Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial

doi:10.1016/S0039-6060(03)00345-3

Surgery

Volume 134, Issue 5, November 2003, Pages 766-771

https://doi.org/10.1016/S0039-6060(03)00345-3 Get rights and content

Abstract

Background

Anastomotic failure is still a significant problem that affects the outcome of pancreaticoduodenectomy. There have been many techniques proposed for the reconstruction of pancreatic digestive continuity, but there have been few prospective and randomized studies that compare their efficacy.

Methods

In the current work, 144 patients who underwent a pancreaticoduodenectomy with soft residual tissue were assigned randomly to receive either a duct-to-mucosa anastomosis (group A) or a 1-layer end-to-side pancreaticojejunostomy (group B).

Results

The 2 treatment groups were found not to have any differences in regards to vital statistics, underlying disease, or operative techniques. The postoperative course was complicated in 54% of the 144 patients, with a comprehensive incidence of abdominal complications in 36% (group A, 35%; group B, 38%; P = not significant). The principal complication was pancreatic fistulas, which occurred in 14% of patients (group A, 13%; group B, 15%; P = not significant). Two patients (2%) required reoperation; the postoperative mortality rate was 1%.

Conclusion

The 2 methods that were studied revealed no significant difference the rate of complications.

Section snippets

Patients and methods

In our institution, beginning in 1990, a database was used prospectively to register patients with periampullary neoplasms. From 1999 to 2001, 179 pancreaticoduodenectomies were performed, of which 144 patients had a soft pancreas (confirmed by a lack of fibrosis on histologic examination) and were assigned randomly into the present study. In 19 patients (11%), the pancreas was found to be fibrotic because of the presence of “groove pancreatitis” that was associated with cystic dystrophy of the

Results

In group A, 40 patients (56%) were male and 32 were female. The median age was 62±10 years. In group B, 46 patients were male (64%), 26 patients were female (median age, 61±12 years). There was no significant difference between the 2 groups. Thirty-six of the 56 patients (64.%) with elevated bilirubin levels (group A, 31 patients; group B, 25) had jaundice. Twenty-nine of these patients (52%) underwent endoscopic biliary drainage; in the remaining patients, drainage was obtained by a

Discussion

Complications that are related to the pancreatic remnant still represents a substantial risk for death after pancreatic head resections.1., 2., 10., 11. In an effort to decrease operative deaths and morbidity, regionalization to high volume institutions (and surgeons) has been championed.12., 13. Nonetheless, the role of prophylactic medications3., 4., 5., 6., 7. and the best choices of surgical techniques1., 2., 8., 9., 10., 11., 14., 15. are still debated. This last issue, in particular,

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Cited by (252)

