Outcomes of Whipple procedure/pancreaticoduodenectomy- an eighteen-year experience at a tertiary cancer care centre in south India

Background: Early postoperative mortality rates after pancreaticoduodenectomy are in the range of 2-5%. Nonetheless, morbidity rates are still at 30-50% calling for apt strategies. The goal of this study was to examine the outcomes in terms of postoperative morbidity and 30-day mortality while additionally reviewing the demographic, clinical and pathological features of patients undergoing Whipple procedure at our government institution and comparing the outcomes with literature. Methods: Data about demographic characteristics, intraoperative findings, postoperative histopathology, postoperative course, early post-operative outcomes, complications, and causes of postoperative death in patients who underwent pancreaticoduodenectomy for periampullary and pancreatic carcinoma between September 2006-August 2023 were collected and analysed. Results: 45 patients were analysed. Mortality rate was 15.6%. Seven patients died perioperatively; three from cardiac cause (myocardial infarction), two from bile leak and sepsis, one from pulmonary embolism, and one as a result of postoperative hemorrhage. The morbidity rate was 54%. The most common early postoperative complication was delayed gastric emptying (31%) followed by postoperative pancreatic fistula (22%). The median overall survival of 39 patients was 21�5 months. The 5-year survival was 17 months. Conclusions: Considering the fact that postoperative morbidity after Whipple procedure was similar to other centres, but the mortality rate being high, better knowledge about salvage techniques, improvements in perioperative care, use of interventional radiology, and running quality improvement projects to standardize postoperative recovery protocol could help in reducing the mortality and improve the outcome.

Postoperative day 3 drain amylase versus fistula risk score: predicting clinically relevant postoperative pancreatic fistula following pancreatico-duodenectomy

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the most common cause of perioperative morbidity following pancreatico-duodenectomy (PD). Early and accurate prediction of CR-POPF can be helpful in postoperative drain management as well as stratifying patients for enhanced recovery protocol after surgery. Both fistula risk score (FRS) and postoperative drain amylase levels have been analyzed in past. However, currently there is no clear consensus regarding the ideal predictor. Present study sought to assess the utility of postoperative day 3 drain amylase (POD-3DA) level as a predictor of CR-POPF in comparison with FRS.Methods: A retrospective analysis was done on 57 patients who underwent PD at our institute between 2014 to 2018. POPF was defined and graded in accordance with ISGPF definition. Receiver operating characteristic (ROC) analysis predicted a threshold of POD3DA >486 IU/l associated with CR-POPF. Sensitivity, specificity and odds ratios with 95%CI calculated and ROC curves were plotted for POD3DA of ≥500 IU/l and FRS (negligible/low vs. moderate/ high) as predictors of CR-POPF.Results: Incidence of POPF and CR-POPF was 63% and 32% respectively. Sensitivity and specificity of POD3DA ≥500 and moderate/high FRS for predicting CR-POPF were 83%, 79% & 78%, 51% respectively. Difference between ROC area under the curve (AUC) for POD3DA ≥500 IU/l (0.868) and FRS (0.692) was significant (p=0.028). Combining FRS and POD3DA ≥500 IU/l improved specificity (87%) at the cost of sensitivity (67%). The negative predictive value of POD3DA <500 IU/l and negligible/low FRS were 91.2% and 83.3% respectively.Conclusions: POD3DA level greater than 5 times of upper normal range is more precise at predicting CR-POPF, hence clinically more reliable for drain and postoperative management.

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.