Objective To evaluate the application of a surgical method in pancreaticoduodenectomy. Methods All the 211 cases of purse-string invaginated pancreaticojejunostomy performed from Dec.1985 to Dec.2007 were reviewed. Firstly, an accordant plastic tube was put and fastened in main pancreatic duct, and pancreas was ligated at 2-3 cm apart from the pancreatic stump to let secretin flow far away. Furthermore, invaginated pancreaticojejunostomy was performed to get closer between pancreas and jejunum. Results Pancreatic fistula and perioperative death didn’t occur among these 211 cases. The complications included 2 cases of incision dehiscence, 4 cases of biliary fistula and 1 case of scission of superior mesentric artery. Conclusion Purse-string invaginated double-layer anastomosis of pancreaticojejunal would be feasible for pancreaticoduodenectomy preventing pancreatic fistula.
Pancreatic and biliary duct fistula are the most severe and common complication following pancreatoduodenectomy. To prevent this complication, anastomosis should be appropriately performed and drainage of the pancreatic and bile duct is crucial. For proper drainage, the authers designed a cross-shaped tube for both the pancreatic and bile duct drainage, which has been practised on 16 patients with no pancreatic and biliary fistula happened. This new model combines the internal and external pancreatic drainages with biliary T-tube drainage and gives better drainage in practice so that the leakage might be lessened.
【Abstract】ObjectiveTo determine the risk factors associated with development of pancreatic fistula after pancreatoduodenectomy (PD). Methods The clinical data of 123 consecutive patients who underwent PD from Dec. 1994 to Dec. 2003 were analysed retrospectively. Results The incidence of pancreatic fistula was 11.4% (14/123). Univariate analysis showed history of upper abdominal operation, texture of pancreas, postoperative serum hemoglobin level, type of pancreatojejunostomy and diameter of pancreatic duct were significantly associated with pancreatic fistula after PD. Multivariate analysis using Logistic regression identified four variables as independent factors associated with the occurrence of pancreatic fistula: history of upper abdominal operation, texture of pancreas, postoperative serum hemoglobin level and type of pancreatojejunostomy. Conclusion History of upper abdominal operation, soft texture of pancreas, postoperative serum hemoglobin level less than 90 g/L and routine invaginated pancreaticojejunostomy are main risk factors associated with development of pancreatic fistula after PD.
Objective To analyze the effect of inner diameter of pancreatic duct following pancreaticoduodenectomy on pancreatic fistula. Methods From January 1995 to December 2008, 256 patients underwent pancreaticoduodenectomy were divided into four groups based on the types of pancreaticojejunostomy: end-to-side “mucosa-to-mucosa” anastomosis group (n=115), end-to-end “mucosa-to-mucosa” anastomosis group (n=71), end-to-end invaginated pancreaticojejunostomy group (n=43) and pancreaticogastrostomy group (n=27). Alternatively, 238 patients were divided into two groups according to drainage ways: stenting tube for internal drainage group (n=132) and stenting tube for external drainage group (n=106). Furthermore, 233 cases were divided into three groups on the basis of inner diameter of pancreatic duct: ≤0.2 cm group (n=54), 0.2-0.4 cm group (n=93) and ≥0.4 cm group (n=76). Then, the incidence rate of pancreatic fistula of each group was compared. Results The incidence of pancreatic fistula was 8.20% (21/256). The incidence of pancreatic fistula for different types of pancreaticojejunostomy was as follow: end-to-side “mucosa-to-mucosa” anastomosis group (7.83%， 9/115), end-to-end “mucosa-to-mucosa” anastomosis group (7.04%, 5/71), end-to-end pancreaticogastrostomy invaginated group (13.95%, 6/43) and pancreaticogastrostomy group (3.70%, 1/27), in which there wasn’t significant difference in 4 groups （χ2=2.763，P=0.430）. There was no significant difference of the incidence of pancreatic fistula between stenting tube for internal drainage group (9.10%, 12/132) and stenting tube for external drainage group (8.49%, 9/106), χ2=0.126, P=0.722. The incidence of pancreatic fistula in ≥0.4 cm group, 0.2-0.4 cm group and ≤0.2 cm group was respectively 0, 15.05% (14/93) and 11.11%(6/54), and the difference was significant (χ2=12.009, P=0.002). No correlation was found between the incidence of pancreatic fistula of different inner diameter of pancreatic duct and the types of pancreaticojejunostomy (χ2=1.878， P=0.598). Conclusion The inner diameter of pancreatic duct is an important factor for postoperative pancreatic fistula. No relationship is found between the types of pancreaticojejunostomy and pancreatic fistula in this study.
