Whipple's cephalic pancreaticoduodenectomy versus pyloric-preserving pancreaticoduodenectomy. Retrospective study.

INTRODUCTION: Controversy exists in the literature as to the best technique for pancreaticoduodenectomy (PD), whether pyloric preservation (PP-CPD) or Whipple's technique (with antrectomy [W-CPD]), the former being associated with a higher frequency of delayed gastric emptying (DGE). METHODS: Retrospective and comparative study between PP-CPD technique (n = 124 patients) and W-CPD technique (n = 126 patients), in patients who were operated for tumors of the pancreatic head and periampullary region between the period 2012 and 2023. RESULTS: Surgical time was longer, although not significant, with the W-CPD technique. Pancreatic and peripancreatic tumor invasion (p = 0.031) and number of lymph nodes resected (p < 0.0001) reached statistical significance in W-CPD, although there was no significant difference between the groups in terms of lymph node tumor invasion. Regarding postoperative morbimortality (medical complications, postoperative pancreatic fistula [POPF], hemorrhage, RVG, re-interventions, in-hospital mortality, Clavien-Dindo complications), ICU and hospital stay, no statistically significant differences were observed between the groups. During follow-up, no significant differences were observed between the groups for morbidity and mortality at 90 days and survival at 1, 3 and 5 years. Binary logistic regression analysis for DGE showed that binary relevant POPF grade B/C was a significant risk factor for DGE. CONCLUSIONS: Postoperative morbidity and mortality and long-term survival were not significantly different with PP-CPD and W-CPD, but POPF grade B/C was a risk factor for DGE grade C.

Surgeon's Experience May Circumvent Operative Volume in Improving Early Outcomes After Pancreaticoduodenectomy.

Introduction Pancreaticoduodenectomy (PD) is a complex procedure with a significant proportion of postoperative complications and improving but notable mortality. PD was the prototype procedure that initiated the lingering debate about the relationship of better operative outcomes when performed at higher-volume centers. This has not translated into practice. Impediments include the absence of a universally accepted definition of a high-volume center among others. Contrary evidence suggests equivalent outcomes for PD at low-volume centers when performed by experienced hepatobiliary surgeons. We reviewed our perioperative outcomes for PD from an earlier period as a low-volume center with an experienced team. Methods A longitudinal study of all PDs completed in our department between 2012 and 2017 was performed. Results A total of 28 PD were performed during this period. Pylorus-preserving PD was performed in 23 patients and classical PD in the remaining. A separate Roux-en-Y loop was used for high-risk pancreatic anastomosis in six cases. The mean patient age was 49.3±12.4 years. The male-to-female ratio was 1.3:1. Preoperative drainage procedures were carried out in 19 patients. The mean serum total bilirubin level was 3.98(±4.5) mg/dL. There was no 90-day mortality. Postoperative complications included wound infection in 10 (36.7%) and respiratory complications in 10 (36.7%) patients. Postoperative bleeding requiring intervention occurred in one patient, and two patients had an anastomotic leak (one pancreatojejunostomy (PJ) and one gastrojejunostomy (GJ)). Delayed gastric emptying (DGE) was noted in three (10.7%) patients. The mean length of hospital stay was 14±7 days. The median overall survival (OS) was 84 months. Conclusion Comparable early outcomes can be achieved at low-volume centers for patients undergoing PD with an experienced team, optimal patient selection, and the ability to rescue for complications.

Treatment of right hepatic artery stump bleeding after pylorus-preserving pancreaticoduodenectomy by covered stent endoprosthesis placement.

Serious complications after pancreaticoduodenectomy include rupture of pseudoaneurysms arising from pancreatic fistula and pancreatojejunostomy leakage. We report a case of successful endovascular minimally invasive treatment using a covered stent endoprosthesis of a right hepatic artery stump bleeding following pylorus-preserving pancreaticoduodenectomy that was not suitable for coil or glue embolization due to an insufficiently short neck.

Oesophageal reconstruction with a reversed gastric conduit for a complex oesophageal cancer patient: a case report.

