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Post-Operative Pancreatic Fistula in Pancreatico-Duodenectomy with Pancreato-Gastrostomy Using Barbed Sutures

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Post-Operative Pancreatic Fistula in Pancreatico-Duodenectomy with Pancreato-Gastrostomy Using Barbed Sutures JOP. J Pancreas (Online) 2016 May 09; 17(3):298-300. ORIGINAL ARTICLE Post-Operative Pancreatic Fistula in Pancreatico-Duodenectomy with Pancreato-Gastrostomy using Barbed Sutures Micaela Piccoli, Bruno Scotto, Barbara Mullineris, Davide Gozzo Civile S. Agostino Estense Hospital, AUSL Modena, Robotic and General Surgery Unit, Modena, Italy ABSTRACT Objective To demonstrate safety of barbed sutures for pancreatogastrostomy after pancreaticoduodenectomy, analyzing our results with Methods st th worldwide literature exclusively about post-operative pancreatic fistula, according to the International Study Group for Pancreatic Fistula definition. From 1 JanuaryResults 2013 to 30 June 2015, 39 patients underwent pancreaticoduodenectomy with PG reconstruction (but only 36 using barbed sutures). We evaluated demographic details of the patients (age, sex and diagnosis), length of post-operative hospital stay and rate of POPF. Out of 36 patients, 6 patients had a clinically relevant grade B/C fistula (16.6%). B grade post- operativeth pancreatic fistula occurred in 4 patients (11.1%), managed with fasting and requiring a delayed discharge. Only 2 patients was atdiagnosed 98th a C grade post-operativeConclusions pancreatic The use fistula of barbed (5,55%), suture one for requiring pancreatogastrostomy a percutaneous reconstruction computed tomography seems to facilitatedrain (discharged the surgical at 38 post-operative day) and the other one required a re-operation because of a pancreatogastrostomy dehiscence with delayed discharge post-operative day. actions and to reduce the rate of post-operative pancreatic fistula after pancreaticoduodenectomy, also in a no high volume center of pancreatic surgery. The results of this observational study should be validated by largest series also inside multicenter randomized trials. INTRODUCTION vs. ea thereJejunostomy is poor (PJ) studies Pancreato-Gastrostomy analyzing the introduction (PG), offinding new similar rates of fistula and other complications [3, 4, 5] but becameSince soon its first the app treatmentrs in 1909, of Pancreaticoduodenectomychoice for malignant and (PD) passed through many changes and improvements and benign diseases of the pancreatic head and periampullary devicesThe tointroduction improve the safetyof new of the surgical procedure technologies [6, 7, 8]. rates of complications, still represent a hard challenge forregion. surgeons, Its technical but during difficulties, the decades associated many renovations with high suggested us to start using a barbed suture (V-Loc™ has been proposed and widely introduced in the surgical wound closure device. Covidien) for the pancreatoenteric practice, with excellent results in terms of reduction gynecology,anastomosis. orthopedics This new and kind general of suturessurgery operationshas been introduced in 2011 and tested for plastic surgery, urology, high-volume centers for pancreatic surgery allowed the beginningof mortality of clinicaland morbidity. trials for newMoreover, surgical the strategies creation and of (laparoscopic myomectomy and hysterectomy [9], breast reconstructions [10], laparoscopic gastric by-pass [11], ofradical applications prostectomy and different [12], hip studies and knee have replacement been published, [13]) long-term results. with excellent results. Many surgeons extended its field The pancreaticoenteric reconstruction after PD is one The aim of this study is to demonstrate the effective safety The main issue is represented by the incidence of post and so we did, starting to use this suture for PG after PD. of the topics debated in literature in the last 20 years [1]. of this suture for pancreatic surgery, analyzing our results most common complications of the anastomosis between with worldwide literature exclusiv pancreaticoperative pancreatic stump and fistula (POPF), which is one of the METHODS ely about POPF. digestive tract [2]. Many trials st th compared two main types of reconstruction, Pancreato- Keywords From 1 January 2013 to 30 June 2015, 39 patients Received December 30th, 2015-Accepted February15th, 2016 underwent PD with PG reconstruction in our General Abbrevations Pancreaticoduodenectomy; Pancreatogastrostomy; Surgery Unit. We evaluated demographic details of Pancreatic Neoplasms; Surgery ISGPF International Study Group For Pancreatic Fistula; the patients (age, sex and diagnosis), length of post- CorrespondencePD pancreaticoduodenectomy; PG pancreatogastrostomy; POPF post- operative hospital stay and rate of POPF. According to operative pancreatic fistula the classification done by the ISGPF, fistula was defined Bruno Scotto