SS  Vol.2 No.2 , April 2011
The Best Choice to Achieve Zero Complications after Pancreatoduodenectomy
Abstract: Pancreatoduodenectomy (PD) has been performed commonly, but the occurrence of pancreatic fistula (PF) is a critical trigger of complications, which are potentially life threatening, and is also associated with markedly prolonged hospitalization. Many techniques have been proposed for connecting the pancreatic stump with the gastrointestinal tract, stomach vs. jejunum, etc. Among the risk factors for PF, such as general patient factors or disease-related factors, the most important is the texture of the remnant pancreas. Surgical technique might be one improvable aspect that can reduce the pancreatic leakage rate, therefore; various methods of managing the pancreatic remnant have been studied. Methods of reconstruction between the remnant pancreas and the intestine include end-to-side with/without duct-to-mucosa anastomosis or end-to-end invagination styles, has been argued. Here, we review several trials for safety and methods of treating the pancreatic stump after PD, and demonstrate our experiences.
Cite this paper: nullS. Osada, H. Imai, Y. Sasaki, I. Yasufuku, R. Asai, Y. Tokumaru, T. Sakuratani and K. Yoshida, "The Best Choice to Achieve Zero Complications after Pancreatoduodenectomy," Surgical Science, Vol. 2 No. 2, 2011, pp. 45-51. doi: 10.4236/ss.2011.22010.

[1]   J. L. Cameron, T. S. Riall, J. Coleman and K. A. Belcher, “One Thousand Consecutive Pancreaticoduodenectomies,” Annals of Surgery, Vol. 244, No. 1, July 2006, pp. 10-15. doi:10.1097/01.sla.0000217673.04165.ea

[2]   M. L. DeOliveira, J. M. Winter, M. Schafer, S. C. Cununingham, J. L. Cameron, C. J. Yeo and P. A. Clavien, “Assessment of Complications after Pancreatic Surgery: A Novel Grading System Applied to 633 Patients Undergoing Pancreaticoduodenectomy,” Annals of Surgery, Vol. 244, No. 6, December 2006, pp. 931-937. doi:10.1097/01.sla.0000246856.03918.9a

[3]   R. T. Poon, S. T. Fan., C. M. Lo, K. K. Ng, W. K. Yuen , C. Yeung , J. Wong, “External Drainage of Pancreatic Duct with a Stent to Reduce Leakage Rate of Panceraticojejunostomy after Pancreaticoduodenectomy,” Annals of Surgery, Vol. 246, September 2007, pp. 425-433. doi:10.1097/SLA.0b013e3181492c28

[4]   A. Mathur, H. A. Pitt, M. Marine, R. Saxena, C. M. Schmidt, T. J. Howard , A. Nakeeb, N. J. Zyromski and K. D. Lillemoe, “Fatty Pancreas: A Factor in Postoperative Pancreatic Fistula,” Annals of Surgery, Vol. 246, No. 6, December 2007, pp. 1058-1064. doi:10.1097/SLA.0b013e31814a6906

[5]   C. Bassi, M. Falconi, E. Molinari, W. Mantovani, G. Butturini, A. A. Gumbs, R. Salvia and P. Pederzoli, “Duct-To-Mucosa Versus End-To-Side Pancreaticojejunostomy Reconstruction after Pancreaticoduodenectomy: Results of a Prospective Randomized Trial,” Surgery, Vol. 134, No. 5, November 2003, pp. 766-771. doi:10.1016/S0039-6060(03)00345-3

[6]   S. Hishinuma, Y. Ogata and J. Matsui, “Evaluation of Pylorus-Preserving Pancreatoduodenectomy with the Imanaga Reconstruction by Hepatobiliary and Gastrointestinal Dual Scintigraphy,” The British. Journal of Surgery, Vol. 86, No. 10, October 1999, pp. 1306-1311. doi:10.1046/j.1365-2168.1999.01232.x

[7]   S. Hishinuma, Y. Ogata and J. Matsui, “Complications after Pylorus-Preserving Pancreatoduodenectomy with Gastrointestinal Reconstruction by the Imanaga Method,” Journal of the American College Surgeons, Vol. 186, No. 1, January 1998, pp. 10-16. doi:10.1016/S1072-7515(97)00133-6

[8]   T. Ohtsuka, K. Yamaguchi, K. Chijiiwa and M. Tanaka, “Effect of Gastrointestinal Reconstruction on Quality of Life and Nutritional Status after Pylorus-Preserving Pancreatoduodenectomy,” Digestive Diseases and Sciences, Vol. 47, No. 6, July 2002, pp. 1241-1247. doi:10.1023/A:1015306110913

