The Outcome of Patients with Different Pancreatic Tumors Treated by Whipple’s Operation at Bangabandhu Sheikh Mujib Medical University

Background: Whipple’s Operation was first introduced by Allan Whipple in the 1930s. During 1960s and 1970’s the mortality rate for the Whipple operation was very high. Pancreatic tumors are one of the important indications for Whipple’s operation. About 85% of patients had adenocarcinoma tumor of the pancreas. 15% of patients had other tumors in the head region. In the Whipple’s operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed. The aim of the study was to find the outcome of patients with different benign and malignant pancreatic tumor who undergone Whipple’s surgery and compare the preoperative finding and postoperative complication.Material & Methods:This study was a cross-sectional observational study which was carried out at the Department of Hepatobiliary and Pancreatic Surgery in Bangabandhu Sheikh Mujib Medical University (B.S.M.M.U), Dhaka, Bangladesh. The study was conducted during the period of August 2010 to July 2012. There were a total of 20 cases.Results:100% having solid pseudo papillary tumor age below 35yrs. After Whipple’s operation for solid pseudo papillary tumor of the pancreas, or benign tumor group, 25% of patients had developed wound infection. But in the case of Whipple’s operation for adenocarcinoma pancreas, 62.25% of patients developed wound infection. At a follow-up after 1 year of Whipple’s surgery, none of the benign tumor cases needed readmission, as all 100% had normal liver function tests, normal levels of CA 19-9, and normal USG findings in the abdomen. On the other hand, 25% of the malignant tumor cases had some form of complication and needed readmission.Conclusion:Most pancreatic tumors were located in the head of the pancreas which can be treated by Whipple’s operation. Adenocarcinoma of the head is the most common indication of surgery and is surgically resect able.

Procedimiento de Whipple: experiencia de un centro en fase de crecimiento en cirugía hepato-bilio-pancreática / Whipple procedure: hepatic-bilio-pancreatic single center experience

La operación de Whipple es el procedimiento quirúrgico de mayor complejidad en cirugía abdominal, este se realiza en pacientes con tumores de la encrucijada pancreatoduodenal, es la única alternativa para tratamiento curativo en fases tempranas de la enfermedad. Objetivo: Determinar los resultados del procedimiento Whipple, en pacientes intervenidos con tumores de la encrucijada pancreatoduodenal en el Hospital General de Enfermedades del Instituto Guatemalteco de Seguridad Social, en el periodo de enero 2,015 a enero 2,020. Método: Descriptivo, observacional, retrospectivo. Resultados: Se incluyeron 42 procedimientos de Whipple, 29 (69%) casos del género masculino y 13 (31%) para el género femenino. La edad media fue de 61.5 años, el 54% presentaban comorbilidad asociada. El 24% utilizo transfusión transoperatoria de hemoderivados, el tiempo quirúrgico de 5.5 horas. La reintervención fue del 4.7%. Complicaciones postoperatorias tempranas 18%. La histología más común fue el carcinoma de cabeza de páncreas en el 43%. La mortalidad postoperatoria temprana fue del 4.7%. El OR de complicaciones asociadas a comorbilidades fue de 1.7 con un IC 0.3046-7.20 y un valor de P: 0.9251 que no es estadísticamente significativo. Conclusiones: Los tumores pancreatoduodenales en nuestra población se presentan en edades más tempranas a lo reportado. La morbimortalidad es similar a lo reportado en otros estudios a nivel latinoamericano, sin embargo las complicaciones están más elevadas que las mejores series internacionales. No existe asociación entre el riesgo de complicaciones con comorbilidades del paciente. (AU)

Whipple operation is the most complex surgical procedure in abdominal surgery, it's performed in patients with tumors of the pancreaticoduodenal crossroads, it is the only alternative for curative treatment in early stages of the disease. Objective: To determine the results of the Whipple procedure in patients operated on with tumors of the ancreaticoduodenal crossroads at the Hospital General de Enfermedades del IGSS in the period from January 2015 to January 2020. Method: Descriptive, observational, retrospective. Results: fourtytwo Whipple procedures were included, 29 (69%) cases of the male gender and 13 (31%) for the female gender. The mean age was 61.5 years, 54% had associated comorbidity. Twentyfour percent used intraoperative transfusion of blood products and surgical time of 5.5 hours. Reoperation was 4.7% with early postoperative complications of 18%. The most common histology was carcinoma of the head of the pancreas in 43%. Early postoperative mortality was 4.7%. The OR of complications associated with comorbidities was 1.7 with a CI 0.3046-7.20 and a P value: 0.9251, which is not statistically significant. Conclusions: Pancreaticoduodenal tumors in our population present at an earlier age than reported. Morbidity and mortality is similar to that reported in other studies. There is no association between the risk of complications with patient comorbidities. (AU)

