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Pancreaticogastrostomy eCommons@AKU Section of General Surgery Department of Surgery October 2017 Pancreaticogastrostomy - an alternate for dealing with pancreatic remnant after pancreaticoduodenectomy - experience from a tertiary care center of Pakistan Tabish Chawla Aga Khan University, [email protected] Hassaan Bari Aga Khan University Shahrukh Effendi Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_gen Part of the Surgery Commons Recommended Citation Chawla, T., Bari, H., Effendi, S. (2017). Pancreaticogastrostomy - an alternate for dealing with pancreatic remnant after pancreaticoduodenectomy - experience from a tertiary care center of Pakistan. Journal of Pakistan Medical Association, 67(10), 1621-1624. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_gen/76 1621 CASE SERIES Pancreaticogastrostomy — an alternate for dealing with pancreatic remnant after pancreaticoduodenectomy — experience from a tertiary care center of Pakistan Tabish Chawla, Hassaan Bari, Shahrukh Effendi Abstract as part of PD. Therefore it was associated with high Whipple's pancreaticoduodenectomy has been refined morbidity and mortality resulting from high rates of over the years to be a safe operation though the leakage from pancreatic stump. morbidity rate still remains high (30-50%). Pancreatic Pancreatcogastrostomy is a repopularized technique fistula is the most important cause of mortality which has been described previously in literature. 3 This following pancreaticoduodenectomy. To prevent it, study was done to review the experience of PG being surgeons have used two anastomotic techniques: done as an alternate to PJ after PD. pancreaticojejunostomy and pancreaticogastrostomy. Recent studies found that pancreaticogastrostomy is Material and Methods associated with fewer overall complications than It is a case series collected at the Department of Surgery of pancreaticojejunostomy. Aga Khan University Hospital, Karachi from July 2008 till This is a retrospective review of patients who underwent March 2016. This case series includes all adult patients Whipple's at Aga Khan University Hospital and had who were diagnosed to have peri-ampullary mass on pancreaticogastrostomy as a preferred anastomosis for preoperative imaging and underwent Pancreatico- pancreatic stump. duodenectomy (Whipple procedure) with pancreatico- gastrostomy as preferred anastomoses, instead of Forty four patients met the inclusion criteria, 27 were pancreatico-jejunostomy, to maintain pancreatico- male. No patient developed post-operative pancreatic enteric continuity. Retrospective review of files of these fistula, 13 (31%) patients had morbidities including patient's was done and a detailed performa was delayed gastric emptying 4(9.1%), wound infection developed to record information on patient's 3(6.8%), and haemorrhage 6(13.6%). Mortality is reported demographics, clinical features, haematological and to be 5 (11.9%). radiological investigations, preoperative ERCP and stenting, final histopathology, surgical details and Pancreaticogastrostomy seems to be a safe alternative duration of hospital stay. Postoperative 30-day mortality and easier anastomosis to perform with less post- and morbidity (including postoperative pancreatic fistula, operative morbidity and mortality. Further data should delayed gastric emptying, haemorrhage and wound become available with greater numbers in the future. infection) were also recorded. The data were analyzed by Keywords: Pancreaticogastrostomy, Pancreatic anastomosis, using Statistical Package for the Social Sciences (SPSS Pancreatic leak. version 20.0). Quantitative variables are reported as means ± standard deviations, Qualitative variables are Introduction reported as proportions and percentages. This case series Pancreaticoduodenectomy (PD) has become increasingly was approved by hospital Ethical Review Committee (ERC acceptable as a safe and appropriate surgical technique number 4083-Sur-ERC-16). for managing malignant or benign diseases of the head of the pancreas and periampullary region. 