Postoperative complications linked to pancreaticoduodenectomy. An analysis of pancreatic stump management.

AIMS: To analyze the role of different procedures in the management of pancreatic stump according to the incidence of postoperative morbidity derived from the data of a single center surgical population. METHODS: From 1989 to 2005 we performed 76 pancreaticoduodenectomies (PD) and 26 distal pancreatectomies (DP). The surgical reconstruction after PD was as follows: 11 manual non-absorbable stitches closure of the main duct, 24 closures of the main duct with linear stapler, 17 occlusions of the main duct with neoprene glue and 24 duct-to-mucosa anastomosis. RESULTS: In the PD group, the morbidity rate was 60%, caused by: pancreatic leakage in 48% of patients, hemorrhagic complications in 10% following surgical procedure and infectious complications in 15%. After DP we recorded: leakage in 3.9%, haemoperitoneum in 15.4% and no complications in 80.7%. The multivariate analysis showed that the in-hospital mortality was linked to the surgical procedure (PD, p=0.003) and to the following complications: pancreatic leakage (p=0.004), haemoperitoneum (p=0.00045) and infectious complications (p=0.0077). Bleeding complications, biliary anastomosis leakage and infectious complications were consequences of pancreatic leakage (p=0.025, p=0.025 and p=0.025 respectively). CONCLUSION: Manual non-absorbable stitch closure of the main duct and occlusion of the main duct with neoprene glue should be avoided in the reconstructive phase.

Minimally invasive esophagectomy: a comparative study of transhiatal laparoscopic approach versus laparoscopic right transthoracic esophagectomy.

BACKGROUND: The development of minimally invasive surgery gave birth to an interest in a mini-invasive approach to esophageal cancer; however, it is still considered to be one of the most complex gastrointestinal surgical operations, and many questions still remain unanswered, regarding the oncologic results of a mini-invasive approach in long-term follow-ups. Here, the authors report on the short-term and long-term results of a series of laparoscopic esophagectomies. PATIENTS AND METHODS: From January 2002 to March 2006, 22 nonrandomized patients were recruited to undergo an esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were carried out using the laparoscopic transhiatal technique in 9 patients; whereas, a combined laparoscopic and right-transthoracic incision was performed in the other 13 patients. RESULTS: The mean follow-up was 21+/-3.23 months (mean+/-SD); range, 2 to 46 months. The overall survival rate resulted 84.0% at 12 months, 61.3% at 24 months, and 51.0% at 36 months. The proportions of cumulative survival showed significant differences when the following variables were considered: site of neoplasm (lower esophagus), American Society of Anesthesiologists 2, chronic obstructive pulmonary disease, type of surgical procedure, and inclusion in neoadjuvant protocol and staging. Recurrence rates were 3 (25%) in the radio-chemotherapy-treated group, and 5 (50%) in the primary surgery group (P=n.s.). CONCLUSIONS: The two-year survival rates (61.3%) recorded in our series are comparable with those reported in other series of both laparoscopic and open surgeries. The logical conclusion was that a less invasive procedure did not imply a less curative one.

The role of pancreatic leakage on rising of postoperative complications following pancreatic surgery.

INTRODUCTION: The variations in methods of pancreatic stump management and the volume of literature available on both main pancreatic duct and pancreaticoenetric anastomosis leak indicates the concern associated with the leak and the continuing efforts to prevent it. Herein we analyzed the role of pancreatic leakage followed by pancreatic surgery on the incidence of postoperative morbidity. PATIENTS AND METHODS: From 1989 to 2005, we performed 76 pancreaticoduodenectomy (PD) and 26 distal pancreatectomy (DP), assumed as control case). During DP the parenchymal transection was performed with a linear stapler. The surgical reconstruction after PD was as follows: 11 manual nonabsorbable stitch closure of the main duct, 24 closure of the main duct with linear stapler, 17 temporary occlusion of the main duct with neoprene glue, and 24 duct-to-mucosa anastomosis. RESULTS: In the PD group, morbidity rate was 60%, caused by pancreatic leakage, with an incidence of 48%, hemorrhagic complication, occurred in 10% of patients following surgical procedure and infectious complication, with an incidence of 15%. After distal pancreatectomy we recorded 80, 7% no complications, 3, 9% leakage, 15, 4% hemoperitoneum. By multivariate analysis bleeding complications, biliary anastomosis leakage, and infectious complications were consequences of pancreatic leakage (P = 0.025, P = 0.025, and P = 0.025, respectively). A significant statistical difference was recorded analyzing re-operation rates between closure of the main duct with linear stapler versus temporary occlusion of the main duct with neoprene glue (t = 0.049) and closure of the main duct with linear stapler versus duct-to-mucosa anastomosis (t = 0.003). CONCLUSIONS: On the ground of our results of bleeding complication, biliary anastomosis leakage and infectious complication were consequences of pancreatic leakage: failure of a surgical anastomosis has serious consequences, particularly in case of anastomosis of the pancreas to the small bowel, because of the digestive capacities of activated pancreatic secretions.

