Impact of reconstruction methods and pathological factors on survival after pancreaticoduodenectomy

Abstract

Background:Surgery remains the mainstay of therapy for pancreatic head (PH) and periampullary carcinoma (PC) and provides the only chance of cure. Improvements of surgical technique, increased surgical experience and advances in anesthesia, intensive care and parenteral nutrition have substantially decreased surgical complications and increased survival. We evaluate the effects of reconstruction type, complications and pathological factors on survival and quality of life.Materials and Methods:This is a prospective study to evaluate the impact of various reconstruction methods of the pancreatic remnant after pancreaticoduodenectomy and the pathological characteristics of PC patients over 3.5 years. Patient characteristics and descriptive analysis in the three variable methods either with or without stent were compared with Chi-square test. Multivariate analysis was performed with the logistic regression analysis test and multinomial logistic regression analysis test. Survival rate was analyzed by use Kaplan-Meier test.Results:Forty-one consecutive patients with PC were enrolled. There were 23 men (56.1%) and 18 women (43.9%), with a median age of 56 years (16 to 70 years). There were 24 cases of PH cancer, eight cases of PC, four cases of distal CBD cancer and five cases of duodenal carcinoma. Nine patients underwent duct-to-mucosa pancreatico jejunostomy (PJ), 17 patients underwent telescoping pancreatico jejunostomy (PJ) and 15 patients pancreaticogastrostomy (PG). The pancreatic duct was stented in 30 patients while in 11 patients, the duct was not stented. The PJ duct-to-mucosa caused significantly less leakage, but longer operative and reconstructive times. Telescoping PJ was associated with the shortest hospital stay. There were 5 postoperative mortalities, while postoperative morbidities included pancreatic fistula-6 patients, delayed gastric emptying in-11, GI fistula-3, wound infection-12, burst abdomen-6 and pulmonary infection-2. Factors that predisposed to development of pancreatic leakage included male gender, preoperative albumin < 30g/dl, pre-operative hemoglobin < 10g/dl and non PJ-duct to mucosa type of reconstruction. The ampullary cancers presented at an earlier stage and had a better prognosis than pancreatic cancer and cholangiocarcinoma. Early stage (I and II), negative surgical margin, well and moderate differentiation and absence of lymph node involvement significantly predicted for longer survival.Conclusions:PJ duct-to-mucosa anastomosis was safe, caused least pancreatic leakage and least blood loss compared with the other methods of reconstruction and was associated with early return back to home and prolonged disease free and overall survival.

Comparative study between invagination and duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy

“…Binziad S et al, (19) demonstrated that PJ duct-to-mucosa anastomosis was secure, produced minimum pancreatic leak and minimum bleeding in comparison to the other approaches of reconstructions. Sert OZ et al, (20) concluded that preoperative elevated ALP, AST, ALT, GGT values, low haemoglobin levels and soft texture of remnant pancreatic tissues were revealed to be connected with PF that happens post-PD.…”

Comparison Between Dunking (Invagination) Pancreaticojejunoanastomosis and Double Layer Duct to Mucosa Anastomosis After Cephalic Duodenopancreatectomy-Whipple Procedure for Pancreatic Cephalic Carcinoma

“…The probability to involve and stratify all potential impact risk factors determining all subgroups in one study are practically impossible. For this reason, there are many reviews collecting and analyzing the data, but the results remain diverse and confusing (13,14,15). Reasonably, until the consensus is reached, every referent institution with high caseload should undertake its own study based on the observations and experience for the eligibility between these 2 techniques, DA (invagination) and DMA.…”

Pancreaticogastrostomy: A Safe Option in Pancreaticoduodenectomy for Pancreatic Head and Periampullary Neoplasms

“…11 Postoperative pancreatic fistula (POPF) is the major cause of postoperative morbidity and its incidence is 9% to 29%. 12 POPF significantly affects the patient's quality of life and also increases the treatment cost. Hospital stay is prolonged and postoperative mortality is also increased.…”