Clinical effect of indocyanine green fluorescence navigation combined with modified pancreaticogastrostomy in laparoscopic duodenum-preserving pancreatic head resection / 中华肝胆外科杂志

Objective:To evaluate the feasibility, safety and efficacy of indocyanine green (ICG) fluorescence imaging navigation combined with modified pancreaticogastrostomy in laparoscopic duodenum-preserving pancreatic head resection.Methods:The clinical data of 14 patients undergoing laparoscopic duodenum-preserving pancreatic head resection with indocyanine green fluorescence navigation technique combined with modified pancreaticogastrostomy from January 2019 to January 2022 in the Department of Hepatobiliary and Pancreatic Surgery, the First Hospital of Hebei Medical University were retrospectively analyzed, including 4 males and 10 females, aged (40.6±7.1) years. The operation time, intraoperative blood loss, postoperative complications and follow-up were recorded.Results:All 14 operations were successfully completed, and there was no intraoperative ICG allergic reaction. The intraoperative ICG staining facilitated the identification of common bile duct. The operation time was (325.71±23.00) min, and the time of modified pancreaticogastrostomy was (18.32±1.52) min. Intraoperative blood loss was 200 (150, 300) ml. There were no case of intraoperative blood transfusion. Postoperative complications include three cases of grade A pancreatic fistula, one of biliary fistula, and one of biliary stricture. All patients were followed up for one to 18 months, and the median follow-up time was 10 months. One patient had intermittent fever after operation. Magnetic resonance cholangiopancreatography showed biliary stricture in one patient one month after operation, which was managed by endoscopic biliary stent implantation.Conclusion:Indocyanine green fluorescence navigation is safe and feasible in laparoscopic duodenum-preserving pancreatic head resection. Combined with modified pancreaticogastrostomy, it helps skip the jejunal anastomosis and improve the efficiency of surgery.

Risk factors for clinically relevant postoperative pancreatic fistula of pancreatic tumor in children / 中华肝胆外科杂志

Objective:To analyze the influencing factors of clinically relevant postoperative pancreatic fistula (CR-POPF) in children with pancreatic tumors after surgery.Methods:The clinical data of 123 children undergoing surgery for pancreatic tumor in Beijing Children's Hospital, Capital Medical University from January 2007 to March 2020 were retrospectively analyzed, including 39 males and 84 females, with a median age of 9.8 years (6.7 to 11.8). Patients without pancreatic fistula and with biochemical leakage were included in control group ( n=95), while patients with grade B and C pancreatic fistula were divided into CR-POPF group ( n=28). The independent influencing factors of CR-POPF were analyzed by univariate and multivariate logistic regression. Results:Among 123 children, 28 cases (22.8%) developed CR-POPF, including 24 cases (85.7%, 24/28) of grade B pancreatic fistula and 4 cases (14.3%, 4/28) of grade C pancreatic fistula. There were significant differences between CR-POPF and control groups in the age > 8 years and 4 months, tumor location, operation time >390 min and procedures (all P<0.05). Multivariate logistic regression analysis showed an increased risk of CR-POPF in children aged > 8 years and 4 months ( OR=8.226, 95% CI: 1.813-37.333, P=0.006) and undergoing duodenum-preserving pancreatic head resection (DPPHR) ( OR=3.353, 95% CI: 1.282-8.767, P=0.014). Conclusion:Age>8 years and 4 months and DPPHR are independent risk factors for CR-POPF in children with pancreatic tumors after surgery.

Application of a modified pancreatogastric anastomosis in laparoscopic duodenum-preserving pancreatic head resection / 中华肝胆外科杂志

Objective:To study the feasibility of a modified pancreatogastric anastomosis in laparoscopic duodenum preserving pancreatic head resection (LDPPHR).Methods:The clinical data of 25 patients with benign or low-grade malignant tumors of pancreatic head undergoing LDPPHR at the Second Hospital of Hebei Medical University from January 2019 to May 2023 were retrospectively analyzed, including 7 males and 18 females, aged (44.9±6.2) years old. According to the methods of pancreatic digestive reconstruction, patients were divided into the observation group ( n=10), who underwent the modified pancreatogastric anastomosis, and the control group ( n=15) who underwent conventional pancreaticojejunal anastomosis and jejuno-jejunal anastomosis. The general data, intraoperative pancreatic digestive reconstruction time, maximum levels of amylase in abdominal drainage within three days postoperatively, postoperative complications, and hospital stay were compared between the groups. Results:All procedures were performed successfully. The intraoperative pancreatic digestive reconstruction time was shorter in the observation group [(27.8±2.4) min vs. (45.8±3.6) min, P=0.010]. The intraoperative blood loss were comparable between the groups [(140.5±14.8) ml vs. (145.2±9.7) ml, P=0.843]. The maximum level of amylase in abdominal drainage within three days postoperatively was lower in the observation group [(809.1±185.5) U/L vs. (1 385.4±481.1) U/L, P=0.031]. No grade C pancreatic fistula or postoperative hemorrhage occurred in either group, and the incidence of grade B pancreatic fistula was lower in the observation group [20.0% (2/10) vs. 60.0% (9/15), P=0.048], with a shorter postoperative hospital stay [(7.9±1.3) d vs. (10.3±2.7) d, P=0.017]. No decrease of life quality or reoperation due to pancreatic fistula, hemorrhage or digestive tract malfunction occurred in either group within a median follow-up of 15.6 months. Conclusion:In LDPPHR, the modified pancreatogastric anastomosis could help shorten the pancreatic digestive reconstruction and lower the risk of postoperative pancreatic fistula.

