Blumgart method using LAPRA-TY clips facilitates pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.

The modified Blumgart method for pancreaticojejunostomy has been shown to reduce the rate of postoperative pancreatic fistula (POPF) in open surgery. We describe a modified Blumgart method using LAPRA-TY suture clips to facilitate laparoscopic pancreaticojejunostomy.We prepared a double-armed 4-0 nonabsorbable monofilament, which was ligated using the LAPRA-TY clip at the tail end, 12-cm in length. Next, the U-suture was placed through the pancreatic stump and the seromuscular layer of the jejunum. We performed duct-to-mucosa suturing with a 5-0 absorbable monofilament. After completing the duct-to-mucosa suturing, as a final step we placed the sutures through the seromuscular layer of the jejunum on the ventral side and tightly secured the thread with the LAPRA-TY clips. We performed laparoscopic Blumgart pancreaticojejunostomy during pancreaticoduodenectomy in 39 patients. We compared the surgical outcomes of 19 patients who underwent Blumgart pancreaticojejunostomy using the LAPRA-TY clips (LAPRA-TY group) with 20 patients undergoing surgery not using the LAPRA-TY clips (conventional group).The rate of clinically relevant postoperative pancreatic fistula in the LAPRA-TY group was 21.1%, which did not differ significantly from the rate of the conventional group. However, the mean time of pancreaticojejunostomy in the LAPRA-TY group was 56.2 min (range, 39-79 min), which was significantly shorter than that of the conventional group (69.7 min; range, 53-105 min, P < .001).Although the modified Blumgart pancreaticojejunostomy using LAPRA-TY suture clips did not improve the pancreatic fistula rate, it allowed for shorter operative times. Thus, this procedure lends itself to positive surgical and patient outcomes.

Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery.

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.

The pancreatic juice length in the stent tube as the predicting factor of clinical relevant postoperative pancreatic fistula after pancreaticoduodenectomy.

Several risk factors for pancreatic fistula had been widely reported, but there was no research focusing on the exocrine output of remnant gland.During the study period of January 2015 to September 2016, 82 patients accepted pancreaticoduodenectomy (PD, end-to-end dunking pancreaticojejunostomy with internal stent tube). All the data were collected, including preoperative medical status, operative course, final pathology, gland texture, pancreatic duct diameter, size of the stent, length of pancreatic juice in the stent tube, width of the pancreatic stump, diameter of the jejunum and the status of postoperative pancreatic fistula (POPF). POPF was defined according to International Study Group of Pancreatic Fistula criteria.The diameter of pancreatic duct in the POPF group was significantly smaller than that in the group without POPF (1.99 vs 2.90 mm, P = .000). The length of pancreatic juice in the stent tube in the POPF group was significantly longer than that in the group without POPF (18.04 vs 6.92 cm, P = .014). There were more pancreatic ductal adenocarcinoma cases and hard glands in the group without POPF. The length of pancreatic juice in the clinically relevant postoperative pancreatic fistula (CR-POPF) group was significantly longer than that in the grade A group (32.4 vs 9.21 cm, P = .000). Multivariate analysis identified gland texture and length of pancreatic juice as independent predictors for pancreatic fistula. Multivariate analysis also identified the length of pancreatic juice as an independent predictor for CR-POPF.The length of pancreatic juice in the stent tube might be a useful predictive factor of POPF after PD, especially for CR-POPF.

[Robotic pylorus-preserving pancreaticoduodenectomy : Video article]. / Roboterassistierte pyloruserhaltende Pankreaskopfresektion : Videobeitrag.

Pylorus-preserving pancreaticoduodenectomy is one of the most complex procedures in general surgery. Laparoscopic pancreaticoduodenectomy was initially described in 1994; however, its worldwide distribution is so far limited to only a few specialist centers. Robotic surgery using the DaVinci® system can overcome many limitations of laparoscopic surgery. The system is a promising tool for a more widespread introduction of minimally invasive surgery for pancreatic diseases. Mortality rates of 0-5% and pancreatic fistula rates of 0-35% are described in the literature; therefore, thorough complication management is crucial in the postoperative course. The video presents a robotic pylorus-preserving pancreaticoduodenectomy for periampullary carcinoma in a female patient.