BACKGROUND: The gastric conduit is the best replacement organ for oesophageal reconstruction, but a reversed gastric conduit (RGC) is rare. Oesophageal reconstruction for oesophageal cancer patients with a previous history of complicated gastrointestinal surgery is rather difficult. Here, we report a case in which oesophageal reconstruction was successfully managed using RGC based solely on the left gastroepiploic artery supply. CASE PRESENTATION: A 69-year-old man with oesophageal cancer had a history of endoscopic intestinal polypectomy and pylorus-preserving pancreaticoduodenectomy (PPPD). The right gastroepiploic artery and right gastric artery had been completely severed. The only supply artery that could be used for the gastric conduit was just the left gastroepiploic artery. Because of the complex history of abdominal surgery, we had no choice but to use the RGC to complete the oesophageal reconstruction, in which the gastric conduit was passed reversely through the hiatus to the oesophageal bed and layered end-to-side manual intrathoracic anastomosis with the esophagus. The patient had transient feeding problems with postoperative delayed thoracic stomach emptying but no anastomotic stenosis or thoracic stomach fistula. He was satisfied with his life and had no long-term complications. There was no significant effect on gut physiological function, and RGC could work normally. CONCLUSIONS: Oesophageal reconstruction with RGC is a feasible procedure for complex oesophageal carcinoma that can simplify complicated surgical procedures, has less influence on gut function, is less invasive, and is safe.

Intraoperative endoluminal pyloromyotomy for reduction of delayed gastric emptying after pylorus preserving partial pancreaticoduodenectomy (PORRIDGE trial): study protocol for a randomised controlled trial.

BACKGROUND: Pylorus-preserving pancreaticoduodenectomy (ppPD) is a standard surgical procedure for the treatment of resectable neoplasms of the periampullary region. One of the most common postoperative complications after ppPD is delayed gastric emptying (DGE) which reduces quality of life, prevents a timely return to a solid oral diet and prolongs the length of hospital stay. In a retrospective analysis, intraoperative endoluminal pyloromyotomy was associated with a reduced rate of DGE. The aim of this study is to investigate the effect of intraoperative endoluminal pyloromyotomy on postoperative DGE after ppPD in a randomised and controlled setting. METHODS: This randomised trial features parallel group design with a 1:1 allocation ratio and a superiority hypothesis. Patients with a minimum age of 18 years and an indication for ppPD are eligible to participate in this study and will be randomised intraoperatively to receive either endoluminal pyloromyotomy or atraumatic stretching of the pylorus. The sample size calculation (n=64 per study arm) is based on retrospective data. The primary endpoint is the rate of DGE within 30 days. Secondary endpoints are quality of life, operation time, estimated blood loss, length of hospital stay, morbidity and mortality. DISCUSSION: DGE after ppPD is a common complication with an incomplete understood aetiology. Prevention of DGE could improve outcomes and enhance quality of life after one of the most common procedures in pancreatic surgery. This trial will expand the existing evidence on intraoperative pyloromyotomy, and the results will provide additional data on a simple surgical technique that could reduce the incidence of postoperative DGE. TRIAL REGISTRATION: German Clinical Trials Register DRKS00013503 . Registered on 27 December 2017.

Case report: Pylorus-preserving pancreatoduodenectomy for focal congenital hyperinsulinism in a 5-month-old baby.

Background: In focal congenital hyperinsulinism (CHI), surgery is the gold standard of treatment, even for lesions localized in the head of the pancreas. We report the video of the pylorus-preserving pancreatoduodenectomy performed in a five-month-old child with focal CHI. Operative technique: Baby was placed in the supine position with both arms outstretched to the up. After transverse supraumbilical incision and mobilization of ascending and transverse colon, exploration and multiple biopsies of the tail and the body of the pancreas ruled out multifocality. Pylorus-preserving pancreatoduodenectomy was performed according to the following steps: extended Kocher maneuver, followed by retrograde cholecystectomy and common bile duct isolation; division of the gastroduodenal artery and of the gastrocolic ligament; division of the duodenum, Treitz ligament and jejunum; transection of the pancreatic body. The reconstructive time was with: pancreato-jejunostomy; hepaticojejunostomy; pilorus-preserving antecolic duodeno-jejunostomy. The anastomoses were accomplished with synthetic absorbable monofilament sutures; two drains were placed close to the biliary and pancreatic anastomoses and to the intestinal anastomosis, respectively. Total operative time was 6 h, with no blood loss and/or intra-operative complications, immediate normalization of blood glucose levels and discharge from surgical ward 19 days after surgery. Conclusions: Surgical treatment of medical unresponsive focal forms of CHI is feasible in very small children: it is mandatory to refer the baby to a high-volume centre for a multidisciplinary management involving hepato-bilio-pancreatic surgeons and experts in metabolic disease.