Experience in the laparoscopic duodenum preserving pancreatic head resection:a report of 4 patients / 中华肝胆外科杂志

Objective To summarized the experience in laparoscopic duodenum-preserving pancreatic head resection ( LDPPHR ) . Methods The clinical data of four patients who underwent LDPPHR from February 2017 to June 2018 in Hunan Provincial People' s Hospital were retrospectively analyzed. The Clinical characteristics, operation time, intraoperative blood loss, biliary fistula rate, pancreatic fistula rate and follow-up data were analyzed. Results The four patients included one patient with a solid pseudopapillary tumor and three patients with a serous cystadenoma. Two patients underwent duodenum-preserving total pancreatic head resection, and two patients underwent duodenum-preserving subtotal pancreatic head resection. The operation time of the four patients was (525. 8 ± 121. 8) minutes, and the blood loss (250. 0 ± 191. 5) ml. Biliary duct drainage was carried out in 2 patients: one patient developed biochemical bile leakage, while another had no postoperative complication. The two patients without biliary drainage developed grade B pancreatic leakage, delayed bile leakage, abdominal bleeding and infection. All the three patients who developed postoperative complications were treated conservatively and they recovered well. Conclusions LDPPHR was designed to better preserve the integrity and function of digestive tract. However, the perioperative complications were high. This operation should only be carried out in large pancreatic centers. Routine biliary drainage is recommended to surgeons with little experience in this operation.

Experience in the laparoscopic duodenum preserving pancreatic head resection: a report of 4 patients / 中华肝胆外科杂志

Objective@#To summarized the experience in laparoscopic duodenum-preserving pancreatic head resection (LDPPHR).@*Methods@#The clinical data of four patients who underwent LDPPHR from February 2017 to June 2018 in Hunan Provincial People’s Hospital were retrospectively analyzed. The Clinical characteristics, operation time, intraoperative blood loss, biliary fistula rate, pancreatic fistula rate and follow-up data were analyzed.@*Results@#The four patients included one patient with a solid pseudopapillary tumor and three patients with a serous cystadenoma. Two patients underwent duodenum-preserving total pancreatic head resection, and two patients underwent duodenum-preserving subtotal pancreatic head resection. The operation time of the four patients was (525.8±121.8) minutes, and the blood loss (250.0±191.5) ml. Biliary duct drainage was carried out in 2 patients: one patient developed biochemical bile leakage, while another had no postoperative complication. The two patients without biliary drainage developed grade B pancreatic leakage, delayed bile leakage, abdominal bleeding and infection. All the three patients who developed postoperative complications were treated conservatively and they recovered well.@*Conclusions@#LDPPHR was designed to better preserve the integrity and function of digestive tract. However, the perioperative complications were high. This operation should only be carried out in large pancreatic centers. Routine biliary drainage is recommended to surgeons with little experience in this operation.

A meta-analysis on surgical treatment of chronic pancreatitis:duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy / 中华内分泌外科杂志

Objective To carry out a meta-analysis,in order to evaluate the effectiveness and safety of the duodenum-preserving pancreatic head resection (DPPHR) and pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy(PPPD) for surgical treatment of chronic pancreatitis.Methods Medline,EMBASE,Cochrane library and other medical databases were searched for the clinical trials (randomized controlled trials) of comparing DPPHR Versus PD/PPPD.A total of 5 clinical trials (8 references) met the inclusion criteria.The data were analyzed using the RevMan 5.3 software.Results The two methods don't have statistical differ ence in terms of operation time (P=0.007),postoperative morbidity (P=0.35) and mortality (P=0.18),pain relief(P=0.36),new onset of diabetes(P=0.11),exocrine insufficiency(P=0.18),short-term(P=0.14) and long-term(P=0.16) quality of life score,the length of hospital stay (P=0.69),and pancreatic fistula (P=0.78).Weight gain (P＜0.000 01) and occupational rehabilitation (P=0.03)were significantly improved in the DPPHR group.However,PD/PPPD group was associated with fewer readmission due to pancreatic diseases.Conclusions DPPHR offers more advantages with regard to the quality of life.However,it needs more high-quality clinical trials to verify the results.