Pancreatic Duct Holder and Mucosa Squeeze-out Technique for Duct-to-Mucosa Pancreatojejunostomy After Pancreatoduodenectomy: Propensity Score Matching Analysis.

BACKGROUND: Duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy can be technically difficult, particularly in cases with a non-dilated pancreatic duct. We devised a novel procedure employing a pancreatic duct holder and mucosa squeeze-out technique facilitating duct-to-mucosa anastomosis. We compared the perioperative outcomes of pancreatoduodenectomy with duct-to-mucosa pancreatojejunostomy between the novel and conventional procedures. METHODS: Our pancreatic holder has a cone-shaped tip with a slit. The holder can expand the pancreatic duct and provides a good surgical field for anastomosis. A small incision for anastomosis is made on the jejunum, while the jejunum is grasped around the incision. Then, the jejunal mucosa becomes squeezed-out and everted. This mucosa squeeze-out technique facilitates suturing the full thickness of the jejunum. Propensity score matching yielded 113 cases each undergoing the novel and the conventional procedure, among 308 cases receiving pancreatoduodenectomy with duct-to-mucosa pancreatojejunostomy. RESULTS: The overall morbidity rate was significantly lower in the novel procedure group. The pancreatic fistula (ISGPF grade B/C) rate was significantly lower in the novel (5 %) than in the conventional (13 %) procedure group. For cases with a non-dilated pancreatic duct (≤3 mm), the rate was significantly lower in the novel (10 %) than in the conventional procedure group (24 %). Multivariate analysis identified a non-dilated pancreatic duct, soft pancreas, and the conventional procedure as factors independently predicting the complication of pancreatic fistula formation. CONCLUSIONS: Our novel procedure facilitates duct-to-mucosa pancreatojejunostomy and decreases the pancreatic fistula rate. This procedure is simple, rational, and useful for achieving anastomosis, particularly in cases with a non-dilated pancreatic duct.

One-layer versus two-layer duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: study protocol for a randomized controlled trial.

BACKGROUND: Although various pancreaticojejunal duct-to-mucosa anastomosis methods have been developed to reduce the postoperative risks of pancreaticoduodenectomy, pancreatic fistula remains the most serious complication with a high incident rate. The aim of this study is to compare the safety and effectiveness of one-layer and two-layer duct-to-mucosa pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy. METHODS/DESIGN: In this study, adult patients who sign consent forms will be recruited and scheduled for elective pancreaticoduodenectomy. One hundred and fourteen patients will be included and randomized before pancreaticojejunal reconstruction and after resection of the lesion from the pancreatic or periampullary region. The primary efficacy endpoint is the incident rate of postoperative pancreatic fistula. Statistical analysis will be based on the intention-to-treat population. Patients will be followed up for 3 months by monitoring for complications and other adverse events. DISCUSSION: This prospective, single-center, randomized, single-blinded, two-group parallel trial is designed to compare one-layer with two-layer duct-to-mucosa anastomosis for pancreaticojejunal anastomosis during elective pancreaticoduodenectomy. TRIAL REGISTRATION: Clinical Trials.gov: NCT02511951 . Registered on 29 July 2015.

[Robotic Pancreatic Surgery]. / Roboterchirurgie des Pankreas.

Pancreatic surgery is one of the most challenging fields in visceral surgery. However, laparoscopic pancreatic surgery has not become the standard of care as yet, especially because of the very demanding reconstruction of anastomoses in pancreaticoduodenectomy. Robotic surgery has been a recent advance in laparoscopy. Its benefits are a better 3D view, a greater degree of freedom corresponding to that of the human hand, and tremor elimination. These factors greatly facilitate the intracorporeal suturing and knot-tying, which offers a technical advantage in performing pancreaticojejunostomy as compared with laparoscopic resections. However, only a few centres are offering this procedure for pancreatic resections. Retrospective analyses show that robotic pancreatic resections are safe und oncologically adequate if performed by experienced surgeons. Prospective, randomised trials comparing laparoscopic and robotic pancreatic resection techniques are not available to date.