1 Results A total of 44 patients were included in this case series, of First successful PD was done by Walter Kausch in 1912. whom 17 patients were females and 27 were males. Mean Allen Whiple in 1935, 2 introduced and popularized the age was 55.5±11.5 years. Most commonly occurring operation. Cameron in 1993 presented his case series of comorbidity was Hypertension (18 patients) and Diabetes 145 consecutive PD from Johns Hopkins Medical institute. Mellitis (14 patients). Most common presenting complaint Initially Pancreaticoenteric anastomoses was not included was jaundice (35 patients, 79.5 %) followed by abdominal pain (25 patients 56.8%). CT Scan Abdomen was used as Aga Khan University Hospital, Karachi, Pakistan. main diagnostic and staging tool and was done in all Correspondence: Hassaan Bari. Email: [email protected] patients. A total of13(29.6%) patients underwent ERCP, 9 Vol. 67, No. 10, October 2017 1622 T. Chawla, H. Bari, S. Effendi Table-1: Demographic and clinico-pathological data. Variables Frequencies Total no. patients (N) 44 Age Mean 55.5 years (SD ±11.5) Gender Male 27 (61.4 %) Female 17 (38.6%) Presenting complaint Nausea 12 (27.3%) Weight loss 16 (36.4%) Abdominal pain 25 (56.8%) Jaundice 35 (79.5%) Preoperative stenting 9 (20.5%) Histopathology AmpullaryAdenocarcinoma 16 (36.4%) Adenocarcinoma CBD 8 (18.2%) Adenocarcinoma Duodenum 4 (9.1%) Carcinoma head of Pancreas 11 (25.0%) Distal CBD Cholangiocarcinoma 2 (4.5%) Chronic Pancreatitis 2 (4.5%) GIST duodenum 1 (2.3%) Duration of Surgery (mean) 7.14 hours (SD±1.0) Duration of hospital stay (mean) 14.1 days (SD±5.6) Morbidity Pancreatic leak/Fistula NONE Figure-1: Pancreaticogastrostomy. Delayed Gastric emptying 4 (9.1%) Haemorrhage 6 (13.6%) Wound infection 3 (6.8%) managed conservatively, and 3 had wound infection. A Choledocho-jejunostomy leak 1 (2.3%) total of 6 patients had Intraluminal gastro-intestinal Mortality 5 (11.4%) haemorrhage; 2 patients had bleeding from SD: Standard deciation. CBD: Common bile duct. GIST: Gastrointestinal stromal tumour. pancreaticogastrostomy and 1 had bleeding from gastrojejunostomy site, out of these 3 patients, one was (20.5%) had stent placement and10 (22.30%) patients had re-explored after endovascular attempts but died even endoscopic biopsy as well. Peroperatively pancreas was after all measures and 2 patient were attempted to be found to be firm in seven patients, soft in eleven patients managed via endovascular means but only one endeavor and in rest consistency was not documented. Mean was successful. The other 3 patients were managed duration of surgery was 7.14±1.0 hours. Mean time period conservatively and required no intervention for control of to establish oral feeding was 7±1.9 days. Final haemorrhage. One patient had a leak from histopathology of the resected specimen was choledochojejunostomy site which was managed ampullaryadeno carcinoma in 16 (36.4%) patients, conservatively by PTC drainage. None of our patients carcinoma head of pancreas in 11(25.0%) patients, adeno developed pancreatic fistula. Five patients expired, 2 due carcinoma Distal CBD in 8 (18.2%) patients and adeno to non-surgical causes, one had massive pulmonary carcinoma duodenum in 4(9.1%) patients, (Table-1). All embolism and the other suffered from aspiration resected specimens had tumour free margins, except pneumonia, acute kidney injury and atrial fibrillation. One 1which was borderline resectable to start with. In 17 patient had ongoing sepsis because of persistent patients lymph nodes were positive for metastases. Mean postoperative cholangitis. The other 2 patients died of duration of hospital stay was 14.1±5.6 days. All the cases massive gastrointestinal hemorrhage. were discussed in multidisciplinary meeting (tumor Discussion board) after surgery and were referred for adjuvant chemo-radiotherapy where necessary. Pancreaticoenteric anastomoses for the first time was introduced by Whipple 4 in 1945. Throughout 1960s Post-operative morbidities were reported in 14 patients. and 70s this procedure was associated with high Four patients had delayed gastric emptying, all were morbidity and mortality. 5 However current statistics J Pak Med Assoc Pancreaticogastrostomy — an alternate for dealing with pancreatic remnant after pancreaticoduodenectomy... 1623 show that preoperative mortality after PD has - Anastomosis is protected against enzymatic damage decreased to < 5% in high volume centers, probably because of acidic environment of stomach which because of innovation in surgical techniques and inactivates the pancreatic proteolytic enzymes. 13 development in perioperative care. 6,7 But post- operative morbidity of pancreatic resection continues - It is known to be a technically easier and tension-free to remain 30 - 50%. 8 Most common postoperative anastomosis as the posterior wall of the stomach lies complications include: Delayed gastric emptying (19- immediately anterior to the mobilized pancreatic 23%), Anastomotic leakage or fistula from remnant, which acts not only as a thick suture bed for the pancreaticoenetrostomy (9-18%), Intra-abdominal anastomosis, but has an excellent blood supply as well abscess (9-10%) and Gastrointestinal or intra- when compared to the jejunum. Moreover absence of a 13,14 abdominal hemorrhage (1- 8%). long jejunal loop eliminates the hanging effect of it. Among the above mentioned complications the most - Early detection of bleeding from the pancreatic remnant dreadful and important
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