Laparoscopic duodenum-preserving subtotal pancreatic head resection: a clinical analysis of eight patients / 中华肝胆外科杂志

Objective@#To summarize the clinical experience of laparoscopic duodenum-preserving subtotal pancreatic head resection (LDPPHR).@*Methods@#The clinical data of 8 patients with LDPPHR performed at the Second Hospital of Hebei Medical University from November 2016 to February 2019 were analyzed retrospectively.@*Results@#All the eight patients underwent LDPPHR successfully. The operation time was 207.0~540.0 minutes. The estimated blood loss was 50.0~200.0 ml. The postoperative hospital stay was 10.0~27.0 days. One patient developed pancreatic fistula of grade B, and one patient developed biliary fistula. Pathologic results showed pancreatic solid pseudopaillary neoplasm in 3 patients, intraductal papillary mucinous neoplasms in 1 patient, mucinous cystadenoma in 1 patient, serous cystadenoma in 1 patient, neuroendocrine neoplasm in 1 patient, and pancreatic true cyst in 1 patient.@*Conclusion@#LDPPHR is a safe and effective surgical method for treatment of pancreatic head inflammatory mass, pancreatic head benign or low-grade malignant tumors.

Application value of superior mesenteric vascular right approach in duodenum-preserving pancreatic head resection for chronic pancreatitis with pancreatic head stones / 中华消化外科杂志

Objective To investigate the application value of superior mesenteric vascular right approach in duodenum-preserving pancreatic head resection for chronic pancreatitis with pancreatic head stones.Methods The retrospective descriptive study was conducted.The clinical data of 3 chronic pancreatitis patients with pancreatic head stones who were admitted to the Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2015 to May 2017 were analyzed.All the 3 patients underwent Beger procedure via superior mesenteric vascular fight approach,dissecting the posterior tunnel of pancreatic neck and gradually cutting off the pancreatic neck close to the right side of superior mesenteric vein.Observation indicators:(1) surgical situations;(2) postoperative situations;(3) postoperative pathological examination situations;(4) follow-up situations.Follow-up was performed by outpatient examination up to December 2017,including abdominal pain,diarrhea,chills,fever,jaundice,blood glucose,liver function and tumor marker examination,and residual or recurrent stones by ultrasound,CT or MRI examination.Measurement data were represented as average (range).Results (1) Surgical situations:all the 3 patients underwent successful Beger procedure via superior mesenteric vascular right approach,including 1 combined with choledochal cyst resection,without perioperative death.The operation time,time of cutting off pancreatic neck and volume of intraoperative blood loss of 3 patients were 400 minutes (range,360-480 minutes),20 minutes (range,15-25 minutes) and 117 mL (range,50-200 mL)respectively.(2) Postoperative situations:time of initial out-of-bed activity,time to anal exsufflation and time for drinking intake were 4 days (range,3-5 days),3 days (range,2-3 days) and 3 days (range,2-4 days).One patient complicated with pancreatic fistula and gastroplegia was improved by abdominal drainage and symptomatic treatment and discharged with drainage-tube at 30 days postoperatively and removed drainage-tube at 47 days postoperatively.One patient with pancreatic fistula was improved by abdominal drainage and symptomatic treatment and discharged with drainage-tube at 28 days postoperatively and removed drainage-tube at 48 days postoperatively.One patient recovered steadily without complications and discharged at 13 days postoperatively after removal of drainage-tube.(3) Postoperative pathological examination showed that 3 patients were diagnosed as chronic pancreatitis complicated with stones of pancreatic head,including 1 along with choledochal cyst and mild atypical hyperplasia.(4) Follow-up situations:3 patients were followed up for 17-27 months with good general conditions and without abdominal pain,diarrhea,chills,fever or jaundice.Blood glucose was controlled well,and liver function and tumor marker were normal.There was no sign of residual and recurrent stones.Conclusion Beger procedure via superior mesenteric vascular right approach for chronic pancreatitis complicated with pancreatic head stones is safe and effective.