as drain output of any measurable volume of fluid on or Civile S. Agostino Estense Hospital PhoneAUSL Modena, Robotic and General Surgery Unit after postoperative day 3 with amylase content greater E-mailModena, Italy than 3 times the upper normal serum value. POPF was +393404658860 classified into three grades: A, B and C. Grade A POPF [email protected] JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 17 No. 3 – Mayrequires 2016. [ISSN little 1590-8577] change in management or deviation from298 JOP. J Pancreas (Online) 2016 May 09; 17(3):298-300. in management or adjustment of the clinical pathway withthe normal noninvasive clinical treatment pathway. Gradesuch asB POPFparenteral needs nutritiona change laparostomypatient required system, a reoperation then a multiorgane for a gastrotomy failure occurredbleeding complicated by wound infection, frequent positioning of or antibiotics. Grade C POPF includes a major change in and the patient died after 53 days of hospitalization DISCUSSION antibiotics,clinical management percutaneous due todrainage life-threatening or surgical complications. intervention (diagnosis: pancreatic head carcinoma). These patients required nutritional support, intravenous [14]. In this study we evaluated the safety of using V-Loc Pancreaticoenteric anastomosis is still a challenge for for PG and for the anterior gastrotomy, in terms of rate solidsurgeons retroperitoneal because of theorgan, risk and of the intestine,anastomotic peritoneal failure. of POPF. Other complications such as biliary leakage or The risk is due to the differences between the pancreas, a gastro-jejunal leakage, as well oncological follow-up and survivalSurgical will Details not be the object of this study. notorgan only working from the via main peristalsis duct, but that also can from disrupt several a minorstable anastomosis site. Moreover, the pancreatic juice is secreted The PG reconstruction was first performed by Waugh ducts that can weaken the anastomosis and contribute to and Clagett in 1946. In recent years it has gained approvals develop a POPF. for many reasons: the excellent blood supply to the stomach enzymes secreted in the stomach are inactivated by According to literature, two main types of anastomosis gastricwall facilitates acid, and thethis anastomoticmay prevent thehealing; auto-digestion the pancreatic of the havecan be reported performed a similar after arate pancreatoduodenectomy: of complications between PJ andthe twoPG. Inmethods, terms ofbut post-operative none of them seemsoutcome, to be many safer surgeons than the anastomosis [15]. Recently, Kech et al TwoAfter traction classical sutures en-bloc are pancreaticoduodenectomy,applied on both edges of the other. pancreatic stump is mobilized from the retroperitoneum. [16] published their results of the RECOPANC multicenter randomized controlled trial, pancreas. Through an anterior and a posterior gastrotomy showing an overall rate of POPF of 20% in PG anastomosis (3 cm each one), we pull over the pancreatic remnant and high volume centers for pancreatic surgery (>80 major and 22% in the PJ one. Analyzing the data and excluding perform the PG with two single-layer running sutures (anterior and posterior) between the pancreatic body and the gastric wall (full thickness). The pancreatic stump pancreatic resections per-year), theet rate al of POPF is higher needs to protrude in the stomach at least two-three cm. after PJ reconstruction (46%) than the PG reconstruction Once the anastomosis is fixed, the anterior gastrotomy is (27%). In their reviews, Harnoss . [17] reported a closed with a double-layer running suture too. The suture rate of POPF between 22% and 26%, considering both selected for the PG has always been PDS 3/0, but since the types of anastomosis. Analyzing the data of the last 2 years introduction of the V-Loc we started using it for this type and half, in our center the rate of POPF is 16.6% (6/36 of pancreatic anastomosis. V-loc has been also used for the patients), which seems to be lower than the mean rate closure of the anterior gastrotomy. In this study we used reported in literature (24%). The only case of death was V-Loc 3/0 suture for 36 patients; the others 3 patients not consequent to a POPF, but to a gastrotomy bleeding received PDS 3/0 suture, and will be excluded from the (complication more frequent in PG reconstruction than currentRESULTS dissertation. in PJ [16]), than followed by positioning of laparostomy The mean age of the patients at the day of the operations system and a multi-organ failure. Although if barbed sutures were produced for few diagnosed with adenocarcinoma of the pancreatic head, extendedkind of surgery in several (gastric operations by-pass, such inguinal as tendonherniorraphy, repair, was 70 years (min 46 years, max 83). 17 patients were Nissen fundoplication, dermal closure), their use has been 5 with ampullary
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