[9]   C. J. Yeo, J. L. Cameron, T. A. Sohn, K. D. Lillemoe, H. A. Pitt, M. A. Talamini, R. H. Hruban, S. E. Ord, P. K. Sauter, J. Coleman, M. L. Zahurak, L. B. Grochow and R. A. Abrams, “Six Hundred Fifty Consecutive Pancreaticoduodenectomies in the 1990s: Pathology, Complications and Outcomes,” Annals of surgery, Vol. 226, No. 3, September 1997, pp. 248-257. doi:10.1097/00000658-199709000-00004

[10]   R. Doi, K. Fujimoto, H. Kobayashi and M. Imamura, “Impact of Reconstruction Methods on Outcome of Pancreatoduodenectomy in Pancreatic Cancer Patients,” World Journal of Surgery, Vol. 29, No. 4, April 2005, pp. 500-504. doi:10.1007/s00268-004-7723-7

[11]   S. Osada, H. Imai, N. Okumura, Y. Tokuyama, Y. Hosono, F. Sakashita and Y. Sugiyama, “A Modified Reconstruction Method to Prevent Critical Complications after Pancreatoduodenectomy,” Hepato-gastroenterology, Vol. 53, No. 8, March/ April 2006, pp. 296-300.

[12]   H. Riediger, F. Makowiec, W. D.Schreck , U. T. Hopt and U. Adam “Delayed Gastric Emptying after Pylorus-Pre-Serving Pancreatoduodenectomy Is Strongly Related to the other Postoperative Complications,” Journal of Gastrointestinal Surgery, Vol. 7, No. 6, September/October, pp.758-765.

[13]   M. Tanakaand M. Sarr, “Total Duodenectomy Effect on Canine Gastrointestinal Motility,” The Journal of Surgical Research, Vol. 42, No. 5, May 1987, pp. 483-493. doi:10.1016/0022-4804(87)90022-9

[14]   T. Ohtsuka, K. Kitahara, S. Matsuyama, T. Shimonishi, Y. Nakafusa and K. Miyazaki, “Complication of the Postoperative Outcome after a Pancreatoduodenectomy Using the Billroth I and II Type of Reconstruction,” Hepato-gastroenterology, Vol. 54, No. 77, July/August 2007, pp. 1570-1574.

[15]   S. Takahata, T. Ohtsuka, T. Nabae, K. Matsunaga, K. Yamaguchi, K. Chijiiwa and M. Tanaka, “Complication of Recovery of Gastric Phase III Motility and Gastric Juice Output after Different Types of Gastrointestinal Reconstruction Following Pylorus-Preserving Pancreatoduodenectomy,” Journal of Gastroenterology Vol. 37, No. 8, August 2002, pp. 596-603. doi:10.1007/s005350200095

[16]   S. E. Lee, S. H. Yang, J. Y. Jang and S. W. Kim, “Pancreatic Fistula after Pancreaticoduodenectomy: A Comparison between the Two Pancreaticojejunostomy Methods for Approximating the Pancreatic Parenchyma to the Jejunal Seromuscular Layer: Interrupted Vs. Continuous Stitches,” World Journal of Gastroenterology, Vol. 13, No. 4, March 2007, pp. 5351-5356.

[17]   G. P. Fragulidis, N. Arkadopoulos, I. Vassiliou, A. Marinis, T. Thedosopoulos, V. Safyla, M. Kyriazi, K. Karapanos, N. Dafnios, A. Polydorou, D. Voros and V. Smyrniotis, “Pancreatic Leakage after Pancreaticoduodenectomy,” Pancreas, Vol. 38, October 2009, pp. e177-e182. doi:10.1097/MPA.0b013e3181b57705

[18]   A. C. Berger, T. J. Howard, E. P. Kennedy, P. K. Sauter, M. Bower-Cherry, S. Dutkevitch, T. Hyslop, C. M. Schmidt, E. L. Rosato, H. Lavu, A. Nakeeb, H. A. Pitt, K. D. Lillemoe and C. J. Yeo, “Does Type of Pancreaticojejunostomy after Pancreaticoduodenectomy Decrease Rate of Pancreatic Fistula? Randomized, Prospective, Dual- Institution Trial,” Journal of the American College Surgeons, Vol. 208, No. 5, May 2009, pp. 738-749. doi:10.1016/j.jamcollsurg.2008.12.031

[19]   J. H. Nguyen, “Distinguishing between Parenchymal and Anastomotic Leakage at Duct-To-Mucosa Pancreatic Reconstruction in Pancreaticoduodenectomy,” World Journal of Surgery, Vol. 14, No. 43, November 2008, pp. 6648-6654.

