Endoscopic Retrograde Cholangiopancreatography in Bilioenteric Anastomosis

For diagnosis and treatment of pancreatobiliary diseases, endoscopic retrograde cholangiopancreatography (ERCP) is useful method nowadays and its technically success rate is usually in about 90%-95% of patients with normal gastric and pancreaticobiliary anatomy. Recently ERCP is significantly challenging after intestinal reconstruction, particularly in patients who have undergone pancreaticoduodenectomy (PD, classic Whipple’s operation) or pylorus-preserving pancreatoduodenectomy (PPPD) with reconstruction. PD and PPPD relate to numerous techniques have been presented for reconstruction of the digestive tract and pancreaticobiliary tree during the resection bilioenteric stricture commonly occurs later in the postoperative course and developed in 5-year cumulative probability of biliary stricture rate of 8.2% and pancreaticoenteric stricture of 4.6%. This complication was no difference in incidence between patients with benign or malignant disease. In PD or PPPD with reconstruction, short pancreatobiliary limb with biliojejunal anastomosis site is made usually, modestly success rate of intubation to blind loop and cannulation with conventional endoscope. However, in combined Reux-en-Y anastomosis, longer pancreatobiliary limb and additional Reux limb are obstacle to success intubation and cannulation by using conventional endoscope. In this situation, new designed enetroscope with dedicated accessories is efficient.

A Preliminary Gastric Emptying Study Using 99mTc-DTPA Scan after Pylorus-Preserving Pancreatoduodenectomy

PURPOSE: Pylorus-preserving pancreatoduodenectomy (PPPD) is an alternative surgical procedure for periampullary lesions. Early delayed gastric emptying is the most common and frustrating complication in the immediate postoperative period after PPPD and late delayed gastric emptying has been reported in some long-term follow-up studies. We evaluated the incidence of early delayed gastric emptying and analyzed temporal changes in gastrointestinal function after PPPD. METHODS: The incidence of early delayed gastric emptying was retrospectively evaluated from the medical records of 15 patients who underwent PPPD. Gastric emptying tests (GETs) using 99mTc-DTPA scan were performed on 11 of the patients every three months until 1 year, where possible. RESULTS: The incidence of early delayed gastric emptying was 6.7%. Five of the eight patients (62.5%) and six of the eight (75%) who underwent scintigraphy at 3 months and 6 months respectively, showed delayed gastric emptying. But at 12 months, all of the four patients who underwent GETs showed normal gastric emptyings. CONCLUSION: The incidence of early delayed gastric emptying after PPPD was 6.7%. Though there were few symptoms in long-term follow-up study using 99mTc-DTPA scan, delayed gastric emptying was frequently observed 3 to 9 months after PPPD. However, gastric emptying might be normalized in almost all patients around 1 year after PPPD.

Induced Hypergastrinemia Can Prevent the Pancreatic Atrophy after Pancreatoduodenectomy in Human

PURPOSE: Following a pancreatoduodenectomy, atrophy of the distal pancreas commonly occurs. It has been demonstrated that gastrin stimulates the regeneration of the pancreas in animals. This study was undertaken to determine whether gastrin has a similar effect in humans and in particular, whether it prevents the atrophy of the distal pancreas after a pylorus preserving pancreatoduodenectomy (PPPD). METHODS: Between March 1999 and May 2000, a randomized prospective study was performed in 56 patients who underwent PPPD for periampullary neoplasms. The patients were allocated to either a lansoprazole group (LG) or a control group (CG). The LG members were given oral lansoprazole (30 mg/day) over 12 weeks postoperatively to induce hypergastrinemia. During the study period, 19 patients were excluded for various reasons. Therefore, a total of 37 patients (LG: n=18; CG: n=19) were eligible for this study. The volume of the distal pancreas was determined using thin sectioned spiral CT data, the nutritional status, the endocrine (insulin level, glucose tolerance test) and exocrine function (stool elastase) of the pancreas. In addition, the serum gastrin level were measured prior to the operation and 3 months after the operation. The two groups were clinically comparable. RESULTS: The serum gastrin level was higher in the LG (P<0.05). In this group, the mean volume of the distal pancreas was reduced by 10% (63,954 mm3+/-57,069 mm3) after PPPD, whereas severe pancreatic atrophy occurred in the CG (71,446 mm3+/-39,753 mm3) (P<0.01). The postoperativeinsulin and stool elastase levels were higher in the LG than in the CG (insulin: 21.1milliunit/ml vs 6.9milliunit/ml; elastase: 59 microgram/g vs 23microgram/g). CONCLUSION: Induced hypergastrinemia prevents pancreatic atrophy after PPPD. This is probably because of the stimulated regenerative activity of the pancreas by gastrin. This has never been previously demonstrated in humans.

