Comparison of Different Techniques of Pancreatic Stump Management in Robot-Assisted Pancreaticoduodenectomy

Abstract

Background: Various technical improvements have decreased the morbidity and mortality after pancreaticoduodenectomy. However, postoperative pancreatic fistula (POPF) is the most feared complication, and the ideal technique for pancreatic reconstruction is undetermined. The aim of this study was to identify the risk factors and incidence of POPF with different types of pancreatic stump management after robot-assisted pancreaticoduodenectomy (RAPD). Materials and Methods: This study is a retrospective review of consecutive patients who underwent RAPD at the University of Illinois Hospital and Health Sciences System between September 2007 and January 2016. The cohort was divided based on the type of pancreatic stump management: pancreatic duct occlusion with cyanoacrylate glue (CG), pancreaticojejunostomy (PJ), posterior pancreaticogastrostomy (PPG), and transgastric pancreaticogastrostomy (TPG). Results: The cohort included 69 patients: pancreatic duct occlusion with CG (n = 18), PJ (n = 12), PPG (n = 11), and TPG (n = 28). Pancreatic duct diameter < 3 mm and duct occlusion with CG were identified as risk factors for POPF (p < 0.05). The incidence of POPF was lower when TPG and PJ were performed (p < 0.001). Conclusions: Reconstruction with PJ and TPG had better results compared to pancreatic duct occlusion with CG and PPG. However, TPG was the technique of choice and showed comparable results to PJ.

Use of barbed suture without fashioning the “classical” Wirsung-jejunostomy in a modified end-to-side robotic pancreatojejunostomy

“…Several techniques of pancreatic anastomosis have been proposed, including pancreato-gastrostomy (PG) and different techniques of PJ, including duct to mucosa and invagination [7][8][9][10][11][12]. Undoubtedly, one of the limitations of RAS for PD relates to the lack of a tactile feedback, since this may contribute to iatrogenic pancreatic parenchymal laceration during knots tying or from suboptimal suture line tension during continuous suturing [13].…”

Post-operative morbidity following pancreatic duct occlusion without anastomosis after pancreaticoduodenectomy: a systematic review and meta-analysis

“…In addition, in 11 studies chemical substances were injected into the main pancreatic duct to achieve a permanent occlusions. [8][9][10]22,26,27,29,31,33,34 No authors reported conflicts of interest regarding the substances used, neither sponsorship from manufacturing companies. In one study both chemical and mechanical occlusion were employed in two different groups of patients.…”

“…A total of 16 studies met the inclusion criteria and were selected for this meta-analysis [8][9][10][22][23][24][25][26][27][28][29][30][31][32][33][34] (Fig. 1).…”

“…Five studies adopted the International Study Group of Pancreatic Fistula (ISGPF) definition, 9,22,23,33,34 with a pooled rate of POPFs (all grades) of 47.8% (95% CI, 37.4 to 58.3). The pooled rate of Clinically relevant POPF (ISGPF grades B and C) from 5 studies 10,22,23,33,34 was 13.6% (95% CI, 10 to 17.5) (Fig.…”

“…3 Despite this recommendation several further studies have since been published, suggesting there remains significant interest in this technique. 9,10 A recent global survey involving more than 800 surgeons from all continents reported that 7% of the surgeons who responded occasionally perform PDO following PD. 11 Recently, the results from a prospective trial conducted in a high-volume center showed that patients at high risk of POPF receiving PDO had postoperative outcomes similtar to those of patients at low risk of POPF receiving pancreaticojejunal anastomosis.…”