Total pancreatic head resection with duodenum and bile duct preserving: a report of 31 patients / 中华肝胆外科杂志

Objective To investigates the role of duodenum and bile duct preserving pancreatic head resection (DBPPHR) in treatment of benign or low-grade malignant diseases located in the head of pancreas.Methods The clinical data of 31 patients who underwent DBPPHR between April 2012 to May 2016 in Zhejiang Provincial People's Hospital and Zhangzhou Municipal Hospital of Fujian Province were analyzed retrospectively.Results Of the 31 patients,4 patients underwent laparoscopic DBPPHR.One patient in the open group was converted to pancreaticoduodenectomy.For the open group,the mean operation time was (165.3 ±63.6) min;the mean estimated blood loss was (258.1 ± 156.9) ml;and the mean postoperative stay was (11.7 ± 6.3) days.The postoperative complications included 1 reoperation due to postoperative bleeding,1 bile leakage and 13 patients developed grade A pancreatic fistula (48.2％).For the laparoscopic group,the mean operation time was 350.0 (280.0 ～ 450.0) min;the mean estimated blood loss was 425.0 (250.0 ～600.0) ml;and the mean postoperative stay was 14 days.Three patients developed postoperative pancreatic fistula (grade A).The pathological diagnosis were:12 patients with pancreatolithiasis,8 patients with serous cystadenoma,4 patients with branched intraductal papillary mucinous neoplasm,5 patients with neuroendocrine tumor and 2 patients with mucinous cystadenoma.The follow-up period was 1 ～ 48 month,and there was no patient with diabetes or diarrhea.Conclusions DBPPHR was safe and efficacious.It is less invasive to treat benign or low-grade malignant diseases located in the head of pancreas.

Clinical efficacy of pancreaticoduodenectomy and duodenum-preserving pancreatic head resection for the treatment of chronic pancreatitis with mass in the head of the pancreas / 中华消化外科杂志

Objective To investigate the clinical efficacy of pancreaticoduodenectomy (PD) and duodenumpreserving pancreatic head resection (DPPHR,including Beger,Frey and Berne procedures)for the treatment of chronic pancreatitis (CP) with mass in the head of the pancreas.Methods The clinical data of 48 patients with CP who were admitted to the Armed Police Corps Hospital of Hunan province(13) and the Third Xiangya Hospital of Central South University (35) between January 2007 and December 2013 were retrospectively analyzed.The operation methods were selected according to clinical symptoms,imaging findings and intraoperative pathological examinations.Twenty-three patients receiving PD (Whipple procedure or pylorus-preserving PD) were allocated into PD group and 25 receiving DPPHR (Beger,Frey and Berne procedures) were allocated into DPPHR group.The operation time,volume of intraoperative blood loss,rate of postoperative pain relief,changes of pancreatic endocrine and exocrine function,complications,duration of hospital stay and hospital expenses in the 2 groups were analyzed.Patients were followed up by telephone interview and outpatient examination up to September 2014.Measurement data with normal distribution were presented as (x) ± s.Comparison between groups was analyzed using the t test.Count data were analyzed using chi-square test or Fisher exact probability.Results Of the 23 patients in the PD group,15 patients received Whipple procedure and 8 patients received pylorus preserving PD.Of 25 patients in the DPPHR group,8 patients received Beger procedure,13 patients received Frey procedure and 4 patients received Berne procedure.The operation time and volume of intraoperative blood loss were (5.5 ± 0.4) hours,(372 ± 174) mL in the PD group,and (4.2 ± 0.6) hours,(272 ± 114) mL in the DPPHR group,showing significant differences between the 2 groups (t =8.712,2.375,P ＜ 0.05).Three patients had massive hemorrhage in the PD group and 2 patients receiving Beger procedure had massive hemorrhage due to portal vein injury,with no significant difference (x2=0.010,P ＞ 0.05).The intraoperative pathologic examinations of frozen section showed chronic inflammation in all pancreatic tissue samples with fibrous tissue proliferations.Overall pain relief rate was 95.7％ (22/23) in the PD group,including 20 complete remissions and 2 partial remissions,and overall pain relief rate was 92.0％ (23/25) in the PD group,including 18 complete remissions and 5 partial remissions,which were no different in overall pain relief rate (x2 =0.000,P ＞ 0.05).The morbidity of postoperative diabetes mellitus and dyspepsia with fatty diarrhea were 38.9％ (7/18) and 35.7％ (5/14) in the PD group,which were no different from 9.5％ (2/21) and 20.0％ (3/15) in the DPPHR group (x2=3.200,0.281,P ＞0.05).The incidence of postoperative complication was 30.4％ (7/23) in the PD group,including 1 case of intra-abdominal hemorrhage,pancreatic fistula and localized peritonitis,1 case of pancreatic fistula,2 cases of biliary fistula,3 cases of delayed gastric emptying.Patients with pancreatic fistula and biliary fistula recovered after 1-week sufficient drainage.The incidence of postoperative complication was 4.0％ (1/25) in the DPPHR group,including 1 case of pancreatic fistula,showing significant difference in incidence of postoperative complication (x2=4.274,P ＜ 0.05).The duration of postoperative stay and hospital expense were (12.4 ± 2.5) days and (57 751 ± 6 772) yuan in the PD group,which were significantly different from (8.2 ± 1.8) days and (49 109 ± 6 168)yuan in the DPPHR group (t =6.576,4.645,P ＜ 0.05).Forty-eight patients were followed up with a median time of 51.6 months (9.0-92.0 months).Of the 2 patients died,1 patient who underwent Frey procedure died 3 months after diagnosis of pancreatic cancer due to epigastric pain at postoperative month 6,the other died 2 years later due to cardiovascular disease.Among 48 patients with follow-up,1 received biliary-intestine drainage 6 months later and other patients had no recurrence or canceration.Conclusions DPPHR is safe and effective for chronic pancreatitis with mass in the head of the pancreas,having advantages such as shorter duration of operation,less intraoperative hemorrhage,faster postoperative recover,shorter duration of hospital stay and delayed hypofunction of pancreatic endocrine and exocrine function.But DPPHR cannot completely replace PD,It is necessary to master indications for all kinds of operations and choose proper operative approaches based on lesion characteristics.

