Toward zero mortality in pancreaticoduodenectomy / Шинэ санаа Шинэ нээлт

ABSTRACT

Background: Pancreaticoduodenectomy (PD) is the traditional treatment forpatients with malignant and benign diseases in the periampullary region. In spiteof advances in surgical techniques and perioperative management, the morbidityrates after PD has been range from 30 to 40 %. Moreover, the mortality afterPD remains 1-5 % even in high-volume centers. A postoperative pancreaticfistula (POPF) is the most common complication after PD, and a POPF from thepancreaticodigestive anastomosis has been the most important cause of morbidity,and also contributes significantly to the prolonged hospitalization and mortalityof patients undergoing PD.Objectives: To review the current surgical and supportive strategies used toprevent the development of POPF, and our procedure and outcome of PD.Systematic review about pancreatico-digestive anastomosis A systematic reviewincluding meta-analysis and randomized controlled trials (RCTs) regardingpancreatico-digestive anastomosis revealed that PJ and PG did not show anysignificant differences in mortality and morbidity including the risk of POPF,whereas b-PJ significantly decreased the risk of POPF compared with c-PJ.External duct stenting has been described to reduce the risk of clinically relevantPOPF in a metaanalysis and RCTs.Surgical procedures According these suggestions described above, PD wasperformed in our institution, with D2 dissection of lymph nodes for malignantdiseases. Mesenteric approach was performed to dissection of lymph nodes. Almostall patients underwent subtotal stomachpreserving PD, in which the pylorus andhalf of the antrum were removed. If the tumor invaded the superior mesentericand portal veins (SMV-PV), the involved SMV-PV was resected and reconstructed.A modified Child’s reconstruction was performed with pancreatico-gastrostomy(PG), end-to-side binding pancreatico-jejunostomy (b-PJ) or conventional PJ (c-PJ). External pancreatic duct stent was placed in all patients. Two closed peritonealdrainage tubes were placed posterior to the pancreatico-digestive anastomosis.Results: From September 2009, we performed 126 consecutive PD, including 83male and 43 female with median age of 69 (34-85) years old. Of these patients,104 cases (82.5) had malignant disease such as pancreatic and bile duct cancer,whereas the others had benign disease such as Intraductal papillary mucinousneoplasm (IPMN). SMV-PV resection and reconstruction was performed in 18patients (14%). Two cases of Hepato- pancreatoduodenectomy was includedin this study. Median operative time of the whole patients was 471 (291-869)min, and median operative bleeding was 675 (44-3875) g. PG was performedfrom September 2009 to March 2012 in 59 patients. In this PG group, POPF(Grade B or C) occurred in 15 cases (25%) and overall complication (Clavien-Dindo IIIa or more) occurred in 25 cases (42%). To reduce POPF, the b-PJ wasintroduced at April 2012 and performed in 42 cases until August 2013. In the b-PJgroup, the incidence of POPF was reduced to 9.5% (4 cases), however, overallmorbidity was not significantly improved (36%, 15 cases). Especially, specificsevere complication associated b-PJ, such as repeated bleeding from pancreaticcut and major anastomotic leakage, occurred and re-operation was performed tothese cases. Finally, the c-PJ was introduced at September 2013 and performedin 25 cases until now. The incidence of POPF was gained to 16% (4 cases) andoverall morbidity was not significantly improved (36%, 9 cases), however, severecomplication due to PJ has not occurred. Importantly, we have archived zeromortality in consecutive 126 PD patients.Conclusion: The systematic review suggested that the successful managementof pancreatic anastomoses may depend more on meticulous surgical technique,surgical volume and other management parameters, rather than on the techniqueused. Whereas the morbidity has been still high, we have archived zero mortalityin consecutive 126 PD. Surgical techniques and perioperative managementsshould be improved more in the future.