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Novel Non-duct-to-Mucosa Pancreaticojejunostomy Reconstruction After Pancreaticoduodenectomy: Focus on the Occurrence of Post-pancreatectomy Hemorrhage and Intra-abdominal Abscess

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Abstract

Background

Postoperative pancreatic fistulas (POPFs) are considered inevitable in some patients after pancreaticoduodenectomy (PD), and measures to minimize their clinical impact are needed. Postpancreatectomy hemorrhage (PPH) and intra-abdominal abscess (IAA) are the most severe POPF-related complications, and concomitant leakage of contaminated intestinal content is considered the main cause. An innovative method, modified non-duct-to-mucosa pancreaticojejunostomy (TPJ), was created to prevent concomitant leakage of intestinal content, and its effectiveness was compared between two periods.

Methods

All PD patients undergoing pancreaticojejunostomy from 2012 to 2021 were included. The TPJ group consisted of 529 patients recruited from January 2018 to December 2021. A total of 535 patients receiving the conventional method (CPJ) from January 2012 to June 2017 were used as a control group. PPH and POPF were defined according to the International Study Group of Pancreatic Surgery definition, but only PPH grade C was included for analysis. An IAA was defined as a collection of postoperative fluid managed by CT-guided drainage with documental culture.

Results

There were no significant differences in the rate of POPF between the two groups (46.0% vs. 44.8%; p = 0.700). Furthermore, the percentages of bile in the drainage fluid in the TPJ and CPJ groups were 2.3% and 9.2%, respectively (p < 0.001). Lower proportions of PPH (0.9% vs. 6.5%; p < 0.001) and IAA (5.7% vs. 10.8%; p < 0.001) were observed for TPJ than for CPJ. On adjusted models, TPJ was significantly associated with a lower rate of PPH (odds ratio [OR] 0.132, 95% confidence interval [CI] 0.051–0.343; p < 0.001) and IAA (OR 0.514, 95% CI 0.349–0.758; p = 0.001) than CPJ.

Conclusions

TPJ is feasible to be performed and is associated with a similar rate of POPF but a lower percentage of concomitant bile in the drainage fluid and subsequent rates of PPH and IAA than CPJ.

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References

  1. Fernandez-del Castillo C, Morales-Oyarvide V, McGrath D, et al. Evolution of the Whipple procedure at the Massachusetts General Hospital. Surgery. 2012;152(3 Suppl 1):S56-63.

    Article  PubMed  Google Scholar 

  2. Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg. 2006;244(1):10–5.

    Article  PubMed  PubMed Central  Google Scholar 

  3. O’Mahoney PRA, Yeo HL, Sedrakyan A, et al. Centralization of pancreatoduodenectomy a decade later: impact of the volume-outcome relationship. Surgery. 2016;159(6):1528–38.

    Article  PubMed  Google Scholar 

  4. Grobmyer SR, Kooby D, Blumgart LH, Hochwald SN. Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications. J Am Coll Surg. 2010;210(1):54–9.

    Article  PubMed  Google Scholar 

  5. Olakowski M, Grudzinska E, Mrowiec S. Pancreaticojejunostomy-a review of modern techniques. Langenbecks Arch Surg. 2020;405(1):13–22.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Schuh F, Mihaljevic AL, Probst P, et al. A simple classification of pancreatic duct size and texture predicts postoperative pancreatic fistula: a classification of the International Study Group of Pancreatic Surgery (ISGPS). Ann Surg. 2021. https://doi.org/10.1097/SLA.000000000000485.

    Article  PubMed  Google Scholar 

  7. Honda G, Kurata M, Okuda Y, et al. Novel device for pancreaticojejunostomy via a pure laparoscopic approach. J Am Coll Surg. 2013;216(6):e73-76.

    Article  PubMed  Google Scholar 

  8. Cheng Q, Zhang B, Zhang Y, et al. Predictive factors for complications after pancreaticoduodenectomy. J Surg Res. 2007;139(1):22–9.