A meta-analysis on surgical treatments for chronic pancreatitis: duodenum-preserving pancreatic head resection versus pylorus-preserving pancreaticoduodenectomy / 中华肝胆外科杂志

Objective To compare the safety and effectiveness of duodenum-preserving pancreatic head resection (DPPHR) with pylorus-preserving pancreaticoduodenectomy (PPPD) in the treatment of chronic pancreatitis with a pancreatic head mass.Methods Medline,Biosis,Cochrane Library,Science Citation Index Database,CBM Database,Wan Fang and CNKI were searched systematically.The bias risk of the included trials was assessed according to the assessing tools as suggested by the Cochrane Handbook.Review Manage 5.2 was used to perform the statistical analysis.Results 7 RCTs with 226 patients were included in the meta-analysis which showed that there were no significant differences between PPPD and DPPHR in overall postoperative morbidity,postoperative hospital stay,complete pain relief,pancreatic fistula,exocrine insufficiency,symptom score at 5 to 7-year follow-up,and quality of life score at 14 to 15-year follow-up (P ＞ 0.05).While DPPHR had significant superiorities in operation time,blood replacement,delayed gastric emptying,occupational rehabilitation after the operations,weight gain,quality of life score at 1 to 2-year follow-up,symptom score at 5 to 7-year follow-up,and physical functioning score at 14 to 15-year follow-up.Conclusions DPPHR is more favourable than PPPD in reducing the use of blood replacement,shortening operation time,delayed gastric emptying,occupational rehabilitation after the operations,weight gain,physical functioning,and in improving quality of life of patients.

Efficacy of duodenum-preserving pancreatic head resection for the treatment of chronic pancreatitis combined with pancreatic duct stones: a prospective analysis / 中华消化外科杂志