Total Laparoscopic Pancreaticoduodenectomy Using a New Technique of Pancreaticojejunostomy with Two Transpancreatic Sutures with Buttresses.

BACKGROUND: Laparoscopic pancreaticoduodenectomy is advantageous as a minimally invasive surgery, but performing the complicated anastomosis is technically difficult. Herein, we present our experiences with total laparoscopic pancreaticoduodenectomy (TLPD) using a unique anastomosis technique, that is, pancreaticojejunostomy using only two transpancreatic sutures with buttresses method (PJt). MATERIALS AND METHODS: From September 2013 to March 2015, 12 TLPDs using PJt for periampullary tumors were performed. In each case, the pancreaticoenteric anastomosis was performed using the PJt technique, a modification of invaginated, end-to-end pancreaticojejunostomy. A pair of transpancreatic sutures were placed on the upper and lower borders of the implanted pancreas through the jejunal limb covering the pancreas stump, and four buttresses were used to reinforce the anastomosis. All medical records and follow-up data were reviewed and analyzed with regard to surgical outcomes, and the results were compared with previously published reports on TLPD. RESULTS: The mean age of the patients was 64.3 ± 12.3 years, and all were diagnosed with pancreas head cancer except 5 patients (4 patients had ampulla of Vater cancer, and the other had chronic pancreatitis). The mean estimated blood loss was 118 ± 57 mL, and the mean hospital stay was 12.5 ± 4.5 days. The mean operative time was 411.6 ± 59.2 minutes, and the pancreas anastomosis time was 20.1 ± 4.8 minutes without any evidence of anastomosis-related complications. CONCLUSIONS: Our novel technique of PJt is a simple, easy, and feasible method for TLPD with the possibility of reducing the burden to the operator and acquiring secure anastomosis.

Laparoscopic Longitudinal Pancreaticojejunostomy Using Barbed Sutures: an Efficient and Secure Solution for Pancreatic Duct Obstructions in Patients with Chronic Pancreatitis.

We describe our laparoscopic longitudinal pancreaticojejunostomy (LPJ) technique using barbed sutures to manage a pancreatic duct obstruction. We performed laparoscopic longitudinal anterior pancreaticojejunostomy using barbed sutures (3-0 absorbable wound closure device, V-Loc, Covidien, Minneapolis, MN, USA) in 11 patients who presented with signs of a pancreas ductal obstruction and chronic pancreatitis. The surgical outcomes and follow-up records at the outpatient department were reviewed, and the effectiveness and feasibility of this method were analyzed. Mean patient age was 54.4 ± 9.5 years, and pancreatic duct stones were removed from all patients without conversion to laparotomy. Overall operative time was 200.7 ± 56.4 min, and estimated blood loss was 42.2 ± 11.2 ml. No pancreatic anastomosis leakage or postoperative bleeding was detected. Mean length of hospital stay was 6.5 ± 0.8 days, and mean time to start a soft diet was 4.8 ± 0.7 days. No patient complained of postoperative abdominal pain, and all patients recovered without significant complications or relapse of pancreatitis. The follow-up period was 4-21 months. Our new laparoscopic longitudinal anterior pancreaticojejunostomy technique (Puestow procedure) using barbed sutures is a potentially efficient and minimally invasive procedure for patients who suffer from pancreatic duct obstruction and chronic pancreatitis.

Mattress sutures for the modification of end-to-end dunking pancreaticojejunostomy.

Despite the improvement of surgical techniques, the rate of anastomotic failure of pancreaticojejunostomy remains high (30%-50%). Here we describe the use of vertical mattress sutures in the modification of dunking pancreaticojejunal anastomosis. In 7 patients who used this technique, neither anastomotic failure nor any major postsurgical complication developed. This technique is an easy, safe, and promising for the performance of pancreaticojejunostomy.