Intraoperative endoluminal pyloromyotomy as a novel approach to reduce delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy-a retrospective study.

BACKGROUND: Delayed gastric emptying (DGE) is one of the most common complications after pylorus-preserving partial pancreaticoduodenectomy (ppPD). The aim of this retrospective study was to assess whether an intraoperative pyloromyotomy during ppPD prior to the creation of duodenojejunostomy reduces DGE. METHODS: Patients who underwent pylorus-preserving pancreaticoduodenectomy between January 2015 and December 2017 were divided into two groups on the basis of whether an intraoperative pyloromyotomy was performed (pyloromyotomy (PM) group) or not (no pyloromyotomy (NP) group). The primary endpoint was DGE according to the ISGPS definition. The confirmatory analysis of the primary endpoint was performed with multivariate analysis. RESULTS: One hundred and ten patients were included in the statistical analysis. Pyloromyotomy was performed in 44 of 110 (40%) cases. DGE of any grade was present in 62 patients (56.4%). The DGE rate was lower in the PM group (40.9%) compared with the NP group (66.7%), and pyloromyotomy was associated with a reduced risk for DGE in univariate (OR 0.35, 95% CI 0.16-0.76; P = 0.008) and multivariate analyses (OR 0.32, 95% CI 0.13-0.77; P = 0.011). The presence of an intra-abdominal complication was an independent risk factor for DGE in the multivariate analysis (OR 5.54, 95% CI 2.00-15.36; P = 0.001). CONCLUSION: Intraoperative endoluminal pyloromyotomy during ppPD was associated with a reduced risk for DGE in this retrospective study. Pyloromyotomy should be considered a simple technique that can potentially reduce DGE rates after ppPD.

Obstructive jaundice secondary to fungal infection: a rare case report.

Obstructive jaundice is characterized by an obstruction of the intrahepatic or extrahepatic biliary system, and the most common causes include pancreatic and duodenal periampullary cancer. There have been some cases reporting obstructive jaundice caused by infection. Deep tissue infection usually develops in the individuals who are immunologically compromised or chronically ill, while a few cases reported in the immunocompetent patients. Those cases were diagnosed by fungal culture or percutaneous biopsy. Here, we presented an interesting case of obstructive jaundice secondary to fungal infection confirmed by postoperative pathological examination. A 79 years old man complaint about upper abdominal discomfort, darkened urine, and skin itch, with a history of esophageal cancer operation 5 years ago. The serology for hepatitis virus and human immunodeficiency virus (HIV) was negative. Imaging examinations showed a nodular located at distal common bile duct. As evidenced by increased level of cancer antigen 19-9 (CA19-9), the patient was highly suspected to be malignant obstructive jaundice. Thus, pylorus preserving pancreaticoduodenectomy (PPPD) was conducted. To our surprise, the ultimate diagnosis was fungal infection at the site of duodenum ampulla by the postoperative pathological examination, with no evidence of malignance. Anti-infective therapy was conducted subsequently, combined by fluconazole, sulperazone and tinidazole. Three weeks later, the patient was generally in good condition and discharged from hospital. During the 2-year follow-up, no fungal infection or tumor recurrence was observed. This case reminded us that fungal infection could be the cause of obstructive jaundice in an elderly person.

Prognostic factors for long-term survival after pancreaticoduodenectomy for periampullary adenocarcinoma. A retrospective cohort study.