Objective To investigate the efficacy of duodenum-preserving pancreatic head resection (DPPHR) for the treatment of chronic pancreatitis combined with type Ⅰ and Ⅲ pancreatic duct stones.Methods The clinical data of 55 patients with chronic pancreatitis and type Ⅰ and Ⅲ pancreatic duct stones who were admitted to the People's Hospital of Hunan Province from June 2008 to June 2013 were prospectively analyzed.All the patients were randomly divided into the pancreatoduodenectomy (PD) group (27 patients) and the DPPHR group (28 patients).There were 18 patients with chronic pancreatitis and type Ⅰ pancreatic duct stones and 9 patients with chronic pancreatitis and type Ⅲ pancreatic duct stones in the PD group.There were 16 patients with chronic pancreatitis and type Ⅰ pancreatic duct stones and 12 patients with chronic pancreatitis and type Ⅲ pancreatic duct stones in the DPPHR group.Patients in the PD group received PD + Child anastomosis + end-toside pancreato jejunal anastomosis + pancreatic stent placement + end-to-side cholangiojejunostomy.Patients in the DPPHR group received free of duodenum + pancreatic duct incision + resection of pancreas at 1 cm ahead of the pancreatic duct + extraction of the pancreatic duct stones + pancreaticoduodenal Roux-en-Y anastomosis.Patients were followed up via out-patient examination till December 2013.The measurement data were analyzed using the t test or Mann-Whitney U test,and the count data were analyzed using the chi-square test.Results During the operation,2 patients in the PD group were converted to the DPPHR group and 1 patient in the DPPHR group was converted to the PD group.No patient died during the perioperative period,and the symptoms including abdominal pain and diarrhea were alleviated at postoperative week 2.The operation time,blood loss,duration of postoperative hospital stay,total expenses and incidence of complications were (7.5 ± 1.6) hours,(460 ± 88) mL,(18.0 ± 3.5) days,(7.8 ± 2.1) × 104 yuan,19.2％ (5/26) in the PD group,and (4.0 ± 1.0) hours,(120 ± 36) mL,(9.5 ± 2.9) days,(3.9 ± 1.2) × 104 yuan,3.4％ (1/29) in the DPPHR group,there were no significant differences in the operation time,blood loss,duration of hospital stay,total expenses and incidence of complications between the 2 groups (t =9.358,11.365,6.325,8.647,x2 =3.976,P ＜ 0.05).Fifty-three patients were followed up,with the median time of 33 months (range,6 months to 5 years).No patient died during the follow-up.Twenty-four patients in the PD group were followed up,2 patients had slight abdominal pain,1 patient had severe abdominal pain due to pancreatic duct stenosis,and the symptom was alleviated after resection of partial pancreas ; the condition of 12 patients was improved among the 19 patients with diabetes.Twenty-nine patients in the DPPHR group were followed up,2 patients had slight pain; the condition of 16 patients were improved among the 22 patients with diabetes.Conclusion DPPHR is an ideal surgical procedure for patients with chronic pancreatitis and type Ⅰ and Ⅲ pancreatic duct stones.

Efficacy of modified duodenum-preserving pancreatic head resection for chronic pancreatitis / 中华消化外科杂志

Objective To investigate the efficacy of a modified duodenum-preserving pancreatic head resection (DPPHR) for the treatment of chronic pancreatitis.Methods The clinical data of 109 patients with chronic pancreatitis who received modified DPPHR at the Union Hospital of Huazhong University of Science and Technology from January 2004 to June 2013 were retrospectively analyzed.Of the 109 patients,66 were with mass in the head of the pancreas,29 were with calcification of the head of the pancreas,14 were with atrophy of the head of the pancreas and stones in the main pancreatic duct.The level of glucose of 56 patients were normal,34 patients had glucose tolerance abnormalities and 19 were complicated with diabetes mellitus.Modified DPPHR was carried out after confirming the diagnosis of chronic pancreatitis and excluding the malignancies by frozen pathological examination.The head of the pancreas was completely resected.The posterior pancreaticoduodenal aortic arch running parallel to the duodenum was preserved to guarantee the blood supply to the remaining duodenum.A thin sheet of the pancreatic tissue behind the intrapancreatic common bile duct and between the common bile duct and the duodenum was preserved to guarantee the blood supply to the common bile duct.The gastrointestinal tract was reconstructed with an anastomosis of the distal pancreas and the jejunum and an end-to-en anastomosis of the proximal jejunum and the distal jejunum.Patients were followed up via out-patient examination to learn the frequency of abdominal pain,analgesics usage and the endocrine function.The pain scale,life quality and endocrine function were evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30),Gastrointestinal Quality of Life Index (GLQI) questionnaire,and oral glucose tolerance test (OGTT),respectively.Patients were followed up till January 2014.The measurement data and the count data were analyzed using the t test and the chi-square test,respectively.Results No patients died during the operation.The operation time,volume of blood loss and blood transfusion were (3.5 ± 0.7) hours,(360 ± 125) mL and (260 ±220) mL,respectively.After the operation,5 patients were complicated with pancreatic leakage,5 with bile leakage,2 with duodenal fistula and 1 with peritoneal bleeding,and all the patients were cured after conservative treatment.Four patients were complicated with abdominal abscess,1 patient of whom was treated by conservative treatment,and the remaining 3 patients were cured by drainage guided by B sonography.The duration of hospital stay was 13.8 days (range,10.0-32.0 days).The median time of follow-up was 18.0 months (range,3.0-24.0 months).A total of 102 patients were followed up for more than 9 months.At postoperative month 9,the ratio of patients with abdominal pain was decreased from 78.90％ (86/109) to 18.63％ (19/102),and the ratio of patients administered analgesics was decreased from 76.47％ (78/102) to 12.75％ (13/102),with significant difference between the indexes before and after operation (x2=76.57,74.31,P ＜ 0.05).The score of the EORTC QLQ-C30 was decreased from 58 ±36 before operation to 15 ±4 after operation,with significant difference (t =11.39,P ＜ 0.05).The score of GLQI was increased from 69 ± 8 before operation to 87 ± 15 after operation,with significant difference (t =20.05,P ＜ 0.05).The patient with diabetes mellitus was cured,and no newly onset of diabetes was found.Two patients received reoperation because of recurrence of stones in the distal pancreatic duct and pancreatogenic portal hypertension.Conclusion Modified DPPHR is effective for the treatment of chronic pancreatitis with low incidence of postoperative complications.