Comparison between a Pylorus-Preserving Pancreatoduodenectomy and a Classical Pancreatoduodenectomy Nutritional status and quality of life

BACKGROUND: This study was performed to prove whether a pylorus-preserving pancreatoduodenectomy (PPPD), now widely used in the treatment of not only positive tumors but also negative tumors, is advantageous for recovering the nutritional status and the quality of life of patients with pancreatic cancer and periampullary regions compared with a classical pancreatoduodenectomy (PD). METHODS: A retrospective study of the nutritional status and the quality of life of 200 patients who had undergone a PPPD (n=92) and a PD (n=118) from January 1993 to July 1998 was performed. The nutritional status was measured by using Broca's index, cholesterol, total protein, and albumin. The quality of life was assessed by one question on how the patients felt about their quality of life. RESULTS: The PD was preferred in advanced stages and had a higher recurrence rate. The PPPD had a shorter operative time, less transfused blood, a longer duration of nasogastric tube drainage, and a shorter postoperative hospital stay. In the PPPD, the nutritional status was improved compared with that in the PD. There were no significant differences in operative mortality or morbidity, gastrointestinal symptoms, and the quality of life between patients having a PPPD and a PD. CONCLUSIONS: This study suggests that there are no differences in postoperative subjective symptoms and the quality of life between patients having a PPPD and those having a PD. However, preserving the pylorus allows a better recovery of nutritional status than a pylorus resection dose. The PPPD hasa survival rate similar to that of the PD. Therefore, the PPPD can be recommended for the procedure in the surgical treatment of diseases of the periampullary regions.

Forty-Year Experience with the Pancreatoduodenectomy

PURPOSE: We reviewed our experience of 700 pancreatoduodenectomies for 40 years to study the clinical characteristics and to find out any changing patterns according to the periods. METHODS: From the first pancreatoduodenectomy in 1961, 700 consecutive pancreatoduodenectomies have been performed in Seoul National University Hospital until August 1999. Annual number of cases, indications, resectability, complications, and survival were analyzed base on three periods (period I: '72-'84; period II: '85-'90; period III: '91-'99). RESULTS: We had got 5 cases or less per year until 1980; thereafter, the number of case increased reaching 70 cases per year recently. Since pylorus-preserving pancreato duodenectomy (PPPD) was introduced in 1990, the proportion of PPPD increased to 60% in 1998. Indications for a pancreatoduodenectomy were periampullary cancer in 85% of the case and other benign or malignant lesions in 15%. The overall resectability was 37% (ampullary: 86%; bile duct: 42%; duodenal: 28%; pancreas; 18%), and there has been an increasing tendency of resectability in pancreatic and bile duct cancer. Overall morbidity rate was 37%, which has been decreasing, however, pancreatic leakage is still an unresolved problem. The overall mortality was 4.7% and improved from 9.1% in period I to 2.5% in period III. There has been a remarkable improvement in the 5-year survival rate for ampullary cancer (period I: 31%; II: 54%; III: 65%) and for bile duct cancer (19%, 32%, 36%), whereas that for pancreatic cancer is still detrimental (7%, 14%, 16%). CONCLUSION: Pancreatoduodenectomy has been increasing probably due to increased incidence of the indications and aggressive resection. Morbidity and mortality have decreased remarkably, and survival has improved, especially for ampullary and bile duct cancer. Therefore, the role of pancreatoduodenectomy for the management of periampullary cancer has become more significant.

Pylorus-preservation Decreases the Extent of Atrophy of Remnant Pancreas after Pancreatoduodenectomy

BACKGROUND: A pylorus-preserving pancreatoducdenectomy (PPPD) preserves the secretion of gastrointestinal (GI) hormones from the distal stomach and the duodenum, whereas they are no longer secreted after standard pancreato-duodenectomy (PD). It has been suggested that some GI hormones exert a trophic effect on the pancreas, though this has not been documented in humans. We postulate that the ablation of GI hormones, such as gastrin and cholecystokinin (CCK) by PD is an important cause of postoperative pancreatic atrophy, and since PPPD preserves the secretion of these hormones, it will be more effective than PD for the maintenance of postoperative pancreatic volume. PURPOSE: To determine whether pylorus preservation after PD affects the volume of the remnant pancreas in long-term survivors, and whether such an effect, is related to the continued secretion of GI hormones following preservation of the pylorus. MATERIALS & METHODS: We measured the postoperative pancreatic volume and the release of gastrin and CCK in patients who had undergone PD or PPPD performed by the same surgeon and survived one year or longer without recurrence. For volumetry, thin-section spiral CT with three-dimensional display was performed; suitable hormone release was measured by radioimmunoassay using antibodies. RESULTS: After PPPD, the pancreatic volume and the gastrin release were significantly greater than after PD and there was a significant correlation between pancreatic volume and stimulated gastrin release. The pancreatic volume was not related to other clinical factors such as type of reconstruction, age, postoperative interval, or nutritional status. CONCLUSION:We have demonstrated that the volume of distal remnant pancreas is greater after PPPD than after PD, and suggest that this is due to preservation by PPPD of GI hormones, which may exert a trophic effect on the pancreas.