Type of Reconstruction After Pancreatoduodenectomy



Fig. 22.1
(a, b) Preset outer-layer U-sutures (three to four sutures) without tying for posterior horizontal mattress sutures on the jejunum



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Fig. 22.2
(a, b) Preset inner-layer sutures (six to eight sutures) without tying for duct-to-mucosa anastomosis using pair-watch suturing technique


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Fig. 22.3
(a, b) Preset inner-layer sutures (six to eight sutures) with partial tying for duct-to-mucosa anastomosis


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Fig. 22.4
(a, b) Inner-layer sutures with complete tying for duct-to-mucosa anastomosis


A337590_1_En_22_Fig5_HTML.jpg


Fig. 22.5
(a, b) Outer-layer U-suturing for anterior horizontal mattress sutures on the jejunum


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Fig. 22.6
(a, b) Completed outer-layer U-suturing with tying for anterior horizontal mattress sutures on the jejunum





22.1.4 Pancreatic Fistula After Pancreatic Reconstructions


POPF has been the leading cause of postoperative morbidity and mortality after PD. The severity of POPF is classified into grades A, B, and C based on the definition of the International Study Group on Pancreatic Fistula (ISGPF) [18]. Grades B and C are clinically relevant postoperative pancreatic fistula (CR-POPF), and grade A is biochemical leakage without clinically relevance. PG has been claimed to be a better pancreatic reconstruction in reducing the incidence and severity of CR-POPF by most retrospective studies [4, 5, 16, 19]. However, not all of the published randomized controlled trials confirm the superiority of PG (Table 22.1). In recent meta-analysis of published randomized controlled trials, PG has been shown to be associated with lower rate of CR-POPF as compared with classic PJ (Table 22.2). PG had been the procedure of choice for pancreatic reconstruction at the author institute since 1997 [4]. In 2012, the modified Blumgart PJ began to be adopted at our institute and has replaced PG as the technique of choice for pancreatic reconstruction after PD thereafter. With the modified Blumgart PJ, only a 1- to 2-cm free pancreatic stump is needed, as opposed to a 3- to 4-cm free pancreatic stump for PG reconstruction. Moreover, only three or four transpancreatic U-sutures are used for the modified Blumgart PJ, instead of the multiple tangential sutures needed for PG or classic PJ. Blumgart PJ has been reported to decrease the CR-POPF rate to 4.3–6.9%, significantly lower than the 10–20% of other techniques (Table 22.3) [8, 9, 11, 14]. Based on our matched historical control study [33], the modified Blumgart PJ appears to be superior to PG in reducing the incidence and severity of CR-POPF. The modified Blumgart PJ can therefore be recommended as a fast, simple, and safe alternative for pancreatic reconstruction after PD.


Table 22.1
Randomized controlled trials for clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy






















































































     
CR-POPF
  
 
Year
n

PGa

PJb

P value

Keck et al. [20]
2015
PG = 149

PJ = 171
20%
22%
NSc

Nakeeb et al. [21]
2014
PG = 45

PJ = 45
15.6%
8.9%
NSc

Topal et al. [22]
2013
PG = 162

PJ = 167
8.0%
19.8%
0.002

Figueras et al. [23]
2013
PG = 65

PJ = 58
11%
33%
0.006

Wellner et al. [24]
2012
PG = 59

PJ = 57
11%
33%
NSc

Fernandez-Cruz et al. [25]
2008
PG = 53

PJ = 55
4%
18%
<0.01

Duffas et al. [26]
2005
PG = 81

PJ = 68
16%
20%
NSc

Bassi et al. [27]
2005
PG = 69

PJ = 51
13%
16%
NSc

Yeo et al. [28]
1995
PG = 73

PJ = 72
12.3%
11.1%
NSc


a PG pancreaticogastrostomy

b PJ pancreaticojejunostomy

c NS not significant



Table 22.2
Meta-analysis of randomized controlled trials for clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy





































 
Year
n

PGa

PJb

P value

Menahem et al. [29]
2015
PG = 562

PJ = 559
11.2%
18.7%
0.0003

Hallet et al. [30]
2015
PG = 339

PJ = 337
8%
20%
<0.0001

Que et al. [31]
2015
PG = 384

PJ = 382
9.1%
16.5%

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Jun 26, 2017 | Posted by in ONCOLOGY | Comments Off on Type of Reconstruction After Pancreatoduodenectomy

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