Outcome of pancreatic anastomoses during pancreatoduodenectomy in two national audits
2021, Surgery (United States)
Evidence on the optimal pancreatic anastomosis during pancreatoduodenectomy is inconclusive. Large multicenter and nationwide registries may provide additional insights. The study compared the practice and outcome of different pancreatic anastomoses during pancreatoduodenectomy, focusing on the rate of postoperative pancreatic fistula, in two large audits of pancreatic surgery.
Posthoc analysis of patients after pancreatoduodenectomy in the Dutch Pancreatic Cancer Audit and the German DGAV StuDoQ|Pancreas registries (January 2014 to December 2017). Postoperative pancreatic fistula (International Study Group of Pancreatic Surgery B/C), postpancreatectomy hemorrhage (International Study Group of Pancreatic Surgery B/C) and Clavien-Dindo ≥3 complications rates were compared for the three most common anastomoses: duct-to-mucosa pancreatojejunostomy, non-duct-to-mucosa pancreatojejunostomy, and non-duct-to-mucosa pancreatogastrostomy. Multivariable adjustment for potential confounders was performed.
Overall, 6,149 patients were included. The most common anastomosis was duct-to-mucosa pancreatojejunostomy (duct-to-mucosa pancreatojejunostomy 59.8%, non-duct-to-mucosa pancreatojejunostomy 21.1%, non-duct-to-mucosa pancreatogastrostomy 12.4%). The overall postoperative pancreatic fistula rate was 14%: duct-to-mucosa pancreatojejunostomy 12.9%, non-duct-to-mucosa pancreatojejunostomy 14.4% (P = .162), non-duct-to-mucosa pancreatogastrostomy 18.3% (P < .001). The rate of postpancreatectomy hemorrhage was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 6.9%, non-duct-to-mucosa pancreatojejunostomy 10% (P < .001), non-duct-to-mucosa pancreatogastrostomy 17.9% (P < .001). The rate of Clavien-Dindo ≥3 complications was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 28%, non-duct-to-mucosa pancreatojejunostomy 32.7% (P = .002), non-duct-to-mucosa pancreatogastrostomy 43.1% (P < .001). In the multivariable analysis, the risk of postoperative pancreatic fistula did not differ significantly between the three anastomoses. The risk of hemorrhage (odds ratio 2.4, 95% confidence interval 1.6–3.5, P < .001) and Clavien-Dindo ≥3 (odds ratio 1.6, 95% confidence interval 1.2–2.1, P = .001) remained significantly higher only for non-duct-to-mucosa pancreatogastrostomy.
Data from two national audits showed no difference in the risk-adjusted postoperative pancreatic fistula rate among the three most used pancreatic anastomoses during pancreatoduodenectomy. Pancreatogastrostomy was inferior to pancreatojejunostomy regarding bleeding and overall major complications.
Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures
2021, Cirugia Espanola
El objetivo principal de este estudio es determinar si la Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático del Hospital Universitario de Badajoz cumple los estándares de calidad exigidos por la comunidad científica a los centros de referencia de cirugía pancreática (CP) en términos de resultados perioperatorios. Los objetivos secundarios consisten en comparar las diferentes técnicas de CP realizadas en función de la morbimortalidad postoperatoria precoz y analizar el impacto de las resecciones extendidas en dichos términos.
Estudio descriptivo, retrospectivo y unicéntrico, correspondiente al periodo 2006-2019. Se compararon los resultados obtenidos con los estándares de calidad propuestos por Bassi et al. y Sabater et al., exigidos a los centros de referencia en cirugía pancreática. La muestra se dividió según técnica quirúrgica y se compararon en términos de morbimortalidad postoperatoria precoz, estudiando el impacto de las resecciones vasculares y viscerales extendidas. Se incluyeron todos los pacientes sometidos a cirugía pancreática en nuestra unidad por patología pancreática, maligna y benigna, desde que ésta se implementó como centro de referencia. Se excluyeron las realizadas de urgencia.
Se analizaron 631 pacientes. Los valores obtenidos en los estándares de calidad se encuentran en rango. La cirugía más frecuente fue duodenopancreatectomía cefálica, la cual asoció mayor tasa de morbimortalidad perioperatoria (p ≤ 0,05). Las resecciones vasculares añadidas impactaron en el grupo de duodenopancreatectomía cefálica asociando mayor estancia media (p = 0,01) y mayor tasa de reintervención (p = 0,02).
La experiencia acumulada permite cumplir con los estándares de calidad exigidos, así como realizar resecciones extendidas a la pancreatectomía con buenos resultados en términos de morbimortalidad postoperatoria.
The main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.
Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.
631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02).
The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.
Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula
2021, Surgery (United States)
Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula.
A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations—both common and uncommon.
Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula.
A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed—risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.
Clinical outcomes and costs of the use of fibrin sealant in pancreaticojejunal anastomosis after pancreaticoduodenectomy: a retrospective analysis study
2021, Annals of Medicine and Surgery
The benefits of using a fibrin sealant to reinforce the pancreaticojejunal anastomosis are still contentious, a fact that justifies the study of its effects on clinical outcomes and costs of pancreaticoduodenectomy.