ObjectiveTo evaluate the predictive value of pancreatic duct diameter and pancreatic gland thickness measured using preoperative CT imaging on pancreatic fistula(PF)following pancreaticoduodenectomy (PD). MethodsOne hundred and fifty-one patients who underwent PD consecutively from January 2013 to April 2014 were reviewed retrospectively. Associations between the gender, age and the pancreatic duct diameter and pancreatic gland thickness from preoperative CT imaging and PF were analyzed. The diagnostic values of the pancreatic duct diameter and pancreatic gland thickness in patients with PF were evaluate by receiver operating characteristic (ROC) analysis. The reliability analysis was done for the pancreatic duct diameter and pancreatic gland thickness by using the intraclass correlation coefficient (ICC). The Spearman rank correlation analysis was done between the pancreatic duct diameter and pancreatic gland thickness. Results①PF occurred in 46 cases (30.1%).②The gender and age were not associated with PF (Gender: χ2=1.698, P=0.193; Age: χ2=0.016, P=0.900). The pancreatic duct diameter and pancreatic gland thickness were associated with PF (Pancreatic duct diameter: OR=0.275, 95% CI 0.164-0.461, P=0.000; Pancreatic gland thickness: OR=1.319, 95% CI 1.163-1.496, P=0.000).③There was no correlation between the pancreatic duct diameter and the pancreatic gland thickness (rs=-0.120, P=0.145).④The area under curve of ROC was 0.814 (95% CI 0.745-0.883, P < 0.001) for the pancreatic duct diameter in predicting the PF, the sensitivity and specificity was 68.6% and 78.3% respectively when the best critical value was 3.5 mm. The area under curve of ROC was 0.762 (95% CI 0.674-0.849, P < 0.001) for the pancreatic gland thickness in predicting PF, the sensitivity and specificity was 63.0% and 85.7% respectively when the best critical value was 31 mm.⑤The ICC of the pancreatic duct diameter and pancreatic gland thickness was 0.984 and 0.992 respectively by two medical diagnostic measurement. ConclusionPancreatic duct diameter and pancreatic gland thickness measured using preoperative CT imaging might be useful in predicting PF following PD.
Objective To investigate the effect of the duct-to-mucosa anastomosis in invaginating end-to-side pancreaticojejunostomy. Methods A retrospective review was conducted for 200 patients treated with pancreaticoduod-enectomy （PD） between August 2005 and December 2012. Reconstruction of digestive tract in PD was done according to the method described by Child. The duct-to-mucosa anastomosis was applied in the invaginating end-to-side pancrea-ticojejunostomy. The outline of the anastomosis structures was as follows：anastomosis of pancreatic duct and jejunal mucosa， anastomosis of pancreatic and jejunal resection margin， and anastomosis of pancreas and jejunal seromuscular layer. A cilicone tube was put into the pancreatic duct and lead to the jejunum. The anastomotic stoma was covered with part of the omentum majus, and put a drainage tube under the anastomotic stoma. Results The operation went smoothly，and no deaths occurred during perioperative period. The surgical time was 280-420 min， the average time was （298±77） min. The pancreatic fistula were observed in 22 patients （11%）， including 17 patients in Grade A， 2 patients in Grade B， and 3 patients in Grade C. The other complications were observed in 19 patients， including 16 patients with addominal infection， 1 patient with bleeding from splenic vein， 1 patient with bleeding from ruptured of pseudoaneurysm at biliary intestinal anastomosis， 1 patient with abdominal abscess. Three patients with pancreatic fistula in Grade C were cured by reoperation, and the other patients with pancreatic fistula were cured by expectant treatment. Conclusions The duct-to-mucosa anastomosis in invaginating end-to-side pancreaticojejunostomy is a simple and safe procedure that has the advantage in reducing the incidence of the pancreatic fistula. Using omentum to cover the anastomotic could localize the diffusion of panreactic fistula， and reduce the incidence of serious complications caused by pancreatic fistula.
ObjectiveTo investigate effect of sealing one-layer anastomosis in pancreaticojejunostomy in patients underwent pancreaticoduodenectomy. MethodsThe clinical data of 85 patients underwent pancreaticoduodenectomy in this hospital from January 2014 to May 2015 were collected. Of all the patients, 28 patients were underwent sealing onelayer anastomosis in pancreaticojejunostomy (sealing one-layer anastomosis group), 27 patients were underwent ductto-mucosa pancreaticojejunostomy (duct-to-mucosa anastomosis group), and 30 patients were underwent end-to-side invaginated pancreaticojejunostomy (end-to-side invagination group). The anastomosis time, time to pull out drainage tube, postoperative hospital stay, and incidence rate of postoperative pancreatic fistula were compared among these three groups. Results①The anastomosis time (min) of the sealing one-layer anastomosis group was significantly shorter than that of the duct-to-mucosa anastomosis group or end-to-side invagination group (12.51±2.96 versus 25.65±3.35, P < 0.05; 12.51±2.96 versus 23.73±5.27, P < 0.05).②The time to pull out drainage tube of the sealing one-layer anastomosis group was significantly shorter than that of the end-to-side invagination group (7.65±1.30 versus 11.15±3.47, P < 0.05).③The postoperative hospital stay had no statistical significances among these three groups (P > 0.05).④The incidence of pancreatic fistula was 3.57% (1/28), 7.41% (2/27), and 10.00% (3/30) among the sealing one-layer anastomosis group, duct-to-mucosa anastomosis group, and end-to-side invagination group respectively, which had no statistical differences among these three groups (P > 0.05). ConclusionSealing one-layer anastomosis in pancreaticojejunostomy might be a safe anastomosis, and it has advantages of simple operation and short operation time.
