Abstract
Although pyloric preservation can be performed during pancreaticoduodenectomy without increased morbidity or mortality or decreased survival, the long-term benefit of this technique remains unproven. In this study, the functional status of patients recovered from pyloric-preserving pancreaticoduodenectomy was evaluated by comparing 6 long-term survivors of the standard Whipple procedure (1–7 years postoperative; mean, 4.7 yr) to a similar group of 6 patients recovered from pylorus preservation pancreaticoduodenectomy (1–7 years postoperative; mean, 3.0 yr). All patients completed a questionnaire evaluating postgastrectomy symptoms. Fasting blood specimens were obtained for hematologic and biochemical analysis. Ten of the 12 patients then underwent endoscopy; perianastomotic and midgastric biopsies were graded for inflammation. Gastric emptying of both liquid and solid phases was measured with an isotopically-labeled meal. Gastric emptying data were compared between groups and also to a group of 7 normal controls studied previously using the same methodology. Analysis of questionnaire results and mean laboratory values revealed no significant differences between the 2 surgical groups. Serum carotene levels were low in most patients. Several patients demonstrated abnormal indices of iron homeostasis. No significant abnormalities were noted on endoscopic examinations and biopsy results did not differ between the 2 surgical groups. Liquid gastric emptying was significantly prolonged in patients following standard pancreaticoduodenectomy (t1/2=98.3±26.2 min) as compared to pylorus preservation patients (t1/2=37.5±10.9 min) or normal controls (t1/2=33.1±2.8 min). We conclude that, in the long-term, pylorus preservation appears to be at least functionally equivalent to the standard pancreaticoduodenectomy. As such, we believe that pyloric preservation, obviating vagotomy and gastric resection, deserves consideration during pancreaticoduodenectomy.
Résumé
La conservation du pylore dans la duodénopancréatectomie céphalique n'augmente pas la morbidité ou la mortalité opératoire, et ne diminue pas la survie à distance. Cependant les bénéfices à long terme de cette conservation restent inconnus. Dans cette étude, on a comparé l'état fonctionnel de 6 patients ayant survécu après l'opération de Whipple (survie moyenne, 4.7 ans; extrêmes, 1 et 7 ans) à celui de 6 autres patients ayant subi une duodénopancréatectomie céphalique avec conservation du pylore (moyenne, 3.0 ans; extrêmes, 1 et 7 ans). Tous les patients ont répondu à un questionnaire concernant les suites de leur gastrectomie. Après prélèvement sanguin à jeun, 10 des 12 patients ont subi une fibroscopie: des biopsies systématiques périanastomotiques et gastriques moyennes ont été pratiquées pour évaluer le degré d'inflammation. La vidange gastrique (phase solide et liquide) a été évaluée aux isotopes. Ces résultats ont été comparés entre eux et à ceux de 7 patients normaux étudiés selon le même méthodologie. L'analyse des réponses aux questionnaires, et des résultats biologiques n'a pas permis de mettre en évidence une différence significative entre les 2 groupes opérés. Les taux de carotène sérique étaient bas chez la plupart des patients. La majorité des patients présentaient des anomalies des taux de fer. Il n'y avait pas de différence significative à l'examen endoscopique et les résultats des biopsies ne différaient pas dans les 2 groupes. La vidange gastrique des liquides était significativement plus longue chez les patients après duodénopancréatectomie standard (t1/2=98.3±26.2 min) que chez les patients avec conservation du pylore (t1/2=37.5±10.9 min) ou chez les sujets normaux (t1/2=33.1±2.8 min). Nous concluons que les résultats fonctionnels à long terme de la conservation pylorique sont aussi bons que ceux de la duodénopancréatectomie céphalique classique. Ainsi, nous croyons que la conservation du pylore, évitant la vagotomie et la résection gastrique, mérite d'être envisagée lors de toute duodénopancréatectomie.
Resumen
La preservación del píloro en la pancreatoduodenectomía, procedimiento introducido por el autor senior en 1978 con el propósito de eliminar los síntomas postgastrectomía, puede ser realizada sin aumento de la morbilidad o mortalidad y sin decremento de la sobrevida; sin embargo, sus beneficios a largo plazo todavía no han sido comprobados. En el presente estudio se valoró el estado funcional de pacientes recuperados después de una pancreaticoduodenectomía con preservación del píloro, comparando 6 sobrevivientes a largo plazo sometidos a la operación de Whipple del tipo estandar (1–7 años postoperatorios; promedio, 4.7 años) con un grupo similar de 6 pacientes sometidos a la pancreaticoduodenectomía con preservación del píloro (1–7 anos postoperatorios; promedio, 3.0 años). Todos los pacientes respondieron un cuestionario para valorar síntomas postgastrectomía. Se obtuvieron muestras de sangre en ayunas para análisis hematológico y bioquímico. Diez de los 12 pacientes fueron luego sometidos a endoscopia; se tomaron biopsias perianastomóticas y de la región gástrica media, las cuales fueron clasificadas según el grado de inflamación. El vaciamiento gástrico tanto de la fase líquida como de la sólida fue medido utilizando comida marcada con isótopos, y los datos fueron comparados entre los grupos del estudio y también con 7 personas controles normales previamente estudiadas utilizando la misma metodología. El análisis de los resultados del cuestionario, así como de los valores de los exámenes de laboratorio, no demostraron diferencias significativas entre los 2 grupos de pacientes operados. Los niveles séricos de carotenos aparecieron bajos en la mayoría de los pacientes y algunos demonstraron índices anormales de homeostasis férrica. No se observaron diferencias significativas en los exámenes endoscópicos, y tampoco en los resultados de las biopsias entre los 2 grupos quirúrgicos. El vaciamento gástrico de líquidos apareció prolongado en forma significativa en los pacientes con pancreatoduodenectomía del tipo estandar (t1/2=98.3±26.2 min) en comparación con aquellos con la operación con preservación del píloro (t1/2= 37.5±10.9 min) o con los controles normales (t1/2=33.1±2.8 min). Nuestra conclusión es que a largo plazo la preservación del píloro parece ser por lo menos funcionalmente equivalente a la pancreatoduodenectomía estándar. Como tal, consideramos que la preservación del píloro, que hace innecesaria la vagotomía y la resección gástrica, merece ser seriamente considerada en el curso de una pancreatoduodenectomía.
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Fink, A.S., DeSouza, L.R., Mayer, E.A. et al. Long-term evaluation of pylorus preservation during pancreaticoduodenectomy. World J. Surg. 12, 663–669 (1988). https://doi.org/10.1007/BF01655880
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DOI: https://doi.org/10.1007/BF01655880