Study of 62 consecutive patients submitted to pancreaticoduodenectomy, divided into two groups of 31 patients each: GWS = group with sealant and GWOS = group without sealant that were compared according to demographic, clinical, laboratory aspects, the incidence of postoperative pancreatic fistula (POPF), according to the definition of the International Study Group on Pancreatic Fistula, updated in 2016, and its postoperative complications categorized according to the Clavien classification, as well as hospital costs evaluated by the absorption costing method (with the exception of those related to medications).
The groups were homogeneous and there were no significant differences in the postoperative clinical course or in the indicators of hospital care between them. Hard texture of pancreatic tissue was the only protective factor against the development of POPF (RR = 0.29 (95%CI:0,12–0,68); p = 0.005). Moreover, hospital costs were higher in GWS than in GWOS (p < 0.0001).
The use of fibrin sealant to reinforce pancreaticojejunal anastomosis did not improve the clinical and healthcare outcomes and, in addition, increased hospital costs.
Additional modifications to the Blumgart pancreaticojejunostomy: Results of a propensity score-matched analysis versus Cattel-Warren pancreaticojejunostomy
2021, Surgery (United States)
Postoperative pancreatic fistula continues to occur frequently after pancreatoduodenectomy.
We have described a modification of the Blumgart pancreaticojejunostomy. The modification of the Blumgart pancreaticojejunostomy was compared to the Cattel-Warren pancreaticojejunostomy in cohorts of patients matched by propensity scores based on factors predictive of clinically relevant postoperative pancreatic fistula, which was the primary endpoint of this study. Based on a noninferiority study design, 95 open pancreatoduodenectomies per group were needed. Feasibility of the modification of the Blumgart pancreaticojejunostomy in robotic pancreatoduodenectomy was also shown. All pancreaticojejunostomies were performed by a single surgeon.
Between October 2011 and May 2019, there were 415 pancreatoduodenectomies with either a Cattel-Warren pancreaticojejunostomy (n = 225) or a modification of the Blumgart pancreaticojejunostomy (n = 190). There was 1 grade C postoperative pancreatic fistula in 190 consecutive modification of the Blumgart pancreaticojejunostomies (0.5%). Logistic regression analysis showed that the rate of clinically relevant postoperative pancreatic fistula was not affected by consecutive case number. After exclusion of robotic pancreatoduodenectomies (the Cattel-Warren pancreaticojejunostomy: 82; modification of the Blumgart pancreaticojejunostomy: 66), 267 open pancreatoduodenectomies were left, among which the matching process identified 109 pairs. The modification of the Blumgart pancreaticojejunostomy was shown to be noninferior to the Cattel-Warren pancreaticojejunostomy with respect to clinically relevant postoperative pancreatic fistula (11.9% vs 22.9%; odds ratio: 0.46 [0.21–0.93]; P = .03), grade B postoperative pancreatic fistula (11.9% vs 18.3%; P = .18), and grade C postoperative pancreatic fistula (0 vs 4.6%; P = .05) as well as to all secondary study endpoints. The modification of the Blumgart pancreaticojejunostomy was feasible in 66 robotic pancreatoduodenectomies. In this subgroup with 1 conversion to open surgery (1.5%), a clinically relevant postoperative pancreatic fistula occurred after 9 procedures (13.6%) with no case of grade C postoperative pancreatic fistula and a 90-day mortality of 3%.
The modification of the Blumgart pancreaticojejunostomy described herein is noninferior to the Cattel-Warren pancreaticojejunostomy in open pancreatoduodenectomy. This technique is also feasible in robotic pancreatoduodenectomy.
Pancreaticojejunostomy for Pancreatico-enteric Anastomosis after Pancreaticoduodenectomy: one procedure with multiple techniques.
2020, Surgery in Practice and Science
Pancreatico-enteric anastomoses after Pancreatico-duodenectomy (PD) has remained a true Achilles' heel in this complex and technically demanding operation. Multiple techniques have been described to achieve safe pancreatico-enteric drainage, however postoperative pancreatic fistula (POPF), still remains the major cause of morbidity. Pancreatico-jejunostomy (PJ) is commonly performed procedure for this purpose, however there are lot of variations in PJ techniques. Herein, we intend to review the commonly practised PJ techniques with emphasis on technical variations and reported outcomes. Literature review suggest that, there is no single, universally accepted or gold standard technique for this purpose. Pancreatic surgeons should be aware of technical aspects of different techniques, so that they can choose the best suited technique as per the clinical scenario.

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^☆: Supported in part by grants from the Associazione Italiana Ricerca Cancro (AIRC), Milan, Italy; Ministero Univesità e Ricerca (Cofin MM06158571 and 2001068593), Rome, Italy; and the Fondazione Cassa di Risparmio di Verona, Verona, Italy.

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Original communicationDuct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial☆

Abstract

Background

Methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Am J Surg

Surgery

Surg Oncol Clin N Am

Am J Surg

Am J Surg

Surgery

Pancreatology

History of pancreaticojejunostomy in pancreaticoduodenectomy: development of more reliable anastomosis technique

J Hepatobiliary Pancreat Surg

Problems of reconstruction during pancreatoduodenectomy

Dig Surg

Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial

Ann Surg

Efficacy of octreotide in the prevention of complications of elective pancreatic surgery: Italian Study Group

Br J Surg

Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis

Br J Surg

A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy

Ann Surg

Management of complications after pancreaticoduodenectomy in a high volume centre: results on 150 consecutive patients

Dig Surg

Original communication
Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial☆