pancreaticojejunostomy vs. pancreaticogastrostomy–after pancreaticoduodenectomy

Ri b86401095 王薏茜

Reference:J. of clinical gastroenterology 2001 31(3):11-8World J of Surg. 2001 25:567-71World J of Surg. 2000 24:86-91Annals of Surgery. 1995 222(4):580-8.

Trend of Whipple: mortality

Before 1980: 5-y survival: 5-6% After 1980: op mortality rate: <5%

Whipple: better prognostic factors

Small tumor: <2cm Histologically negative surgical margins Negative locoregional lymph nodes No vessel invasion of the tumor More experienced surgeon >40% 5-year survival rate

pancreaticojejunostomy

The pancreatic remnant is invaginated into jejunum to prevent leakage in an end-to-end fashion

Complications of Whipple: 40-50%

Sabiston 16th edition 2001

Leading complications Delayed gastric emptying Healing failure of pancreatic anastomosis:

Incidence: 10-20% pancreatic fistula formation intra-abdominal abscess hemorrhage wound infection Mortality rate: 40-50% Account for >50% of post-Whipple mortality Somatostatin: limited use

Ways to prevent pancreatic leakage

pancreaticogastrostomy

Pylorus-preserving operation Hemigastrectomy

pancreaticogastrostomy

Direct visualization with anterior gastrostomy

Posterior approach from outside

Advantages of pancreaticogastrostomy

Other statistical data of PG (1): 16.5% complication rate Loyola medical center: 102 consecutive PG 1986-1998

Other statistical data of PG (2) Pancreatic leak rate after PG: 0-14% John Hopkins: the only randomized pros

pective study: 1993-1995, 145 patients Pancreatic leak rate: 11.7% No significant difference between PG PJ Univariable logistic regression: ampullary or

duodenal disease, surgical volume, pancreatic texture, operation time, and intraoperative red blood cell transfusions,

Physiologic studies of Whipple After Whipple, >50% of exocrine gland are resec

ted, >20% of patients will experience increased fecal fat and weight loss in 1 year.

Measure chemotrypsin activity with N-benzoyl-L-tyrosyl-p-amiobenzoic acid and PABA Pre-operative: significantly depressed Post-op: slowly recovery of function 1 year post-op: normalizing

Excellent residual exocrine activity Importance of ductal drainage

Physiologic studies of PG Animal study:

Mild increase in basal gastric pH No change in:

Maximal gastric output Gastrin, secretin secretion Gastric pH response to gastrin, secretin Pre- post-prandial hormone level and pH

Neurohormonal relationship between stomach, pancreas, duodenum is maintained

Physiologic studies of PG: human study 3 y after Whipple+PG Normal circadian rhythm of gastrin/secretin

Fasting serum gastrin: 93.5+/-20.3 73.9+/-8.2 Fasting serum secretin: 84.1+/-6.4 73.6+/-5.0

Basal gastric pH still <3 Amylase, lipase, chemotrypsin activity are present in the sto

mach when pH>3 Amylase, lipase, chemotrypsin are normally activated in the s

mall intestine Decreased amylase, lipase, chemotrypsin level in stool

Normal: 882+/-234 PG: 151+/-20 PJ: 136+/-25 Chronic pancreatitis: 58

Physiologic studies of PG

Physiologic studies of PG

Gastric pH 24 hours study

Physiologic studies of PG: GI motility

No post-op patients have normal jejunal motility pattern during the fasted or fed status.

PG did yield a more “normal-like” tracing

Timing of arrivals of biliary and pancreatic secretions?

Conclusion PG is better, or at least not worse than P

J Complications Pancreatic leakage

There are no untoward physiologic effects of invaginating the pancreatic stump into the stomach, specifically in relation to gastric pH, pancreatic enzyme activity, and GI motility.