BACKGROUND: Periampullary adenocarcinoma (PAAC) had a poor prognosis, and pancreaticoduodenectomy (PD) remains the only potentially curative treatment. The study aimed to identify the impact of different clinicopathological factors on long-term survival following PD for PAAC. PATIENTS AND METHODS: This study is a retrospective cohort study for the patients who underwent PD for pathologically proven PAAC from January 2010 to January 2019. Statistical analysis was done using Cox regression multivariate analyses for independent risk factors for survival. RESULT: There were 137 patients with PAAC who underwent PD, 79 patients (57.7%) underwent pylorus-preserving PD. Pancreatico-jejunostomy was done in 108 patients (78.8%). The primary analysis showed that risk factors for poor long-term survival include patients with co-morbidities like hypertension or ischemic heart disease, Carbohydrate Antigen 19-9 > 400U/ml, tumor size > 3 cm, poor tumor differentiation, positive lymph nodes invasion, lymphovascular invasion, and Perineural invasion. Multivariate analysis demonstrated that large tumor size > 3 cm (HR: 0.177, 95%CI: 0.084-0.374, P = 0.002), poorly differentiated tumor (HR: 0.059, 95%CI: 0.020-0.0174, P = 0.016), and perineural invasion in the pathological study (HR: 0.101, 95%CI: 0.046-0.224, P = 0.006) were independent risk factors for poor 5-years survival. The prognosis was better in ampullary adenocarcinoma (5-year survival was 42.1%) than pancreatic adenocarcinoma (5-year survival was 24.3%). The 1, 3, 5 and 7-year overall survival rates were 84.5%, 57.4%, 35.9% and 20.1% respectively. CONCLUSION: It seems from the current study that Tumor size > 3 cm, poor tumor differentiation, and Perineural invasion were independent predictors of poor survival in patients with PAAC.

Clinical outcomes of pancreaticoduodenectomy for pancreatic ductal adenocarcinoma depending on preservation or resection of pylorus.

BACKGROUNDS/AIMS: The comparative effectiveness of pylorus-resecting pancreaticoduodenectomy (PRPD) and pylorus- preserving pancreaticoduodenectomy (PPPD) in pancreatic head cancer is still disputed. The aim of this study was to analyze the data obtained from a large, single center with PPPD compared with PRPD in terms of postoperative outcomes, including blood glucose levels and survival in patients with pancreatic head cancer. METHODS: Between January 2007 and December 2016, a total of 556 patients with pancreatic head cancer underwent either PPPD or PRPD. We analyzed the clinicopathologic data to assess short- and long-term outcomes retrospectively. RESULTS: For underlying disease, patients with DM in PPPD were fewer than in PRPD (33.0% vs. 46.2%, p=0.002). The median value of CA19-9 was significantly higher in PRPD than in PPPD (129.36 vs. 86.47, p=0.037). The incidence of Clavien-Dindo grade III to V major complications in PPPD was significantly higher than in PRPD (20.4% vs. 13.4%, p=0.032). Resection of pylorus was shown to reduce complications in univariate and multivariate analyses (p=0.032 and = 0.021, respectively). The 5-year survival rates were 27.6% in the PPPD group and 22.4% in the PRPD group (p=0.015). CONCLUSIONS: The results of PPPD and PRPD showed no significant differences from those reported conventionally in previous studies. Although further well-designed studies are needed, it is more important to select the range of surgical resection for the patient's disease regardless of resection of pylorus.

Solid pseudopapillary Tumor of the Pancreas: Radiological and surgical review.

Solid Pseudopapillary Neoplasms of the pancreas are rare pancreatic tumors with low-grade malignant potential, typically affecting young females. In this review, we discuss the surgical anatomy; the imaging characteristics, and image reporting essentials for proper surgical planning along with the atypical features which should caution the physician regarding the risk of malignancy. We also discuss the common surgical procedures and organ preservation surgeries along with a comprehensive review of the literature.

Advanced Endoscopic Rescue of a Complication (Duodenojejunostomy Leak) After a Pylorus-Preserving Pancreaticoduodenectomy in a Post-Esophagectomy Patient with Pancreatic Adenocarcinoma: A Case Report and Review of the Literature.