ObjectiveTo explore the risk factors of intraabdominal complications (IACs), pancreatic fistula (PF), and operative death after pancreatoduodenectomy (PD), and to provide a theoretical basis in reducing the rates of them. MethodsClinical data of 78 patients who underwent standard PD surgery in The Third People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from Jun. 2003 to Nov. 2011 were collected to analyze the influence factors of IACs, PF, and operative death. ResultsThere were 29 cases suffered IACs (13 cases of PF included), and 6 case died during 1 month after operation. Univariate analysis results showed that IACs and PF occurred more often in patients with soft friable pancreas, diameter of main pancreatic duct less than 3 mm, preoperative biliary drainage, no pancreatic duct stenting, and without employment of somatostatin (P < 0.05), no influence factor was found to be related to operative death. Multivariate analysis results showed that patients with no pancreatic duct stenting (OR=1.867, P=0.000), soft texture of remnant stump (OR=1.356, P=0.046), and diameter of main pancreatic duct less than 3 mm (OR=2.874, P=0.015) suffered more IACs; PF was more frequent in patient with no pancreatic duct stenting (OR=1.672, P=0.030), soft texture of remnant stump (OR=1.946, P=0.042), and diameter of main pancreatic duct less than 3 mm (OR=1.782, P=0.002);no independent factor was found to have relationship with operative death. ConclusionsSoft texture of remnant stump, diameter of main pancreatic duct less than 3 mm, and no pancreatic duct stenting are independent risk factors that should be considered in indications for PD surgery.
ObjectiveTo evaluate the postoperative complications after pancreaticoduodenectomy with modified triple-layer(MTL) duct-to-mucosa pancreaticojejunostomy and with resection of jejunal serosa, analyse the risk factors of pancreatic fistula, and compare effects with two-layer(TL) duct-to-mucosa pancreaticojejunostomy. MethodsData on 184 consecutive patients who underwent the two methods of pancreaticojejunostomy during standard PD between January 1, 2010 and January 31, 2013 were collected retrospectively. The risk factors of pancreatic fistula were investigated by using univariate and multivariate analyses. ResultsA total of 88 patients received TL and 96 underwent MTL. Rate of pancreatic fistula for the entire cohort was 8.2%(15/184). There were 11 fistulas(12.5%) in the TL group and four fistulas(4.2%) in the MTL group(P=0.039). Body mass index, pancreatic texture, pancreatic duct diameter, and methods of pancreaticojejunostomy had significant effects on the formation of pancreatic fistula on univariate analysis. Multivariate analysis showed that pancreatic duct diameter less than 3 mm and TL were the significant risk factors of pancreatic fistula. ConclusionsMTL technique effectively reduced the pancreatic fistula rate after PD in comparison with TL, especially in patients with pancreatic duct diameter less than 3 mm.
ObjectiveTo summarize the clinical characteristics of traumatic pancreatitis (TP) after pancreatic trauma and illustrate the experience of specialized treatment. MethodsClinical data of 73 patients with TP treated in our hospital from January 2008 to June 2014 were collected. The pancreatic injury location, grade, and TP pathogenic factors were analyzed, summarized the common problem and the regularity in TP course, and summarized the treatment strategy, methods of surgical intervention, operation key points and difficulties of TP. ResultsThe grade of pancreatic trauma in the all of patients was mainly to levels of 2, 3, and 4, the head of the pancreas injury accounted for 31.5% (23/73), cervical pancreatic body and tail injuries accounted for 68.5% (50/73). Fifty-nine patients were from other hospitals referral. The occurrence of TP peak period was 4-7 days after pancreatic trauma. Pancreatic fistula and uncontrolled peritoneal infection were the treatment difficulty of TP. It's the effective minimally invasive treatment methods for TP that percutaneous catheter drainage, pancreatic duct stent placement, and endoscopic abscess debridement. Forty-two patients with TP needed reoperations, and 19 cases underwent more than 2 times operation. ConclusionsBecause of the condition of TP is complex and changeable, and difficulty to treat, so the early definitive diagnosis and appropriate surgical strategy play a crucial role in the treatment of TP. Besides, professional team of pancreatic surgery has advantages in estimating patients' conditions, selecting and performing surgical interventions.