[20]   C. Bassi, M. Falconi, E. Molinari, R. Salvia, G. Butturini, N. Sartori, W. Mantovani and P. Pederzoli, “Reconstruction by Pancreaticojejunostomy Versus Pancreaticogastrostomy Following Pancreatectomy: Results of a Comparative Study,” Annals of surgery, Vol. 242, No. 6, December 2005, pp. 767-773.

[21]   Y. Murakami, K. Uemura, Y. Hayashidani, T. Sudo, N. Hashimoto, H. Ohge and T. Sueda , “No Mortality after 150 Consecutive Pancreatoduodenectomies with Duct-To-Mucosa Pancreaticogastrostomy,” Journal of Surgical Oncology, Vol. 97, No. 3, March 2008, pp.205-209. doi:10.1002/jso.20903

[22]   J. P. Duffas, B. Suc and S. Msika, “A Controlled Randomized Multicenter Trial of Pancreatogastrostomy or Pancreaticojejunostomy after Pancreatoduodenectomy,” The American Journal of Surgery, Vol. 189, No. 6, July 2005, pp. 720-729. doi:10.1016/j.amjsurg.2005.03.015

[23]   M. N. Wente, S. V. Shrikhande, M. W. Muller, M. K. Diener, C. M. Seiler, H. Friess and M. W. Buchler, “Pancreaticojejunostomy Versus Pancreaticogastrostomy: Systemic Review and Meta-Analysis,” The American Journal of Surgery, Vol. 193, No. 2, February 2007, pp. 171-183. doi:10.1016/j.amjsurg.2006.10.010

[24]   E. Lemaire, D. O’Toole, A. Sauvanet, P. Hammel, J. Belghiti and O. Ruszniewski, “Functional and Morphological Changes in the Pancreatic Remnant Following Pancreaticoduodenectomy with Pancreaticogastric Anastomosis,” British Journal of Surgery, Vol. 87, No. 4, April 2000, pp. 434-438. doi:10.1046/j.1365-2168.2000.01388.x

[25]   Y. Tomimaru, Y. Takeda, S. Kobayashi, S. Marubashi, C. M. Lee, M. Tanemura, H. Nagao, T. Kitagawa, K. Dono, K. Umeshita, K. Wakasa and M. Monden , “Comparison of Postoperative Morphological Changes in Remnant Pancreas between Pancreaticojejunostomy and Pancreaticogastrostomy after Pancreaticoduodenectomy,” Pancreas, Vol. 38, No. 2, March 2009, pp. 203-207. doi:10.1097/MPA.0b013e31818e1772

[26]   U. Adam, F. Makowiec, H. Riedinger, W. D. Schareck, S. Benz and U. T. Hopt, “Risk Factors for Complications after Pancreatic Head Resection,” The American Journal of Surgery, Vol. 187, No. 2, February 2004, pp. 201-208. doi:10.1016/j.amjsurg.2003.11.004

[27]   N. Akamatsu, Y. Sugawara, M. Komagome, N. Shin, N. Cho, T. Ishida, Ozawa and D. Hashimoto, “Risk Factors for Postoperative Fistula after Pancreaticoduodenectomy: The Significance of the Ratio of the Main Pancreatic Duct to the Pancreas Body as a Predictor of Leakage,” Journal of Hepato-Biliary-Pancreatic Sciences, Vol. 17, May 2010, pp. 322-328. doi:10.1007/s00534-009-0248-6

[28]   E. Molinari, C. Bassi, R. Salvia, G. Butturini, S. Crippa, G. Talamini, M. Falconi and P. Pederzoli, “Amylase Value in Drain after Pancreatic Resection as Predictive Factor of Postoperative Pancreatic Fistula: Results of a Postoperative Study in 137 Patients,” Annals of surgery, vol. 246, No. 2, August 2007, pp. 281-287. doi:10.1097/SLA.0b013e3180caa42f

[29]   C. J. Yeo, J. L. Cameron, K. D. Lilemoe, P. K. Sauter, J. Coleman, T. A. Sohn, K. A. Campbell and M. A. Choti , “Does Prophylactic Octreotide Decrease the Rates of Pancreatic Fistula and Other Complications after Pan-creaticoduodenectomy? Results of a Prospective Ran-domized Placebo-Con-Trolled Trial,” Annals of surgery, Vol. 232, No. 3, September 2000, pp. 419-429. doi:10.1097/00000658-200009000-00014