The Frey procedure with the use of 2 types of ultrasonically activated scalpels for chronic pancreatitis: report of a case.

A surgical procedure is the only way to relieve intractable pain in patients with chronic pancreatitis and an inflammatory mass in the pancreas head. Although the Frey procedure is safer and more effective for pain relief than is standard pancreaticodudenectomy, it is often associated with such complications as pancreatic fistula and postoperative hemorrhage. A 64-year-old man was admitted to our hospital because of increasingly frequent episodes of epigastralgia. This patient had continued to abuse alcohol until recently and was regularly using painkillers to relieve severe pain due to chronic pancreatitis. The patient underwent the Frey procedure with the use of 2 types of ultrasonically activated scalpel. There were no surgery-related complications. The patient was discharged 18 days after the operation. Neither recurrence of pain nor locoregional complications have been observed for 2 years after the procedure. Herein we report the use of the Frey procedure to treat an enlarged mass of the pancreatic head and discuss the efficacy of the ultrasonically activated scalpel for excavation of the pancreatic head and long dichotomy of the pancreatic duct.

The comparison of clinical results between hand suturing and mechanical stapling for gastrojejunostomy and jejunojejunostomy after SSPPD.

BACKGROUND: Mechanical stapling method is widely established alternative to conventional hand suturing. METHOD: For gastrointestinal anastomoses. In this study, we compare the clinical results of mechanical stapling with those of hand suturing for gastrojejunostomy and jejunojejunostomy after Subtotal Stomach Preserving Pancreaticojejunostomy (SSPPD). METHODS: Between 2002 and 2007, 42 patients who underwent SSPPD with concise records on operative procedure and time required for gastrojejunostomy and jejunojejunostomy were enrolled. Out of 42 patients, the mechanical stapling for gastrojejunostomy and jejunojejunostomy after SSPPD was performed for 19 patients and hand suturing for those in SSPPD was done for 23 patients. RESULTS: All clinical characteristics were similar in both groups. There was no statistical difference between both groups in the rate of complications related to gastrojejunostomy and jejunojejunostomy. However, days of nasogastric intubation and days until liquid diet in the stapled group were significantly shorter than those in the hand sutured group. Time required for gastrojejunostomy and jejunojejunostomy was significantly shorter in the stapled group than in the hand sutured group. CONCLUSIONS: This study suggested that stapled anastomoses might require a shorter time to perform and decreased time for nasogastric intubation and until liquid diet is introduced.

The pancreaticojejunal anastomotic stent: friend or foe?

BACKGROUND: The efficacy of pancreaticojejunal (P-J) anastomotic stents in preventing clinically relevant postoperative pancreatic fistulas (CR-POPF) after pancreatic resection is poorly understood. We sought to compare the outcomes of stented and nonstented patients in light of recognized risk-factors for the development of CR-POPF and to determine whether outcomes differed once there was a change in practice where use of stents was abandoned. METHODS: A total of 444 patients underwent proximal pancreatic resection with P-J reconstruction from 2001 to 2011. At the surgeon's discretion, a PJ stent (5- or 8-Fr Silastic tube) was placed in 59 patients (13.3%; 46 internal, 13 external). Demographics, comorbidities, and adjusted outcomes were evaluated between groups of nonstented (n = 385) and stented patients; these outcomes included a subgroup analysis of internally and externally stented patients. Risk factors for CR-POPF (International Study Group on Pancreatic Fistula grade B/C) development have been previously defined as soft gland, small duct size, high-risk pathology, or excessive blood loss (>1,000 mL). Outcomes were interpreted in reference to the risk factor profile (the number of absolute risk factors present; 0-4), and to the fistula risk score, a prospectively validated score which accurately predicts the risk and impact of pancreatic fistula based on these variables. RESULTS: Preoperative demographics of age, sex, body mass index, American Society of Anesthesiologists class, and physiologic and operative severity score for the enumeration of mortality and morbidity (ie, POSSUM) score were equivalent between cohorts. The CR-POPF risk-factor profile and fistula risk score were greater in stented patients (P < .01). When compared with nonstented patients, stented patients actually had greater rates of CR-POPF (29% vs 11%), major complications (29% vs 14%), greater mean duration of stay (13.7 days vs 9.6 days), and total costs ($33,594 vs $22,411; all P < .05). When high-risk cases were scrutinized, P-J stent use did not offer protection, as CR-POPF was uniformly more common when stents were used. Rates and severity of CR-POPF did not increase when the use of stents was abandoned, further implying that they did not confer protection from fistula development. Extended postoperative imaging was available for 23 stented patients. Of these, one-third of stents were retained past 6 weeks, and one-fourth beyond 6 months. Four patients required additional procedures to manage stent-related complications. CONCLUSION: The use of P-J stents does not decrease the incidence or severity of CR-POPF after proximal pancreatic resection, both overall and for high-risk scenarios. In some patients, P-J stents may lead to short- and long-term adverse outcomes.

