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