Analysis of survival after pancreatic resection for oncological pathologies.

Surgical treatment of pancreatic cancer is to date the only modality that offers a chance of long-term survival. Potentially curative surgery is an option for only about 15% of patients with pancreatic adenocarcinoma. The aim of this study was to determine the survival and to assess the association of clinical, pathological, and treatment features with survival of patients who underwent resection of pancreatic cancer at the Department of Surgery of Udine University Hospital. From November 1989 to December 2005, 137 consecutive patients, who underwent surgical procedures for pancreatic cancer, were followed in our department. We performed 76 pancreatico-duodenectomy, 26 distal pancreatectomies and 35 total pancreatectomies. The surgical reconstruction after pancreatico-duodenectomy was as follows: 11 closures of the main duct with manual nonabsorbable stitches, 24 closures of the main duct with a linear stapler, 17 occlusions of the main duct with neoprene glue and 24 duct-to-mucosa anastomoses. Mean survival time was 27.7 +/- 26.93 months (mean +/- SD) and mean disease-free survival time was 25.4 +/- 23.06 months (mean +/- SD). 1, 3, 5, 7 and 9-year survival rates were 63.9, 33.7, 21.17, 12.7 and 10.2%, respectively. Significant differences in survival were recorded by the Log-rank test for age > 70 (p = 0.001), surgical procedures (p = 0.00046) and presence of metastases (p = 0.0055) The treatment of pancreatic cancer is undertaken with two different aims. The first is radical surgery for patients with early-stage disease, mainly stage I and partly stage II. In all other cases, the aim of treatment is the palliation of the several distressing symptoms related to this cancer. The standard treatment option for resectable tumours is radical pancreatic resection according to the Whipple procedure or total pancreatectomy.

A comparative study of the transhiatal laparoscopic approach versus laparoscopic gastric mobilisation and right open transthoracic esophagectomy for esophageal cancer management.

AIM: Regarding the surgical treatment of esophageal cancer, a question was raised by the introduction of minimally invasive surgery, because of the technical complexity of the techniques involved and its uncertain benefits. We evaluated the impact of laparoscopic esophagectomy on the surgical approach to esophageal cancer. PATIENTS AND METHODS: From January 2002 to March 2006, 22 non-randomized patients were recruited to undergo esophagectomy for neoplastic disease. The esophagectomy and esophagogastroplasty were performed using the laparoscopic transhiatal technique (THE) in 9 cases, while a combined laparoscopic gastric mobilisation and right transthoracic incision (TT/LE) was performed in the other 13. RESULTS: Mean follow up was 21+/-3.23 months, range 2-46 months. Overall cumulative survival was 84.0% at 12 months, 61.3% at 24 months, 51.0% at 36 months. THE achieved better results than TT/LE on the ground with regard to the time it took to complete the procedure (p=0.046) and the hospital stay times (p=0.039), and the time in ICU, postoperative oral feeding resumption, number of retrieved lymph nodes. CONCLUSION: The clinical benefits of minimally invasive techniques regard the time it takes to complete the procedure, the time in ICU, postoperative oral feeding resumption and the hospital stay times. Minimally invasive surgery might be not less curative and effective than open surgical procedures, as found in our small non-randomzed series of patients. Larger series should confirm these results.