Can isolated pancreaticojejunostomy reduce pancreas fistula after pancreaticoduodenectomy with Roux-en-Y reconstruction?

Abstract

Can isolated pancreaticojejunostomy reduce pancreas fistula after pancreaticoduodenectomy with Roux-en-Y reconstruction?INTRODUCTION Pancreaticoduodenectomy (PD) is a surgical procedure that is commonly accepted in cases of malignant and benign diseases of the pancreas and periampullary region. Due to the developments in perioperative patient care and operative techniques, mortality and morbidity observed in PD cases have decreased gradually in recent years (1, 2). Operative mortality has fallen to 1% in broad series. Postoperative pancreatic fistula (POPF) is definitely the most important complication of PD, being the most important reason of perioperative mortality and morbidity (3,4). Pancreaticojejunostomy is the weakest point of reconstruction, both due to the consistency of pancreatic tissue and the frequency of fistulas of this anastomosis (1,5,6). Conventional reconstructions include performing hepaticojejunostomy and gastrojejunostomy on the same loop together with an end-to-end or end-to-side pancreaticojejunostomy. In cases of pancreatic leakages, dangerous and high-output fistulas can be observed if bile juice and stomach content are included in the pancreatic leakage as a result of the proximity of pancreas and hepatic canal anastomosis (7). It is considered that mixing of the pancreatic enzymes and bile juice and stomach content delays in methods of Roux-en-Y reconstruction (RYR) and isolated pancreatic drainage, thus pancreatic fistulas and mortality and morbidity based on them may be decreased, therefore these methods have been preferred increasingly in the last years (8). MATERIAL AND METHODSIn this study, our objective is to provide information on whether isolated pancreaticojejunostomy decreases POPF rates or not in Roux-en-Y reconstructions performed after PD in General Surgery Clinic of Adana Numune Training and Research Hospital, as well as the technical details of the procedure.The reconstruction methods applied on patients who underwent PD between March 2011 and December 2013 were retrospectively analyzed. In our clinic, all patients with a periampullary tumor are subjected to classic Whipple operation. Reconstruction was performed on all patients in the form of Rouxen-Y anastomosis, but they varied as follows; Type 1: Only pancreatic anastomosis to the Y limb, Type 2: Pancreas and hepatic canal anastomosis together to the Y limb (Figure 1, 2).Demographic characteristics, preoperative comorbidities, operation and postoperative follow-up findings, complications, and histopathological findings of the patients were recorded. Objective: Pancreaticoduodenectomy is a surgical procedure which is commonly accepted in cases of ampulla of Vater, head of pancreas, distal common bile duct neoplasms and severe chronic pancreatitis. Pancreatic fistula is still a serious problem after reconstruction. Yet, there is no consensus on a single reconstruction method. Material and Methods:The reconstruction methods on patients who had pancreaticoduodenectomy due to pancreatic tumor, and results of these recons...

Early and Long-Term Morbidity and Mortality Following Pancreaticoduodenectomy for Periampullary Tumors in Elderly Patients

“…The expanding elderly population is predicted to significantly affect surgical practice, and there has been a 25-30% increase in general surgeries performed over the past two decades, coinciding with a consistent increase in the number of geriatric cancers [1,7]. Despite the PD or Whipple procedure representing a curative treatment modality in periampullary tumors, this procedure is accompanied by high morbidity and mortality rates [7,10,11]. In elderly patients, the rate of dramatic complications may be double, even when surgeries are performed at high-volume centers.…”

“…In this period, there have been delays in cancer diagnosis and treatment due to restricted public access [8,9]. Patients generally prefer to attend low-or medium-volume centers for pancreatic surgery due to financial concerns, long waiting lists at high-volume centers (over 28 cases per year), the prevalence of low-volume intensive care units, high hospital occupancy rates, and the impact of the COVID-19 pandemic [10,11,12,13,14]. However, research suggests that low-volume centers have increased morbidity and mortality (11.4-14.5% mortality) rates in the elderly [14].…”

Long-term postoperative outcomes of Roux-en-Y cholangiojejunostomy in patients with benign biliary stricture

“…Too long biliary output loop used for drainage may be twisted, folded and obstructed due to adhesion, thus resulting in poor biliary drainage and increasing the chance of cholestasis and intestinal bacterial reproduction. In comparison, too short biliary output loop used for drainage may cause reflux easily [26,27]. During follow-up, it was found that there was disuse atrophy of jejunum due to too short biliary output loop in some patients, whose length was less than 30 cm and even 20 cm, thus causing further narrow of the intestinal cavity.…”

Pancreaticojejunostomy anastomosis techniques after pancreaticoduodenectomy: a critical review

“…In the literature, some crucial studies report that isolated pancreatic anastomosis can reduce the rate of PFAO (32,33). However, a meta-analysis focusing on comparing isolated-PJ anastomosis versus conventional reconstruction by Li et al (25) found that isolated-PJ (Rouxen-Y reconstruction) did not appear to reduce the incidence of PFAO.…”

“…Erciyes Med J 2021; DOI: 10.14744/etd.2021.26628. ©Copyright 2021 by Erciyes University Faculty of Medicine -Available online at: www.erciyesmedj.comHowever, the superiority of the isolated PJ anastomosis was not statistically significant for the rate of PFAO and other complications(32)(33)(34)(35).The addition of Braun's enteroenterostomy to a standard reconstruction after PD is a widely used method in various clinics to reduce morbidity. Braun enteroenterostomy is performed approximately 40 cm distal to the hepaticojejunostomy anastomosis and 20-30 cm distal to the pancreaticogastrostomy anastomosis.…”