Duodenum-preserving pancreatic head resection in benign and low-grade malignant pancreatic tumors

BACKGROUNDS/AIMS: With development of imaging techniques, pancreatic tumors are being diagnosed more frequently. Applying the standard surgical procedures for pancreatic head tumors, such as pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy may seem too extensive for benign or low-grade malignant pancreas head tumors. Duodenum-preserving pancreatic head resection (DPPHR) has been safely performed in patients with chronic pancreatitis. Recently, DPPHR has been used as a limited surgical procedure to remove benign or low-grade malignant pancreatic head lesions. This study is aimed to evaluate the results of DPPHR in benign or low-grade malignant tumors. METHODS: Between 2004 and 2012, six patients underwent DPPHR due to benign or low-grade malignant pancreas tumor. We performed this retrospective analysis based on the medical records. RESULTS: Five of six patients were diagnosed as intraductal papillary mucinous neoplasms. Remaining one patient was diagnosed as solid pseudopapillary neoplasm. The median age of patients was 60.3 (27-75) years, and the median follow-up period was 24 months. The operation time, blood loss and length of stay were 442.5 minutes, 680 ml and 19.2 days, respectively. There was no mortality. Five patients experienced complications including 1 delayed gastric empting, 2 bile duct strictures, 1 pancreatic fistula and 1 duodenal stricture. No recurrence or metastasis was found during follow-up. CONCLUSIONS: In benign and low-grade malignant lesions of pancreatic head, DPPHR could be alternative to traditional surgery. For applying DPPHR in pancreas tumor, a thorough preoperative examination and utilization of frozen section for sufficient resection margin are required.

Vascular Anatomy of the Pancreaticoduodenal Region

PURPOSE: Duodenum-preserving pancreatic head resection (DPPHR) is a suitable surgical procedure in the treatment of benign pancreatic head tumor, chronic pancreatitis and low-grade malignancy of pancreatic head. The main advantage of this procedure is the preservation of the duodenum, which plays a key role in digestive functions. To create a practical guideline for vascular preservation during DPPHR, we examined the anatomy of pancreaticoduodenal arteries (PDA) by specimen angiography. METHODS: From March 2000 to September 2001, 9 specimens were obtained from patients undergoing pancreaticoduodenectomy. As soon as the specimens were obtained, 4 PDA were cannulated and specimen angiography was performed. RESULTS: Arcade formation between the superior and inferior PDA was found in all of the cases. The anterior inferior PDA and posterior inferior PDA exhibited common trunk formation. Many communicating arteries between both arcades were found. The papillary branch, originating from the posterior superior PDA, was found in 4 cases. CONCLUSION: To preserve the blood supply to the duodenum, complete preservation of both arteries may not be necessary. However, the preservation of the posterior superior PDA may be needed to maintain the blood supply of the papillary and distal bile ducts.

Duodenum-preserving pancreatic head resection / 한국간담췌외과학회지

BACKGROUND: Recently, partial pancreatectomy has been performed for treatment of benign pancreatic lesion with special attention to functional preservation of adjacent organs. In contrast to traditional pancreaticoduodenectomy( Whipple's procedure) and pylorus-preserving pancreaticoduodenectomy(PPPD), the duodenum-preserving pancreatic head resection(DPPHR) preserves stomach, duodenum, jejunum, extrahepatic bile duct, and this procedure is reported to preserve function of adjacent organs, to reduce morbidity and mortality rates. The indications of DPPHR are benign lesion of the head of the pancreas as well as complications of chronic pancreatitis, including distal common bile duct obstruction, duodenal obstruction, colonic stenosis, pseudocyst of the head of the pancreas, internal pancreatic fistula, portal or splenic vein stenosis. Also this procedure is indicated for the management of the pancreatic head injury. Reconstructive methods following resection of the pancreatic head are modified variously, this methods are end-to-end anastomosis of the pancreatic duct, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, pancreaticoduodenostomy. MATERIALS AND METHODS: The authors performed DPPHR in 4 patients; pseudocyst of the pancreatic head 1, pancreatic head injury 2, chronic pancreatitis 1. Two patients with pseudocyst of the pancreatic head and pancreatic head injury underwent end-to-end anastomosis of the pancreatic duct after resection of the head of the pancreas. This procedure involved insertion of feeding tube into the pancreatic duct and then end-to-end anastomosis of the pancreatic duct. Other two patients with pancreatic head injury and chronic pancreatitis underwent Roux-en-Y pancreaticojejunostomy after resection of the head of the pancreas. RESULTS: Two patients with end-to-end anastomosis of the pancreatic duct developed leakage of the anastomotic site of the pancreatic duct at 3rd and 8th postoperative days, respectively. So this patients were performed reoperation, Roux-en-Y pancreaticojejunostomy. But the peripancreatic abscess developed after reoperation and then performed drainage of the abscess. This patients were improved and discharged. Total hospital stay was 35days and 34days, respectively. Other two patients underwent Roux-en-Y pancreaticojejunostomy after resection of the head of the pancreas. This patients were improved without complications and discharged within 1 month. CONCLUSIONS: In our experiences, DPPHR can be appropriated in the treatment of complications of chronic pancreatitis, benign lesion of the head of the pancreas, pancreatic head injury. And we consider that the Roux-en-Y pancreaticojejunostomy is more safe reconstructive method, compare with the end-to-end anastomosis of the pancreatic duct.