A new feasible technique of mesh-reinforced pancreatojejunostomy and pancreatogastrostomy: retrospective analysis of 61 cases.

BACKGROUND: Pancreatic leak was the major concern after pancreatoduodenectomy. METHODS: A total of 61 patients who underwent mesh-reinforced pancreatojejunostomy or pancreatogastrostomy from August 2005 to November 2011 were retrospectively analyzed. RESULTS: The mean anastomosis time of mesh-reinforced pancreatojejunostomy was 25 minutes ranging from 22 to 35 minutes. In mesh-reinforced pancreatogastrostomy, the mean anastomosis time ranged from 20 to 38 minutes with an average of 30 minutes. Blood loss was 200 to 4,000 ml with an average of 710 ml in all patients. There was one case of pancreatic leak of Class A, three cases of pancreatic leak of Class B, one case of pancreatic leak of Class C, one case of choledochojejunostomy leakage, one case of gastrojejunostomy leakage, and three cases of abdominal bleeding. CONCLUSION: As a new technique, mesh-reinforced pancreatojejunostomy and pancreatogastrostomy might be a safe and feasible procedure to prevent postoperative pancreatic leak. TRIAL REGISTRATION: This research is waivered from trial registration because it was a retrospective analysis of medical records.

Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy.

BACKGROUND: Postoperative pancreatic fistula (POPF) remains one of the most common causes of morbidity following pancreaticoduodenectomy (PD). This randomized trial examined whether external stent drainage of the pancreatic duct decreases the rate of POPF after PD and subsequent pancreaticojejunostomy (PJ). METHODS: Consecutive patients who underwent PD with subsequent construction of a duct-to-mucosa PJ were randomized into a stented and a non-stented group. The primary outcome was the incidence of clinically relevant POPF. Secondary outcomes were morbidity and mortality rates, and hospital stay. RESULTS: Of 114 PD procedures, 93 were suitable for inclusion in the study after informed consent. The rate of clinically relevant POPF was significantly lower in the stented group than in the non-stented group: three of 47 (6 per cent) versus ten of 46 (22 per cent) (P = 0·040). Among patients with a dilated duct, rates of POPF were similar in both groups. Among patients with a non-dilated duct, clinically relevant POPF was significantly less common in the stented group than in the non-stented group: two of 21 (10 per cent) versus eight of 20 (40 per cent) (P = 0·033). No significant differences in morbidity or mortality were observed. Univariable analysis identified body mass index (BMI), pancreatic cancer,pancreatic texture, pancreatic duct size and duct stenting as risk factors related to clinically relevant POPF. Multivariable analysis taking these five factors into account identified high BMI (risk ratio(RR) 11·45; P = 0·008), non-dilated duct (RR 5·33; P = 0·046) and no stent (RR 10·38; P = 0·004) as significant risk factors. CONCLUSION: External duct stenting reduced the risk of clinically relevant POPF after PD and subsequent duct-to-mucosa PJ.