    Article  PubMed  Google Scholar 

  9. Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142(1):20–5.

    Article  PubMed  Google Scholar 

  10. Tien YW, Wu YM, Liu KL, Ho CM, Lee PH. Angiography is indicated for every sentinel bleed after pancreaticoduodenectomy. Ann Surg Oncol. 2008;15(7):1855–61.

    Article  PubMed  Google Scholar 

  11. Tien YW, Lee PH, Yang CY, Ho MC, Chiu YF. Risk factors of massive bleeding related to pancreatic leak after pancreaticoduodenectomy. J Am Coll Surg. 2005;201(4):554–9.

    Article  PubMed  Google Scholar 

  12. Andrianello S, Marchegiani G, Malleo G, et al. Pancreaticojejunostomy with externalized stent vs pancreaticogastrostomy with externalized stent for patients with high-risk pancreatic anastomosis: a single-center, phase 3, randomized clinical trial. JAMA Surg. 2020;155(4):313–21.

    Article  PubMed  Google Scholar 

  13. Floortje van Oosten A, Smits FJ, van den Heuvel DAF, van Santvoort HC, Molenaar IQ. Diagnosis and management of postpancreatectomy hemorrhage: a systematic review and meta-analysis. HPB (Oxford). 2019;21(8):953–61.

    Article  CAS  PubMed  Google Scholar 

  14. Lin YJ, Ho TW, Wu CH, et al. Specific bile microorganisms caused by intra-abdominal abscess on pancreaticoduodenectomy patients: a retrospective cohort study. Curr Oncol. 2021;29(1):111–21.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187–96.

    Article  PubMed  Google Scholar 

  16. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161(3):584–91.

    Article  PubMed  Google Scholar 

  18. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613–9.

    Article  CAS  PubMed  Google Scholar 

  19. Wu JM, Ho TW, Yen HH, et al. Endoscopic retrograde biliary drainage causes intra-abdominal abscess in pancreaticoduodenectomy patients: an important but neglected risk factor. Ann Surg Oncol. 2019;26(4):1086–92.

    Article  PubMed  Google Scholar 

  20. Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013;216(1):1–14.

    Article  PubMed  Google Scholar 

  21. Bassi C, Falconi M, Molinari E, et al. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial. Surgery. 2003;134(5):766–71.

    Article  PubMed  Google Scholar 

  22. Kanda M, Fujii T, Kodera Y, Nagai S, Takeda S, Nakao A. Nutritional predictors of postoperative outcome in pancreatic cancer. Br J Surg. 2011;98(2):268–74.

    Article  CAS  PubMed  Google Scholar 

  23. Pedrazzoli S, Liessi G, Pasquali C, Ragazzi R, Berselli M, Sperti C. Postoperative pancreatic fistulas: preventing severe complications and reducing reoperation and mortality rate. Ann Surg. 2009;249(1):97–104.

    Article  PubMed  Google Scholar 

  24. Kwon HJ, Ha HT, Choi YY, Kim SG. The effects of the end-to-side inverted mattress pancreaticojejunostomy on postoperative pancreatic fistula: a single surgeon’s experience. Ann Surg Treat Res. 2015;89(2):61–7.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Yao GL, An MJ, Fan YG. Invaginated duct to mucosa pancreaticojejunostomy reduce postoperative pancreatic leakage: a matched case-controlled study. Medicine (Baltimore). 2021;100(49):e27834.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Kelemen D, Papp R, Kaszás B, Bíró Z, Vereczkei A. Pancreatojejunostomy with modified purse-string suture technique. Langenbecks Arch Surg. 2016;401(3):403–7.

    Article  PubMed  Google Scholar 

  27. Kusnierz K, Mrowiec S, Lampe P. A comparison of two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy. Gastroenterol Res Pract. 2015;2015:894292.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Buc E, Flamein R, Golffier C, et al. Peng’s binding pancreaticojejunostomy after pancreaticoduodenectomy: a French prospective study. J Gastrointest Surg. 2010;14(4):705–10.

