Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection

Kleespies, Axel; Rentsch, Markus; Seeliger, Hendrik; Albertsmeier, Markus; Jauch, Karl‐Walter; Bruns, Christiane

doi:10.1002/bjs.6634

Cited by 156 publications

(137 citation statements)

References 46 publications

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“…The median LOS was 7.5 (range 5-57) days in the RAPD group, as compared to 8 (range [6][7][8][9][10][11][12][13][14] days in the HLAPD group (p = 0.78), and mean total 7-day opioid use was 142.599 ± 68.2 mg of intravenous morphine equivalents in the RAPD group versus 176.9 ± 112.7 mg of intravenous morphine equivalents in the HLAPD group (Fig. 2).…”

Section: Resultsmentioning

confidence: 99%

“…18 Zureikat and colleagues 6 used the same approach and reported a 21% leak rate among all patients undergoing robotic ducttomucosa pancreaticoje junostomies, which is less than other groups that opted for alternative measures, such as sclerosis with fibrin glue. 11 Giulianotti and colleagues 1 reported a 36.5% pancreatic fistula rate in the RAPD patients who underwent sclerosis compared with those who underwent anastomosis (21%). Given multiple failed attempts to decrease pancreatic leak rates reported in the literature and in light of the present findings, there may be an inherent pancreatic leak rate that must be accepted and managed early, despite minimally invasive approaches.…”

Section: Discussionmentioning

confidence: 98%

“…A duct-to-mucosa pancreaticojejunostomy is performed in a Blumgart fashion. 11 Using a 3-0 silk, several stitches are placed through the pancreas and back through the jejunum. Three duct-to-mucosa stitches using 4-0 suture are placed along the 9, 6 and 3 o'clock positions.…”

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confidence: 99%

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Early experience with robotic pancreatic surgery in a Canadian institution

Piedimonte¹,

Wang²,

Bergman³

et al. 2015

cjs

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Background: Pancreatic resections have traditionally been associated with substantial morbidity and mortality. The robotic platform is believed to improve technical aspects of the procedure while offering minimally invasive benefits. We sought to determine the safety and feasibility of the first robotic pancreaticoduodenectomies performed at our institution. Methods:We retrospectively reviewed data on all patients who underwent robotic-assisted pancreaticoduodenectomy (RAPD) between July 2010 and June 2014 and compared them to outcomes of patients undergoing hybrid laparoscopic pancreaticoduodenectomies (HLAPD) during the same time period.Results: Fifteen patients were scheduled for RAPD; 2 were converted to an open approach and 1 to a mini-laparotomy during the laparoscopic portion of the procedure. Patients who had RAPD (n = 12) had a median duration of surgery of 596.6 (range 509-799) minutes, estimated blood loss of 275 (range 50-1000) mL and median length of stay of 7.5 (range 5-57) days. Mean total opioid use up to postoperative day 7 was 142.599 ± 68.2 versus 176.9 ± 112.7 mg equivalents of intravenous morphine for RAPD and HLAPD, respectively. There was no significant difference between RAPD and HLAPD in any parameters, highlighting the safety and feasibility of a step-wise minimally invasive learning platform. Most patients in the RAPD group had malignant pathology (88.2%). Oncologic outcomes were maintained with no significant difference in ability to resect lymph nodes or achieve negative margins. There were 4 (28.5%) Clavien I-II complications and 3 (29.4%) Clavien III-IV complications, 2 of which required readmission. There were no reported deaths at 90 days. Complication, pancreatic leak and mortality rates did not differ significantly from our laparoscopic experience. Conclusion:Outcomes of RAPD and HLAPD were comparable at our centre, even during the early stages of our learning curve. These results also highlight the safety, feasibility and patient benefits of a step-wise transition from open to hybrid to fully robotic pancreaticoduodenectomies in a high-volume academic centre.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 98%

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Early experience with robotic pancreatic surgery in a Canadian institution

Piedimonte¹,

Wang²,

Bergman³

et al. 2015

cjs

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“…This anastomosis has been successful in two comparable, retrospective series [17,18] and in a clinical randomized trial [19] .…”

