A Prospective Randomized Trial of Pancreaticogastrostomy Versus Pancreaticojejunostomy After Pancreaticoduodenectomy

Abstract

ObjectiveThe authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy afte pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula Summary Background DataPancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications. MethodsBetween May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rid fluid on or after postoperative day 10. ResultsThe pancreaticogastrostomy (n = 73) and pancreaticojejunostomy (n = 72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (17/145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (1 1.1 %) groups. Pancreatic fistula was associated with a significant prolongation of postoperative hospital stay (36 ± 5 vs. 15 ± 1 days) (p < 0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p < 0.05). A multivariate 580

Prevention and Treatment of Complications in Pancreatic Cancer Surgery

“…However, a recent prospective randomized trial by Yeo et al [45]was not able to support this assumption: they showed similar pancreatic fistula rates after pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%), indicating that the experience of the surgeon doing the pancreaticointestinal anastomosis is of more importance than the type of reconstruction.…”

“…Although it is not associated with higher mortality, its occurrence results in longer hospitalization [45, 50], reduced quality of life and increasing health costs. It occurs in about one third of patients after pancreaticoduodenectomy (a range of 25–70% is described in the literature) [45, 50, 74, 75, 76]. The wide range of incidence of delayed gastric emptying in several studies is probably based on different definitions of this complication.…”

“…Another hypothesis postulates that the circulating levels of motilin, a hormone which stimulates gastric motility and which is mainly produced in the duodenum and the proximal jejunum, are significantly reduced by the resection of the duodenum [79]. Based on this hypothesis, a prospective, randomized, placebo-controlled study that administered the motilin agonist, erythromycin, found a tendency (not significant) toward reduced postoperative delayed gastric emptying (19 vs. 30% in the verum group) [45]. …”

Pancreaticogastrostomy after Subtotal Pancreatectomy for Cancer

“…This observation adds to the multiple reports of good experience with this anastomosis [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]. However, in a prospective randomized study comparing pancreaticojejunostomy and pancreaticogastrostomy, Yeo et al [13]found no difference in the pancreatic anastomotic leak rate in their 145 patients. Pancreatic fistulas were though more common in their patient group than in other reported studies of pancreaticogastrostomy (table 1).…”

Outcome following Pancreaticoduodenectomy in Patients Undergoing Preoperative Biliary Drainage / with Invited Commentary

“…Ampullary tumors are localized on presentation in 78% of cases and seldom have vascular encasement or dissemination [15]. Nevertheless, patients with ampullary tumor have a soft pancreas, which is more prone to anastomotic leaking with its associated morbidity and mortality [16, 17]. …”