Background: Approximately 4% of patients develop a second upper gastrointestinal cancer after esophagectomy, and nearly 60,000 people are diagnosed with pancreatic cancer in the United States each year. The need for a Whipple procedure after esophagectomy is rarely reported. Post-esophagectomy anatomy, particularly the vascular supply, makes this a complex operation. Herein, we describe the advanced endoscopic rescue of a duodenojejunostomy (DJ) leak after pylorus-preserving pancreaticoduodenectomy (PPPD) in a post-esophagectomy patient. Presentation: A 72-year-old male with a remote history of esophageal cancer treated with minimally invasive three-hole esophagectomy and chemoradiation presented to our institution for evaluation and management of newly diagnosed pancreatic cancer. The patient had undergone common bile duct (CBD) stent placement by his gastroenterologist 2 weeks earlier after experiencing jaundice, weight loss, and steatorrhea. Endoscopic ultrasound confirmed the presence of a pancreatic head and neck mass, obstructing and dilating the main pancreatic duct and CBD. Fine-needle biopsy revealed a poorly differentiated adenocarcinoma. A PPPD was performed without intraoperative complications. The patient was subsequently readmitted with a DJ leak requiring interventional radiology and advanced endoscopic intervention. Conclusions: PPPD in patients with pancreatic cancer can be performed after previous esophagectomy. Careful dissection is crucial to avoid injury to the remaining right gastric and right gastroepiploic arteries that supply the gastric conduit after esophagectomy. The DJ is at risk after this operation, and access to tertiary care inclusive of interventional radiology and advanced endoscopic teams is critical to the correction and healing of a leak of this anastomosis.

Intraoperative Pancreatic Ductoscopy for Ampullary Adenocarcinoma During Pancreatic Resection: A Case Report.

Background: Periampullary neoplasms can be challenging to work up and diagnose preoperatively. Herein, we report the case of a patient whose preoperative workup failed to detect a malignancy, yet, underwent a pylorus-preserving pancreaticoduodenectomy (PPPD) with intraoperative pancreatic ductoscopy (IPD) and was ultimately found to have an ampullary adenocarcinoma. Presentation: A 78-year-old woman presented with 4 weeks of nausea, weight loss, jaundice, and light-colored stools. She underwent outpatient diagnostic studies, including magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography with pancreatic duct (PD) stenting and papillotomy. These revealed common bile duct dilatation measuring 2 cm, PD dilatation measuring 7 mm, a 17 mm cyst in the head of the pancreas, and a firm nodule noted between the biliary and pancreatic orifices. Cytologic and pathologic analyses were initially nondiagnostic. A repeat ampullary biopsy was negative for dysplasia and malignancy. A computed tomography scan was then performed and showed cystic pancreatic lesions with pancreatic ductal dilation. Suspicion remained high for periampullary tumor or a main duct intraductal papillary mucinous neoplasm, and the patient underwent a PPPD with IPD and tolerated the procedure well. Her final specimen pathology revealed well-to-moderately differentiated ampullary adenocarcinoma, pancreaticobiliary type with positive nodal disease. Conclusions: Given the relatively poor prognosis of patients with node-positive pancreaticobiliary-type ampullary adenocarcinoma, clinical suspicion should remain high for malignancy in patients with lesions located in the periampullary region and a negative preoperative workup, as aggressive treatment approaches are warranted to maximize their chance for survival.

Comparing the surgical outcomes of stapled anastomosis versus hand-sewn anastomosis of duodenojejunostomy in pylorus-preserving pancreaticoduodenectomy.

BACKGROUNDS/AIMS: This study is to evaluate the perioperative outcomes of the duodenojejunostomy (DJ) procedure in pylorus preserving pancreaticoduodenectomy (PPPD). METHODS: In this study, as noted between 2010 and 2018, there were 77 PPPDs which were performed at our hospital by one surgeon. We began the circular stapled method from 2014, and continue with this procedure for the aforementioned surgeries including and up to today. The clinical data for the study were collected retrospectively to compare clinical outcomes of the two methods, the circular stapled anastomosis and the hand - sewn anastomosis. RESULTS: There were 34 patients in a circular stapled group, and 43 in a hand-sewn group as identified for this study. The delayed gastric emptying (DGE) occurred in 6 (17.64%) patients in the circular stapled group, and 10 (23.3%) in the hand-sewn group (p=0.547). It is noted that there was a serum albumin level measured on the 14th day after the operation, which was significantly high in the circular stapled group (3.41±0.47 (g/dl) vs 2.92±0.39 (g/dl), p<0.001). There were no significant differences in terms of the incidence of postoperative complications (58.8% vs 58.1%, p=0.952) and mortality rates (5.9% vs 0, p=0.192) among the patient participants in this study. CONCLUSIONS: We conclude that using a circular stapler for the DJ procedure in PPPDs do not increase the development of a DGE, and is also helpful for the benefit of the patient's nutritional status going forward during recovery from the operation.