Surgical Management of Intraductal Papillary Mucinous Tumor of the Pancreas

BACKGROUND: Intraductal papillary mucinous tumor (IPMT) of the pancreas is a rare tumor arising in the main pancreatic duct or its subbranches. It is characterized by a diffusely or focally dilated main pancreatic duct filled with mucus and a mucus secretion through a patulous duodenal papilla. METHODS: The clinicopathologic characteristics of eight IPMT cases which were resected surgically from January 1994 to August 1998 at Seoul National University Hospital were reviewed to consider the optimal surgical treatment. RESULTS: The range of ages was from 49 to 70 years with a mean age of 59.3. Five were men and three were women. The prominent symptom was upper abdominal pain. Seven patients had been treated for pancreatitis before. Tumor markers didn't correlate with the pathologic status. In all the cases, a dilated pancreatic duct with secretion of mucin was found in the radiologic studies. Four lesions were located in the uncinate process, 3 in the body, and 1 diffusely. One total pancreatectomy, 1 Whipple's procedure, 3 pylorus-preserving pancreatoduodenectomies, 1 duodenum-preserving resection of the head of the pancreas, and 2 subtotal pancreatectomies were performed. Three lesions were malignant, another three were borderline malignant, and the remaining two were benign. Three were multiple lesions. Lesions for which the main pancreatic duct was dilated more than 0.5 cm, lesions greater than 2.5 cm, lesions with a mural nodule greater than 1.0 cm, or type 1, 2, 3 lesions were borderline malignant or malignant. There was no lymphatic metastasis. After a follow-up duration from 1 month to 56months, all patients are alive at the time of study and have experienced no locoregional recurrence or distant metastasis. CONCLUSIONS: In the radiologic studies, an IPMT should be considered in a multilobulating cystic lesion with the dilated main pancreatic duct. The lesions are variable from benign to malignant and often spread intraductally. When the lesion seems to be malignant, an aggressive resection is recommended.

Duodenum-preserving Pancreatic Head Resection for Benign Pancreatic Head Lesion

Pancreatoduodenectomy has been a standard procedure for periampullary cancer. Even when the benign lesion is limited to the pancreatic head, the same procedure has been applied if the lesion should be removed surgically. The duodenum has a key role in the digestive physiologic function. However, removal of the pancreatic head while preserving the duodenum has been considered a very risky procedure because of duodenal ischemia. Since the vascular anatomy of the peripancreatic area was thoroughly examined and a meticulous dissection technique was developed, duodenum-preserving procedure has been tried by several surgeons with success. In this paper we report our experience of duodenum-preserving pancreatic head resection. To our knowledge this is the first report in Korea. The lesions were insulinoma and two serous cystadenomas located at the pancreatic head. Total removal of the pancreatic head was performed trying to preserve pancreaticoduodenal vascular arcade without a Kocher maneuver. The common bile duct was totally preserved in all cases and cholecystectomy with T-tube choledochostomy was performed in one case. The pancreatic duct was ligated just distal to the ampullary portion and the distal pancreas was anastomosed to the posterior wall of the stomach. Operation time was 7 hours 30 minutes in one and 5 hours and 30 minutes in two cases. Transfusion was not required at all. Pancreatic leakage was developed in one case and cured with conservative management. Any complication related to the preservation of the duodenum(leakage or obstruction) had not developed. The patients were discharged on postoperative 46 day(due to pancreatic leakage), 18 days and 11 days respectively. In conclusion, duodenum-preserving pancreatic head resection is recommended for benign pancreatic head lesions, such as benign cystic tumor and localized chronic inflammation.