Does internal stenting of the pancreaticojejunostomy improve outcomes after pancreatoduodenectomy? A prospective study

Smyrniotis, Vassilios; Arkadopoulos, Nikolaos; Kyriazi, Maria; Derpapas, Michael; Theodosopoulos, Theodosios; Gennatas, Constantine; Kondi-Paphiti, A.; Vassiliou, Ioannis

doi:10.1007/s00423-009-0585-6

Cited by 46 publications

(22 citation statements)

References 21 publications

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“…On the other hand, most studies and meta-analyses report no statistically significant difference in POPF incidence with internal stent use. [26][27][28][29] Nevertheless, internal stenting appears to have been successful in avoiding complications since none of the True-DMA patients developed postoperative pancreatitis, pancreatic insufficiency, or duct stricture as shown by follow up CT scanning.…”

Section: Discussionmentioning

confidence: 99%

“True” Duct-to-Mucosa Pancreaticojejunostomy, with Secure Eversion of the Enteric Mucosa, in Whipple Operation

Karavias

Chaveles

et al. 2015

Journal of Gastrointestinal Surgery

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Section: Discussionmentioning

confidence: 99%

“True” Duct-to-Mucosa Pancreaticojejunostomy, with Secure Eversion of the Enteric Mucosa, in Whipple Operation

Karavias

Chaveles

et al. 2015

Journal of Gastrointestinal Surgery

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“…Additionally, there is a debate regarding pancreatic duct stenting and its drainage methods. Although some authors have reported similar complication rates between stented and non-stented patients,2526 we believe that it is necessary to stent the anastomosis to promote duct-mucosa healing, especially in patients with a small pancreatic duct 27. With respect to the stent drainage methods, external drainage showed somewhat better results in terms of morbidity 28.…”

Section: Discussionmentioning

confidence: 83%

An intuitive method of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: use of one-step circumferential interrupted sutures

Kim

Shin

Lee

et al. 2017

Ann Hepatobiliary Pancreat Surg

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Pancreaticoenteric anastomosis is the origin of postoperative pancreatic fistula (POPF). Although a variety of methods have been proposed to decrease the POPF rate, randomized controlled trials performed so far have failed to demonstrate superiority of any particular method to the others. Cattell-Warren duct-to-mucosa pancreaticojejunostomy (PJ) is a widely practiced procedure. Their method is challenging, especially when the pancreatic duct is small. We assumed that the difficulty resides in the pancreatic duct becoming difficult to access when the posterior row is tied before suturing the anterior row. We have modified the duct-to-mucosa PJ so that the entire circumference of the inner layer can be sutured and tied in one-step by anchoring and retracting the anterior row. The jejunal roux-limb and pancreatic stump are positioned spatially apart, allowing enough space for free needle work. During a 13-year period, 151 patients underwent pancreaticoduodenectomy with this method, and the cumulative POPF and mortality rates were 37.1% and 4.6%, respectively. These rates were stable throughout the study period, implicating a relative independence from surgeons' experience. We believe that our method is intuitive, easy to grasp, and can be readily adopted even by surgeons not accustomed to pancreaticoduodenectomy.

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“…Subsequent screening resulted in four prospective randomized trials examining only external pancreatic stents following PD [6][7]9,14]. Of note, the present study excluded two trials previously included by Markar et al [10]; 1) the 2009 prospective trial conducted by Smyrniotis et al [5] on the basis that this study examined internal stents only, and 2) the 2006 trial conducted by Winter et al [4] on the basis that internal stents were included and because these authors utilized an alternating method of allocating patients to either treatment or control arms, which may have inadvertently introduced selection bias as described by Doll [15]. Baseline and intra-operative demographics of the study populations are listed in Table 1.…”

