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

<b><i>Introduction:</i></b> 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. <b><i>Methods:</i></b> 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. <b><i>Results:</i></b> Twenty-five of 65 patients with soft pancreatic texture (38.5%) developed POPF. POPF became less frequent as the pancreatic duct stent size increased (<i>p</i> = 0.003). The factors associated with POPF development were a 7.5-Fr pancreatic duct stent (<i>p</i> = 0.005), 5.0-Fr pancreatic duct stent (<i>p</i> = 0.031), and male sex (<i>p</i> = 0.008). Pancreatic duct stent size and pancreatic duct diameter did not differ between the POPF and non-POPF groups. <b><i>Discussion/Conclusions:</i></b> In patients with a soft pancreas, the placement of a 7.5-Fr pancreatic duct stent may reduce the incidence of POPF.

Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.

Invaginated Duct to Mucosa Pancreaticojejunostomy Reduced Postoperative Pancreatic Leakage: A Matched Case-controlled Study

Background Postoperative pancreatic leakage was also the obstacle of pancreaticoduodenectomy (PD) which always followed the failure of pancreaticojejunostomy. Dozens of pancreaticojejunostomy had been reported. None showed superiority over others. To assess the potential advantages of invaginated duct to mucosa pancreaticojejunostomy (invaginated D-M PJ), we introduced this study.Methods Retrospectively analyzed the related data from the patients who had their pancreaticodedunostomy due to malignant tumor in The First Affiliated Hospital to Henan University of Science and Technology during January 2017 to August 2019. According to the different procedure of pancreaticojejunostomy, the patients divided into custom D-M group and invaginated D-M group. Sex, age, pancreatic duct size and pancreatic texture were matched. Pancreatic leakage and other complications were compared. SPSS 16.0 was employed for analysis.Results 48 pairs of patients were involved. Both groups had almost the same baseline characterisitics, such as Sex (P=1.000), Age (P=0.897), ASA (P=0.575), BMI (P=0.873), pancreatic duct size (P=0.932), pancreatic texture (P=1.000) and tumor origin (P=0.686). No statistical difference was observed relation to operation outcomes, such as operation time (P=0.632), pancreaticojejunostomy time (P=0.748), blood loss (P=0.617) and number of required transfusion (P=0.523). Pancreatic leakage was significantly declined for invaginated D-M group (P=0.005). The difference of other complications, such as, bleeding (P=0.617), biliary leakage (P=0.646), pneumonia (P=0.594) and thrombosis (P=0.714), didn’t reach statistical significance. Postoperative hospitalization was almost the same for both groups (P=0.764).Conclusions Invaginated D-M PJ could reduce pancreatic leakage followed PD. Invaginated D-M PJ should be a choice for the patients who had PD.

Kiguchi Method, A Novel Simplified Technique For Pancreaticojejunostomy In Minimally Invasive Pancreaticoduodenectomy, Significantly Reduces Postoperative Pancreatic Fistula Rate In Patients With A Soft Pancreatic Texture

Background: Minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is especially demanding due to pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) remains the most serious complication in MIPD as well as in open pancreaticoduodenectomy (OPD). Conventional PJ in MIPD did not improve the POPF rate and hospital stay, contrary to expectations. High POPF rates have been attributed to technical issues encountered during MIPD, including motion restriction and insufficient water tightness; therefore, we have developed the Kiguchi method as a novel PJ technique optimized for MIPD. Herein, we describe the technique and assess its impact in patients with a soft pancreatic texture, which has been reported to be significantly related to POPF.Methods: The retrospective study included 188 patients with a soft pancreatic texture. Briefly, 143 patients underwent OPD with conventional PJ (OPD group); 19 patients underwent MIPD with conventional PJ (Old-MIPD group), including 7 and 12 patients undergoing LPD and RPD, respectively; and 26 patients underwent MIPD using the Kiguchi method (New-MIPD group), including 15 and 11 patients undergoing LPD and RPD, respectively. Short-term outcomes were assessed, and POPF risk factors were determined using univariate and multivariate analyses.Results: The grade B/C POPF rate was significantly lower in the New-MIPD group than in the Old-MIPD and OPD groups (3.8% vs. 42.1% and 36.4%, respectively). The median hospital stay was significantly shorter in the New-MIPD group than in the Old-MIPD and OPD groups (23 vs. 33 and 31 days, respectively). By multivariate analysis, the PJ method and male sex were significant POPF risk factors. Among the patients without POPF, the hospital stay was significantly shorter in those undergoing MIPD than in those undergoing OPD, suggesting the advantage of MIPD. Conclusions: The novel Kiguchi method significantly reduced the POPF rate in patients with a soft pancreatic texture.