Fish-Mouth Closure of the Pancreatic Stump and Parachuting of the Pancreatic End with Double U Trans-Pancreatic Sutures for Pancreatico-Jejunostomy

PURPOSE: Leakage of pancreatico-jejunal anastomosis (PJ) remains the primary cause of morbidity and mortality after Whipple's operation. To reduce the occurrence thereof, the present author recently began to apply a modification of the Blumgart method of anastomosis after Whipple's operation (hereinafter referred to as Lee's method), with very good results. MATERIALS AND METHODS: The modified method and technique utilizes fish-mouth closure of a beveled pancreatic stump and parachuting of the pancreatic end with double U trans-pancreatic sutures (symmetric horizontal mattress-type sutures between the full thickness of the pancreas and the jejunal limb) after duct-to-mucosa pancreatico-jejunostomy. RESULTS: Eleven cases of pylorus preserving Whipple's operation have been performed without a clinically significant postoperative pancreatic fistula. CONCLUSION: This new method (Lee's method) may dramatically reduce the occurrence of postoperative pancreatic fistula after Whipple's operation.

Clinical significance of setting nasojejunal nutrition tube in Whipple operation / 中国综合临床

Objective To investigate the clinical significance of setting nasojejunal nutrition tube in Whipple operation,which can promote patient recovery and prevent complications.Methods Fourty-one patients were undergone Whipple operation and they were randomly divided into eternal nutrition (EN) and parenteral nutrition group (PN).Patients in EN group were set nasojejunal nutrition tube during Whipple operation in order to supply eternal nutrition at earlier period,while in PN group were supplied parenteral nutrition in earlier period.The operative procedure time,the complication in post-operation,the cost of hospitalization and the periods of hospitalization of two groups were recorded.The scores of nutritional status were measured.Results The operative time in EN group and PN group were (200.71 ±51.33)min and (160.48 ± 47.62) min,and no significant difference was found between two groups (t =-1.524,P ＞ 0.05).The hospitalization expenses in EN group was (38835.65 ± 537.69)yuan,lower than that in PN group ((47833.18 ±659.24) yuan,t =2.073,P ＜ 0.05).The hospital periods of EN group and PN group were 10 (3) d and 18(3) d,and the difference was significant (Z =-5.374,P ＜0.001).There were 2 cases who occurred complications after operation in EN group,including 1 cases with incision infection,and 1 cases of pancreatic fistula.Nine cases occurred complications in PN group,including 3 cases with incision infection,2 cases with pancreatic fistula,2 cases with pulmonary infection,2 cases with gastric paralysis,and all were cured by conservative treatment.There was statistically significant difference in the incidence of postoperative complications (P =0.027).All cases with complication were recovery after corresponding treatment.At 7th day after operation,hemoglobin in EN group and PN group were (113.09 ± 12.35) g/L and (107.04 ± 11.81) g/L,and the difference was significant (t =2.035,P ＜ 0.05).The levels of retinol binding protein,serumalbumin,serum prealbumin,serum transferrin in EN group were (42.62 ± 5.64) mg/L,(40.24 ± 6.79) g/L,(321.43±31.28) mg/L,(32.86±4.67) mg/L,(32.86 ±4.67) mg/L,significant different from those in PN group ((15.50 ± 4.26) mg/L,(31.52 ± 5.92) g/L; (197.86 ± 37.71) mg/L,(23.59 ± 4.32) mg/L; t=2.398,2.606,2.119,2.569; P ＜0.01 or P ＜ 0.05).Conclusion Nutritional status and prognosis are improved obviously by setting nasojejunal nutrition tube in Whipple operation.And the cost of hospitalization,the periods of hospitalization are decrease.

Ampullary tumours (ampullomas) in the elderly – an interdisciplinary problem.