[30]   A. Ramos-De la Medina and M. G. Starr, “Somatostatin Analogues in the Prevention of Pancreas-Related Complications after Pancreatic Resection,” Journal of Hepato-Biliary-Pancreatic Surgery, Vol. 13, No. 3, March 2006, pp. 190-193. doi:10.1007/s00534-005-1033-9

[31]   S. Connor, N. Alexakis, O. J. Garden, E. Leandros, J. Bramis and S. J. Wigmore, “Meta-Analysis of the Value of Somatostain and Its Analogues in Reducing Complications Associated with Pancreatic Surgery,” British Journal of Surgery, Vol. 92, No. 9, September 2005, pp. 1059-1067. doi:10.1002/bjs.5107

[32]   E. Rosso, P. Bachellier, E. Oussoultzoglou, R. Scurtu, N. Meyer, H. Nakano, G. Verasay and D. Jaeck, “Toward Zero Pancreatic Fistula after Pancreaticoduodenectomy with Pancreaticogastrostomy,” The American Journal of Surgery, Vol. 191, No. 6, June 2006, pp. 726-732. doi:10.1016/j.amjsurg.2005.09.012

[33]   G. V. Aranha , P. Hodul, E. Golts, D. Oh, J. Pickleman and S. Creech, “A Comparison of Pancreaticogastrostomy and Pancreaticojejunostomy Following Pancreaticoduodenectomy,” Journal of Gastrointestinal Surgery, Vol. 7, No. 5, August 2003, pp. 672-682. doi:10.1016/S1091-255X(02)00432-8

[34]   M. Tani, M. Kawai, S. Hirono, S. Ina, M. Miyazawa, A. Shimizu and H. Yamaue, “A Prospective Randomized Controlled Trial of Internal Versus External Drainage with Pancreaticojejunostomy for Pancreaticoduodenectomy,” The American Journal of Surgery, Vol. 199, No. 6, June 2010, pp. 759-764. doi:10.1016/j.amjsurg.2009.04.017

[35]   S. Ohwada, Y. Tanahashi, T. Ogawa, S. Kawate, K. Hamada, K. I. Tago, T. Yamada and Y. Morishita, “In Situ Vs Ex Situ Pancreatic Duct Stents of Duct-To-Mu-cosa Pancreaticojejunostomy after Pancreaticoduodenectomy with Billroth I-Type Reconstruction,” Archives of Surgery, Vol. 137, No. 11, November 2002, pp. 1289-1293.

[36]   M. Kawai, M. Tani, H. Terasawa, S. Ina, S. Hirono, R. Nishioka, M. Miyazawa, K. Uchiyama and H. Yamaue, “Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients,” Annals of surgery, Vol. 244, No. 1, July 2006, pp. 1-7. doi:10.1097/01.sla.0000218077.14035.a6

[37]   S. Osada, Y. Sanada, Y. Tanaka, A. Ikawa, Y. Tokuyama, N. Okumura, Y. Hosono, K. Nonaka, T. Takahashi, K. Yamaguchi and K. Yoshida, “Clinical evaluation of modified reconstruction method after pancreatoduodenectomy,” Hepato-gastroenterology, Vol. 56, No. 91-92, May/June 2009, pp. 619-623.

[38]   E. Hidaka, A. Yanagisawa, M. Seki, K. Takano, T. Setoguchi and Kato, “High Frequency of K-Ras Mutations in Biliary Duct Carcinoma of Cases with Long Common Channel in the Papilla of Vater,” Cancer Research, Vol. 60, No. 522, February 2000, pp. 522-524.

[39]   E. C. Lai, S. H. Lau and W. Y. Lau, “Measures to Prevent Pancreatic Fistula after Pancreatoduodenectomy: A Comprehensive Review,” Archives of Surgery, Vol. 144, No. 11, November 2009, pp. 1074-1080.

[40]   D. You, K. Jung, H. Lee, J. Heo, S. Choi and D. Choi, “Comparison of different pancreatic anastomosis techniques using the definitions of the International Study Group of Pancreatic Surgery: a single surgeon’s experience,” Panceas Vol. 38, No. 8, November 2009, pp. 896-902. doi:10.1097/MPA.0b013e3181b365f7

[41]   D. B. Adams, “The Pancreatic Anastomosis: The Danger of a Leak, Which Anastomotic Technique Is Better?” Journal of Gastrointestinal Surgery, Vol. 13, No. 7, March 2009, pp.1182-1183. doi:10.1007/s11605-009-0865-z