Section: Resultsmentioning

confidence: 99%

“…This is then closed with a purse-string suture, externalized via a stab incision in the anterior abdominal wall, and closed by suturing the serosa of the jejunum to the peritoneum of the abdominal wall. In both cases migration of the catheter is prevented with an absorbable suture attachment to the jejunal mucosal surface [4][5][6][7][8][9]. The final PJ reconstruction is then carried out with an end-to-side, duct-to-mucosa anastomosis using 1-or 2-layer interrupted fine sutures [6].…”

mentioning

confidence: 99%

A Meta-Analysis and Systematic Review of Pancreatic Duct Stent

Prashant¹,

Thoens²,

Mauricio³

et al. 2014

Pancreat Disord Ther

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IntroductionThe National Cancer Institute has estimated that there will be as many as 45,220 new cases of pancreatic cancer in the U.S. in 2012 and that as many as 38,460 patients will die of the disease this year alone [1]. Pancreaticoduodenectomy (PD) remains the sole potentially curative intervention for several types of peri-ampullary and pancreatic carcinomas and pathologies. Postoperative Pancreatic Fistula Formation (POPF) as a result of pancreaticojejunostomy (PJ) anastomotic failure remains one of the most serious and dreaded complications following PD. POPF is believed to be a consequence of pancreatic exocrine secretion seepage across a compromised anastomotic site, with the most likely mechanism being autodigestion and destruction of the tissue surrounding the PJ anastomotic site leading to dehiscence and seepage into the abdominal cavity. The release of these activated pancreatic juices then cause peripancreatic collections, intra-abdominal abscesses, hemorrhage, and POPF [2].Protection of this anastomotic site has therefore been the focus of many modifications to the original Whipple procedure. Stent placement across the PJ anastomsis has been proposed to protect the integrity of the site by diverting the potentially caustic exocrine secretions of the pancreatic remnant away from the delicate anastomotic site. In addition, such stents have been theorized to promote precise placement of anastomotic sutures, facilitate decompression of the pancreatic remnant, and maintain patency of the pancreatic duct postoperatively [3,4].Two similar though uniquely different procedures have been integrated into the traditional PD procedure with varying reports of actual efficacy; an internal and an external pancreatic duct stent. The internal stent technique is generally performed by inserting a 6 cm stent into the pancreatic duct such that one-half of its length remains within the duct itself, bridges across the anastomotic site, and empties into the jejunal lumen. In contrast, the external stent utilizes a longer stent placed similarly within the pancreatic duct stump, bridges across the anastomotic site into the jenual lumen, but the tail of which is exited through a small enterotomy site in the free end of the jejunal loop. This is then closed with a purse-string suture, externalized via a stab incision in the anterior abdominal wall, and closed by suturing the serosa of the jejunum to the peritoneum of the abdominal wall. In both cases migration of the catheter is prevented with an absorbable suture attachment to the jejunal mucosal surface [4][5][6][7][8][9]. The final PJ reconstruction is then carried out with an end-to-side, duct-to-mucosa anastomosis using 1-or 2-layer interrupted fine sutures [6].Previous meta analysis performed by Markar et al. [10] examined the combined effect of placement of either stent type on clinical outcome following PJ. Based on the integrated data sets, these authors identified a non-statistically significant trend towards reduced pancreatic fistula with the use of either sten...

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Does internal stenting of the pancreaticojejunostomy improve outcomes after pancreatoduodenectomy? A prospective study

Abstract: Internal stenting of a duct-to-mucosa pancreatojejunostomy does not diminish the rate of pancreatic fistula formation or alter overall patient's outcome.

Cited by 46 publications

References 21 publications

“True” Duct-to-Mucosa Pancreaticojejunostomy, with Secure Eversion of the Enteric Mucosa, in Whipple Operation

“True” Duct-to-Mucosa Pancreaticojejunostomy, with Secure Eversion of the Enteric Mucosa, in Whipple Operation

An intuitive method of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: use of one-step circumferential interrupted sutures

A Meta-Analysis and Systematic Review of Pancreatic Duct Stent

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