    Article  PubMed  Google Scholar 

  29. Morelli L, Di Franco G, Guadagni S, et al. Technical details and results of a modified end-to-side technique of pancreatojejunostomy: a personal series of 100 patients. J Gastrointest Surg. 2017;21(12):2090–9.

    Article  PubMed  Google Scholar 

  30. Fujii T, Sugimoto H, Yamada S, et al. Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study. J Gastrointest Surg. 2014;18(6):1108–15.

    Article  PubMed  Google Scholar 

  31. Wang M, Xu S, Zhang H, Peng S, Zhu F, Qin R. Imbedding pancreaticojejunostomy used in pure laparoscopic pancreaticoduodenectomy for nondilated pancreatic duct. Surg Endosc. 2017;31(4):1986–92.

    Article  PubMed  Google Scholar 

  32. Isselbacher KJ, Senior JR. The intestinal absorption of carbohydrate and fat. Gastroenterology. 1964;46:287–98.

    Article  CAS  PubMed  Google Scholar 

  33. Elmslie R. The effect of bile on the activation of trypsinogen and the activity of trypsin in pancreatic juice. Br J Surg. 1965;52:465–70.

    Article  CAS  PubMed  Google Scholar 

  34. Sarkany RP, Moreland BH. Enhancement of the autocatalytic activation of trypsinogen to trypsin by bile and bile acids. Biochim Biophys Acta. 1985;839(3):262–7.

    Article  CAS  PubMed  Google Scholar 

  35. Kitamoto Y, Yuan X, Wu Q, McCourt DW, Sadler JE. Enterokinase, the initiator of intestinal digestion, is a mosaic protease composed of a distinctive assortment of domains. Proc Natl Acad Sci USA. 1994;91(16):7588–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Muili KA, Wang D, Orabi AI, et al. Bile acids induce pancreatic acinar cell injury and pancreatitis by activating calcineurin. J Biol Chem. 2013;288(1):570–80.

    Article  CAS  PubMed  Google Scholar 

  37. Luthen RE, Niederau C, Grendell JH. Effects of bile and pancreatic digestive enzymes on permeability of the pancreatic duct system in rabbits. Pancreas. 1993;8(6):671–81.

    Article  CAS  PubMed  Google Scholar 

  38. Mussle B, Hempel S, Kahlert C, Distler M, Weitz J, Welsch T. Prognostic impact of bacterobilia on morbidity and postoperative management after pancreatoduodenectomy: a systematic review and meta-analysis. World J Surg. 2018;42(9):2951–62.

    Article  PubMed  Google Scholar 

  39. Mintziras I, Maurer E, Kanngiesser V, Lohoff M, Bartsch DK. Preoperative bacterobilia is an independent risk factor of SSIs after partial PD. Dig Surg. 2020;37(5):428–35.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

This study was supported by grant number 110-2221-E-002 -014 -MY3 from the Ministry of Science and Technology, Taiwan, which had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Authors and Affiliations

  1. Department of Surgery, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan, ROC

    Jin-Ming Wu MD, PhD, Young-Jen Lin MD, Chien-Hui Wu MD, Ting-Chun Kuo MD & Yu-Wen Tien MD, PhD

  2. Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu County, Taiwan, ROC

    Jin-Ming Wu MD, PhD

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  1. Jin-Ming Wu MD, PhD
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  2. Young-Jen Lin MD
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  3. Chien-Hui Wu MD
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Correspondence to Yu-Wen Tien MD, PhD.

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Wu, JM., Lin, YJ., Wu, CH. et al. Novel Non-duct-to-Mucosa Pancreaticojejunostomy Reconstruction After Pancreaticoduodenectomy: Focus on the Occurrence of Post-pancreatectomy Hemorrhage and Intra-abdominal Abscess. Ann Surg Oncol 30, 5063–5070 (2023). https://doi.org/10.1245/s10434-023-13114-1

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