A Novel Anastomosis Technique for Laparoscopic Pancreaticoduodenectomy: Case Series of Our Center's Experience

Background: Laparoscopic pancreaticoduodenectomy has developed rapidly in recent years. Postoperative pancreatic fistula is still the most dangerous complication of laparoscopic pancreaticoduodenectomy. Baumgart pancreaticojejunostomy is considered one of the safest anastomosis procedures, with low rates of pancreatic fistula. We modified Blumgart pancreaticojejunostomy and applied the modified procedure during laparoscopic pancreaticoduodenectomy. The modified procedure entailed a longitudinal U-shaped suture through the pancreas for anastomosis of the pancreatic duct and the jejunal mucosa.Methods: We prospectively collected and retrospectively analyzed the data of 120 patients who underwent laparoscopic pancreaticoduodenectomy from January 2016. The total operative time, time for complete pancreaticojejunostomy, postoperative pancreatic fistula rate, postoperative delayed gastric emptying, postoperative bleeding, postoperative length of hospital stays, and mortality within 90 days after surgery were analyzed. An analysis of laparoscopic pancreaticojejunostomy compared with open pancreaticojejunostomy is also reported.Results: In the laparoscopic pancreaticojejunostomy group, the average total operative time, the average time for complete pancreaticojejunostomy, and the average intraoperative blood loss were 271 min, 35.3 min, and 184 ml, respectively. The total postoperative clinically relevant pancreatic fistula rate was 9.2% (Grade B and C fistulas). The incidence rates of postoperative delayed gastric emptying and postoperative biliary fistula were ~2.5 and 1.7%, respectively. The postoperative bleeding rate was 0.83%, and the average postoperative indwelling time of the abdominal drainage tube was 7.3 days. The postoperative length of hospital stay was 10.8 days, and the mortality rate within 90 days after surgery was 0.83%. The rates of clinically relevant postoperative clinically relevant pancreatic fistula are comparable between laparoscopic and open surgery, there were no other severe postoperative complications in either group. The mean postoperative length of hospital stay was significantly shorter in the laparoscopic pancreaticojejunostomy group.Conclusion: The modified laparoscopic-adapted Blumgart anastomosis simplifies and facilitates the creation of the pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy. The rates of clinically relevant postoperative pancreatic fistula are comparable with those obtained by open surgery, and length of stay are shoter.

Central versus Distal Pancreatectomy for Benign or Low-Grade Malignant Lesions in the Pancreatic Neck and Proximal Body

The purpose of this meta-analysis was to compare the clinical outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP). PubMed, Web of Knowledge, and Ovid's database were searched for studies published in English language between January 1990 and December 2018. A meta-analysis was performed to compare the clinical outcomes of CP versus DP. Nineteen trials with 1440 patients were analyzed. Although there were no significant differences in the rate of intra-operative blood transfusion between two groups, CP costs more operative time as well as had more intraoperative blood loss than DP. Furthermore, the overall complication rate, pancreatic fistula rate, and the clinically significant pancreatic fistula rate were significantly higher in the CP group. On the other hand, CP had a lower risk of endocrine (odds ratio: 0.17; 95% confidence interval: 0.10, 0.29; P < 0.05) and exocrine insufficiency (odds ratio: 0.22; 95% confidence interval: 0.10, 0.48; P < 0.05). CP was associated with a higher pancreatic fistula rate, and it should be performed in selected patients who need preservation of the pancreas, which is of utmost importance.

Simplicity and Safety: Minimized Pancreatic Fistula Rate after Distal Pancreatectomy through Pancreas Stump Sutured Fish-Mouth Closure

Pancreatic stump leak after distal pancreatectomy (DP) is a major determinant for impaired postoperative recovery. Factors influencing pancreatic fistula (PF) occurrence remain of interest. Prospectively collected data from an academic surgical oncology practice were examined for predictors of PF. Seventy-five of 294 pancreatectomy patients underwent DP (26%). There were 33 men and 42 women, with a median age of 61 years (range: 18–85 years). Underlying conditions included cancer (60%) and benign processes (40%). Resections were comprising open DP (64%), laparoscopic DP (21%), and open multivisceral resections (15%). Of 21 cases with postoperative complications (28%, no death), six were PFs (8%, 2 grade A and 4 grade B). The median length of stay was six days (4–24). The PF rate was 2.0 per cent in 50 patients after sutured fish-mouth closures, but 20 per cent in cases using other techniques including stapling ( P = 0.007); no other variable was linked to PF occurrence. Length of stay was linked to complications, resection extent, malignancy, and transfusions (all at P < 0.02), but not to PF. PF rate after DP in this experience is unaffected by splenic vessel resection but seems to be minimized through a sutured fish-mouth closure technique.

Continuous dunking pancreaticojejunostomy: our experience with first fifty cases

Introduction- Different techniques and modifications have been described to bring down the incidence of pancreatic fistula rate. However, no techniques have been accepted as a gold standard. Since 2011, we have been performing pancreaticojejunostomy by continuous dunking technique. Here, we intend to present our experience with the defined technique.Methods: Prospectively maintained medical records of the patients (operated between Sept 2011 to Jan 2016) undergoing pancreaticoduodenectomy and pancreaticoenteric reconstruction by continuous dunking techniques were reviewed and analyzed. Postoperative complications mainly, incidence of post pancreatectomy fistula (POPF), hemorrhage (PPH) and delayed gastric emptying (DGE) along with other major complications were analyzed. Subgroup analysis was also performed to find the difference in fistula rate in patients with or without addition of Braun’s anastomosis. ISGPS definition was used to define the major, surgery specific complications of pancreaticoduodenectomy.Results: Total 51 patients underwent pancreaticojejunostomy with the defined technique with Male to female ratio of 23:28. Total 13.7% (7/51) patients received preoperative biliary drainage. Overall, clinically significant fistula rated was 15.6% (8/51), PPH 13.7% (7/51) and 0% clinically significant DGE (overall DGE 13.7%, 7/51). Mortality rate was 5.8% (3/51). Subgroup analysis performed between patients with or without addition of Braun’s anastomosis revealed 0% clinically significant fistula rate with no mortality in the group.Conclusion: Surgery specific complications following pancreaticoduodenectomy and pancreaticoenteric reconstruction with our technique are comparable to published results from high volume centers. Addition of Braun’s anastomosis is a promising modification to bring down the POPF rate to a minimum.