Comparison of Pancreatic Function after Pylorus Preserving Pancreatoduodenectomy according to the Pancreatoenterostomy

ABSTRACT

BACKGROUND: Since the introduction of the Whipple procedure, it has been the standard treatment method for periampullary carcinomas. However, since the pancreatoduodenectomy has high operative morbidity and mortality, numerous modifications of the pancreatoduodenectomy have been developed to reduce the operative risk. Among the modifications of the pancreatoduodenectomy, the pancreatogastros tomy was developed to reduce pancreatic leakage, which is the most serious complication after a pancreatoduodenectomy. Many favorable data about the pancreatogastrostomy have been published recently. However, some surgeons are reluctant to do a pancreatogastrostomy for fear of early remnant pancreatic insufficiency due to reflux of gastric juice. For that reason, we compare the functional aspects of a pancreatoduodenectomy between a pancreatojejunostomy (P-J) and a pancreatogastrostomy (P-G). METHODS: We studied 35 patients who underwent a pylorus-preserving pancreatoduodenectomy (PPPD) with a diagnosis of a periampullary carcinoma (n=34) or pancreatitis (n=1) at Seoul National University Hospital between 1994 and 1997 and who lived without recurrence for over 1 year. The mean age was 57 year, and the sex ratio was 2015. Among them, 20 patients received a pancreatojejunostomy; the others received a pancreatogastrostomy. To compare the two groups, we analyzed (1) general nutritional status, (2) gastrointestinal (GI) symptoms and pancreatic exocrine function by measuring fecal elastase, and (3) pancreatic endocrine function by using the oral glucose tolerance test (GTT). RESULTS: After a PPPD, the body weight was decreased in both groups compared to that of the preoperative healthy state, but there was no difference between two groups. Also, no statistical difference could be found in triceps skin-fold thickness and serum protein and albumin and postoperative gastrointestinal symptoms except steatorrhea. There were 4 mild and 15 severe pancreatic exocrine insufficiencies in P-J patients, but all P-G patients showed severe pancreatic insufficiency on the stool elastase test. Excluding preoperative diabetes patients, 44% (7/16) of the P-J patients had an abnormal GTT after the operation, but 75% (9/12) of the P-G patients had an abnormal GTT (p=0.114). CONCLUSION: Exocrine and endocrine pancreatic insufficiencies developed after a PPPD, but did not induce the general malnutrition. A P-G had more deterioration of the pancreatic function than a P-J did. Thus, we must consider the general nutritional status, as well as the risk of pancreatic leakage, in the determination of pancreatoenteric anastomosis.