Invaginated Duct to Mucosa Pancreaticojejunostomy Reduced Pstoperative Pancreatic Leakage: A Matched Case-Controlled Study

Background Postoperative pancreatic leakage was also the obstacle of pancreaticoduodenectomy (PD) which always followed the failure of pancreaticojejunostomy. Dozens of pancreaticojejunostomy had been reported. None showed superiority over others. To assess the potential advantages of invaginated duct to mucosa pancreaticojejunostomy (invaginated D-M PJ), we introduced this study.Methods Retrospectively analyzed the related data from the patients who had their pancreaticodedunostomy due to malignant tumor in The First Affiliated Hospital to Henan University of Science and Technology during January 2017 to August 2019. According to the different procedure of pancreaticojejunostomy, the patients divided into custom D-M group and invaginated D-M group. Sex, age, pancreatic duct size and pancreatic texture were matched. Pancreatic leakage and other complications were compared. SPSS 16.0 was employed for analysis.Results 48 pairs of patients were involved. Both groups had almost the same baseline characterisitics, such as Sex (P=1.000), Age (P=0.897), ASA (P=0.575), BMI (P=0.873), pancreatic duct size (P=0.932), pancreatic texture (P=1.000) and tumor origin (P=0.686). No statistical difference was observed relation to operation outcomes, such as operation time (P=0.632), pancreaticojejunostomy time (P=0.748), blood loss (P=0.617) and number of required transfusion (P=0.523). Pancreatic leakage was significantly declined for invaginated D-M group (P=0.005). The difference of other complications, such as, bleeding (P=0.617), biliary leakage (P=0.646), pneumonia (P=0.594) and thrombosis (P=0.714), didn’t reach statistical significance. Postoperative hospitalization was almost the same for both groups (P=0.764).Conclusions Invaginated D-M PJ could reduce pancreatic leakage followed PD. Invaginated D-M PJ should be a choice for the patients who had PD.

The Individualized Selection of Pancreaticoenteric Anastomosis in Pancreaticoduodenectomy

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.

Risk factors for pancreatic fistula following distal pancreatectomy: a retrospective study of 211 consecutive patients

Background Postoperative pancreatic fistula (POPF) is a common complication following distal pancreatectomy (DP). Although the mortality from these procedures has decreased in the past decades, the rate of POPF remains high. The aim of this study was to identify risk factors associated with POPF after DP. Methods A retrospective review of a consecutive series of 211 patients who had undergone DP between January 2016 and October 2018 at a single institution was conducted. Patient demographic data, perioperative data and clinicopathological parameters were analysed to evaluate their correlation with the incidence of POPF using univariate and multivariate models. POPFs were defined by 2016 International Study Group criteria. Results Two hundred eleven consecutive patients were identified. The overall pancreatic fistula rate was 15.64%, and no 30-day or 90-day mortality was seen. Four predictors were independently associated with POPF: soft pancreatic texture (odds ratio (OR): 4.23, 95% confidence interval (CI): 1.71-10.45, P = 0.002), longer operating time (OR: 4.18, 95% CI: 1.67–10.46, P = 0.002), higher difference of albumin (OR: 6.41, 95% CI: 2.40–17.08, P <0.001), and history of cardiovascular disease(OR: 5.05, 95% CI: 1.97-13.01, P = 0.001). Conclusions Although DP can be performed with a low rate of mortality, POPF remains a common complication. Pancreatic texture, operating time, the difference of albumin and cardiovascular disease were risk factors for POPF after DP.