Section: Pj By Invaginationmentioning

confidence: 95%

Reconstruction after pancreatoduodenectomy: Pancreatojejunostomyvspancreatogastrostomy

Gómez¹

2014

WJGO

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Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy (PD) in order to decrease postoperative complications, mainly pancreatic fistulas (PF). In this work, we compare the two most frequent techniques of reconstruction after PD, pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), in order to determine which of the two is better. A systematic review of the literature was performed, including major meta-analysis articles, clinical randomized trials, systematic reviews, and retrospective studies. A total of 64 articles were finally included. PJ and PG are usually responsible for most of the postoperative morbidity, mainly due to the onset of PF, being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia. The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG. PF, delayed gastric emptying and mortality were not different. Although there was heterogeneity between these studies, all were conducted in specialized centers by highly experienced surgeons, and the surgical care was likely to be similar for all the studies. The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa. Exocrine function appears to be worse after PG than after PJ, resulting in severe atrophic changes in the remnant pancreas. Depending on the type of PJ or PG used, the PF rate and other complications can also be different. The best method to deal with the pancreatic stump after PD remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles such as good exposure and visualization. In conclusion, up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD. Core tip: Pancreatoduodenectomy is a technique with a high rate of morbidity and mortality. Surgeons try to find the best technique of reconstruction in order to decrease postoperative complications. We compare the two most frequent techniques of reconstruction after pancreatoduodenectomy, namely pancreatojejunostomy and pancreatogastrostomy, to determine which of the two is better. We offer a systematic review of the main papers published with all the pros and cons of each technique. The best method to deal with the pancreatic stump after pancreatoduodenectomy remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles, such as good exposure and visualization. TOPIC HIGHLIGHTSeptember 15, 2014|Volume 6|Issue 9|

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“…The senior author had the chance to learn this anastomosis from Blumgart in 2002 and has applied this anastomosis in all cases of WPD since 2003. Results of this anastomosis have started to emerge now and seem to be favorable [13,14]. We present here an appraisal of this anastomosis based on our experience in the last 7 years.…”

Section: Introductionmentioning

confidence: 99%

Blumgart’s Technique of Pancreaticojejunostomy: An Appraisal

Mishra

Saluja²,

Gupta³

et al. 2011

Dig Surg

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Background: Although mortality of Whipple’s pancreaticoduodenectomy (WPD) is reduced to <5%, morbidity still remains between 30 and 50%. Pancreaticojejunal anastomosis remains the main cause of morbidity. Blumgart anastomosis using transpancreatic U sutures has been proposed to decrease the leak rate and its associated morbidity. We analyzed the results of Blumgart anastomosis applied in consecutive cases of WPD. Methods: Of 189 patients with periampullary or pancreatic cancer admitted, 100 patients underwent WPD. Except for 2 patients (no duct identified preoperatively), all patients underwent pancreaticojejunostomy by the Blumgart anastomotic technique. The records of 98 patients were analyzed for pancreatic leak and its related complications using the definitions given by the International Study Group for Pancreatic Surgery. Results: Of 98 patients, 63 were men. The mean operative time was 390 min (270–690 min) and blood loss was 275 ml (100–1,000 ml). Overall mortality was 3.06%. The clinically significant pancreatic anastomotic failure leak was seen in only 7 (7.14%) cases (grade B, n = 4; grade C, n = 3) with one patient requiring relaparotomy due to leak. Only one patient died due to a leak-related complication. Conclusion: Blumgart pancreaticojejunal anastomosis can be routinely used for reconstruction in WPD. It is a technically simple procedure and is associated with low rates of fistula and its related complications.

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Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection

Abstract: BA appears to be a fast, simple and safe technique for pancreaticojejunostomy. It might reduce leakage rates and surgical complications after partial pancreaticoduodenectomy.

Cited by 156 publications

References 46 publications

Early experience with robotic pancreatic surgery in a Canadian institution

Early experience with robotic pancreatic surgery in a Canadian institution

Reconstruction after pancreatoduodenectomy: Pancreatojejunostomyvspancreatogastrostomy

Blumgart’s Technique of Pancreaticojejunostomy: An Appraisal

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