Modified Whipple on an 18-month-old with traumatic pancreatic transection and duodenal rupture.

The emergence of the Whipple procedure revolutionized operative management of pancreatic disease since its introduction (Fernandez-del Castillo et al., 2012 [1]). This operation classically involves removal of the head of the pancreas along with the duodenum, gallbladder, a portion of the bile duct, and part of the stomach (Warshaw and Thayer, 2004; Evans et al., 2007 [2,3]). We report a beneficial outcome of a modified Whipple on a paediatric trauma patient post- motor vehicle accident (MVA). After Advanced Trauma Life Support (ATLS) was initiated and haemodynamic stability was achieved, exploratory laparotomy revealed pancreatic transection and duodenal rupture. Partial pancreaticoduodenectomy, pancreaticoduodenostomy, cholecystojejunostomy, and pyloric-sparing gastrojejunostomy were performed. Post-operative acute pancreatitis resolved with antibiotics and supportive care. While paediatric abdominal trauma does not typically warrant a Whipple, patients with severe injury to the pancreas and neighboring organs with major vascular injury may offer no other intra-operative choice (Adams, 2014; Thatte and Vaze, 2014; Debi et al., 2013 [[4], [5], [6]]). Our patient's growth was followed post-operatively. At a 20-year post-operative follow-up, he reported no further hospitalizations or complications such as diabetes, biliary stricture, gallstones, or growth retardation. We review the literature to expose the novelty of using a Whipple to treat paediatric abdominal trauma, and the advantages of a pylorus-preserving Whipple. Indications for damage control surgery and non-operative management were contrasted with those for definitive surgery to reconstruct the biliary tree to further elucidate why the latter option was chosen.

Application of an early oral feeding protocol after pylorus-preserving pancreaticoduodenectomy.

PURPOSE: This study evaluates the effect of an enhanced recovery after surgery (ERAS)-based nutrition support protocol on oral intake and weight change in patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD). METHODS: A 14-day postoperative nutrition support protocol was developed to initiate oral intake after 1 week of enteral tube feeding and parenteral nutrition (early oral feeding, EOF). Forty-eight patients who underwent PPPD participated in the study (non-EOF, n = 23; EOF, n = 25). General information, nutrition supply route and amount, blood chemistry, and weight changes were tracked. RESULTS: The enteral tube feeding duration was 2.7 days shorter in the EOF group than in the non-EOF group. Furthermore, the EOF group started oral liquid and soft diets 1.1 and 2.5 days earlier than the non-EOF group, respectively. Compared with the non-EOF group, the EOF group reported a higher energy intake (22.1%; p = 0.001) and protein intake (17.4%; p = 0.000) via oral route. Although cumulative energy and protein intakes were similar in both groups, weight reduction in the EOF group (3.6 ± 0.1%, 2.2 ± 0.7 kg) was significantly less than the non-EOF group (8.2 ± 0.9%, 5.2 ± 0.5 kg). The blood levels of total protein and transferrin increased and prealbumin decreased, regardless of the EOF application. Serum albumin increased significantly only in the EOF group. CONCLUSION: The EOF protocol developed for post-PPPD patients enables the early initiation and increase in the amount of oral intake while significantly alleviating weight loss.

Pancreaticoduodenectomy with right gastric vessels preservation: impact on intraoperative and postoperative outcomes.