Background & objectives: Ampullary cancer is one of the periampullary tumours with better prognosis, but relapses occur early in some patients. This study was carried out to assess whether pancreatoduodenectomy (PDE, Whipple operation) could be a safe therapeutic procedure for elderly patients with periampullary tumours. Methods: Between 2005 and 2007, 19 patients (12 male, 7 female) aged over 65 yr (range 66 and 83 yr) with diagnosis of ampulloma were operated. Results: Of the 19 patients, 6 underwent local surgical ampullectomy with reinsertion of ductus choledochus and Wirsungi’s duct for benign or early cancer lesion and 13 underwent PDE (Whipple operation). Of these 13, only one was in T1 stage, one was in T4 stage, two patients were T3 and the rest in T2 stage. Lesion of lymphatic system had 40 per cent of patients in T2 stage and all in T3 and T4 stages. One patient died of pulmonary embolism several days after operation. Post-operative complications occurred in 3 cases: 1 patient with partial dehiscence of gastroenteroanastomosis – treated by conservative approach, 2 patients with dehiscence of pancreatojejunoanastomosis. Interpretation & conclusions: Diagnosis and therapy of ampullary tumours is multimodal. With careful patient selection, PDE can be performed in elderly people (>65 yr) safely. The post-operative morbidity in this group is essentially influenced by their multi-morbidity.

Using Multidetector-Row CT for the Diagnosis of Afferent Loop Syndrome Following Gastroenterostomy Reconstruction

PURPOSE: To assess the clinical manifestations and multidetector-row computed tomography (MDCT) findings of afferent loop syndrome (ALS) and to determine the role of MDCT on treatment decisions. MATERIALS AND METHODS: From January 2004 to December 2008, 1,100 patients had undergone gastroenterostomy reconstruction in our institution. Of these, 22 (2%) patients were diagnosed as ALS after surgery that included Roux-en-Y gastroenterotomy (n=9), Billroth-II gastrojejunostomy (n=7), and Whipple's operation (n=6). Clinical manifestations and MDCT features of these patients were recorded and statistically analyzed. The presumed etiologies of obstruction shown on the MDCT were correlated with clinical information and confirmed by surgery or endoscopic biopsy. RESULTS: The most common clinical symptom was acute abdominal pain, presenting in 18 patients (82%). We found that a fluid-filled C-shaped afferent loop in combination with valvulae conniventes projecting into the lumen was the most common MDCT features of ALS. Malignant causes of ALS, such as local recurrence and carcinomatosis, are the most common etiologies of obstruction. These etiologies and associated complications can be predicted 100% by MDCT. CONCLUSION: Our results suggest that MDCT is a reliable modality for assessing the etiologies of ALS and guiding treatment decisions.

An Anesthetic Management of a Patient with Parkinson's Disease Who Underwent Whipple's Operation by Enteral Levodopa Administration / 대한마취과학회지

Parkinson's disease is a relatively common neurologic disorder that afflicts approximately 1% of the population over 50 years old. Many drugs currently used for the treatment of Parkinson's disease may interact with anesthetic drugs. Brief interruption of levodopa during surgery may result in exacerbation of Parkinson's symptoms. However, safe and effective way to administer levodopa during surgery are not widely known. We report the perioperative treatment of a patient with Parkinson's disease by using intraoperative administration of levodopa through nasogastric tube and feeding jejunostomy tube. This method of levodopa administration successfully prevented the exacerbation of Parkinsonian symptoms.

A Case of Biliary Papillomatosis which Underwent Curative Resection / 대한소화기내시경학회지

Biliary Papillomatosis is an extremely rare pathologic entity. Only about 40 cases of intrahepatic or diffuse intra- and extrahepatic papillomatosis have been described since the first report in 1959 by Caroli. Although this is a histologically benign lesion, its course is unfavaurable because of its tendency to extend to the entire biliary tract, high recurrence rate following local excision and the probability of progression to malignancy. We described herein a case of biliary papillomatosis associated with diffuse bile duct dilatation. The patient, a 59-year-old male, was admitted to our hospital because of right upper abdominal pain and weight loss. Cholangiogram revealed multiple round filling defects in common hepatic duct with intrahepatic bile duct dilatation. The patient underwent Whipple's operation with right lobectomy. Grossly, multiple small pin-head sized polypoid masses were seen in common bile duct, common hepatic duct and right intrahepatic duct. Microscapically, papillary epithelial hyperplasia with moderate cellular atypia was seen and there was no evidence of stromal invasion. He is healthy with a follow-up for 7 months.