BACKGROUND: Sympathetic denervation of the antropyloric area combined with relative devascularization from division of the right gastric vessels (RGV) during pancreaticoduodenectomy (PD) could predispose to delayed gastric emptying (DGE). Therefore, some authors advocated for RGV preservation (RGVP), where feasibility and utility for the prevention of post-operative DGE have never been investigated. METHODS: From 2011 to 2014, patients who underwent classic Whipple PD (CWPD, n = 34), standard pylorus-preserving PD (PPPD, n = 44) or PPPD with RGVP (n = 22) were retrospectively analysed. RESULTS: RGVP was not possible in 12% of the cases because of an intraoperative injury of the RGV. There was no difference between CWPD, standard PPPD and PPPD with RGVP in terms of intraoperative blood loss, operative time, number of lymph node harvested and resection margins. Post-operative morbidity and mortality were comparable between the three groups, including rate (27%, 34% and 32%, P = 0.77) and severity of DGE, delay in removing nasogastric tube and use of prokinetics. Hospital stay was similar in all the compared groups. CONCLUSION: This is the first study comparing post-operative outcomes after PPPD with RGVP, standard PPPD and CWPD. Although feasible and safe, RGVP during PPPD appeared to offer no obvious clinical benefit in terms of preventing post-operative complications, especially DGE.

Pylorus-preserving pancreaticoduodenectomy versus standard pancreaticoduodenectomy in the treatment of duodenal papilla carcinoma.

It is not known whether pylorus-preserving pancreaticoduodenectomy (PPPD) is as effective as the standard pancreaticoduodenectomy (SPD) in the treatment of duodenal papilla carcinoma (DPC). A retrospective cohort trial was undertaken to compare the results of these two procedures. Clinical data, histological findings, short-term results, survival and quality of life of all patients who had undergone surgery for primary DPC between January 2003 and February 2010 were analyzed. According to the inclusion criteria and the surgical methods, 116 patients were divided into the PPPD group (n=43) and the SPD group (n=73). There were no significant differences in various indices, including surgery duration, extent of intraoperative hemorrhage and postoperative pathological indexes. The incidence of postoperative complications, including pancreatic fistula and delayed gastric emptying, were also similar between the two groups (20.9 vs. 21.9%; P=0.900 and 11.6 vs. 5.4%; P=0.402). Long-term survival and quality of life were identical following a median follow-up of 45.6 months (range, 4-144 months). Within 6 months, there was a decreased loss of appetite following the pylorus-preserving procedure (26.9 vs. 49.3; P=0.003). The procedures were equally effective for the treatment of DPC. PPPD offers minor advantages in the early postoperative period but not in the long term.

CT-Guided Intranodal Lymphangiography for Postoperative Chylous Ascites.

The utility and minimal invasiveness of ultrasound-guided intranodal lymphangiography have already been reported by several researchers. Although ultrasound-guided intranodal lymphangiography is known to be not technically difficult in general, a patient's edematous groin due to hypoalbuminemia resulting from chylous ascites made it too challenging to detect and prick the lymph nodes precisely. This report describes a 71-year-old female with refractory chylous ascites due to an operation for an extrahepatic bile duct cancer, who was successfully treated by computed tomography (CT)-guided intranodal lymphangiography. After switching from ultrasound- to CT-guided lymphangiography, the procedure was successfully performed, and the refractory chylous ascites was treated.

Dilemmas in the management of screen-detected lesions in patients at high risk for pancreatic cancer.

In 3-5 % of all cases of pancreatic ductal adenocarcinoma (PDAC), hereditary factors influence etiology. While surveillance of high-risk individuals may improve the prognosis, this study describes two very different outcomes in patients with screen-detected lesions. In 2000, a surveillance program of carriers of a CDKN2A/p16-Leiden-mutation consisting of annual MRI was initiated. Patients with a suspected pancreatic lesion undergo CT-scan and Endoscopic Ultrasound, and surgery is offered when a lesion is confirmed. In 2015, two patients with a screen-detected solid lesion were identified. In both patients, lesions were visible on MRI and CT scan, while the EUS was unremarkable. Surgical resection of the head of the pancreas resulted in nearly fatal complications in the first patient. This patient was shown to have a benign lesion. In contrast, timely identification of an early cancer in the second patient was accompanied by an uneventful postoperative course. These cases underline the risks inherent to a PDAC prevention program. All patients should be fully informed about the possible outcomes before joining a surveillance program.