Completion pancreatectomy following pancreaticoduodenectomy: Clinical experience

Abstract

While pancreaticoduodenectomy is today performed with an operative mortality of less than 5%, the incidence of significant operative morbidity remains at least 25%. Albeit rarely, completion pancreatectomy during the early postoperative period may be required to manage uncontrolled pancreatic anastomotic leaks. From 1964 to 1988, pancreaticoduodenectomy was performed on 479 patients at our institution, 178 (37%) of whom required re-operation in the early postoperative period. Of these, 11 (6%) patients underwent completion pancreatectomy at a mean interval of 18 days following Whipple resection. The indications prompting re-operation included a suspected pancreatic leak (n = 8), intraabdominal hemorrhage (n = 2), and pancreaticocutaneous fistula (n = 1). Operative findings necessitating completion pancreatectomy included pancreatic anastomotic dehiscence with severe surrounding inflammation/necrosis prohibiting reanastomosis or repair (n = 10) and necrotizing pancreatitis with uncontrolled hemorrhage (1). Seven (64%) of these 11 patients died postoperatively of sepsis and multiple organ failure. The mean hospital stay in the 4 surviving patients was 46 days (range, 26 to 53 days). These 4 patients survived for a mean period of 24 months following hospital dismissal.

Incidence, Risk Factors, and Treatment of Pancreatic Leakage After Pancreaticoduodenectomy: Drainage versus Resection of the Pancreatic Remnant

“…The advantageous results for completion pancreatectomy in our study contradict reports in the literature that document mortality as high as 64-71%. 2,21 This difference could result from the fact that completion pancreatectomy was performed in a relatively early stage of deterioration in this series. Completion pancreatectomy was performed after a mean of 5 days after the initial resection.…”

“…In two other studies, resection of the remnant was performed after 6 and 18 days, respectively, after the initial resection. 21,22 Induction of insulin-dependent diabetes mellitus is a major disadvantage of completion pancreatectomy. This apancreatic diabetes can lead to severe episodes of hypoglycemia that can be very difficult to manage and can even lead to death.…”

“…This intervention is reported to carry a mortality rate of 17-71%. 2,9,21,22 Completion pancreatectomy is most often performed as a last resort in severely septic patients after multiple other interventions. The reticence to perform completion pancreatectomy is probably related to the major disadvantage of the resulting insulin-dependent diabetes mellitus.…”

Komplikationen in der Pankreaschirurgie

“…Prädispo-niert sind vor allem jene Gefäße, die während der Lymphadenektomie im Bereich des Ligamentum hepatoduodenale und des Pankreasoberrandes bis hin zum Abgang des Truncus coeliacus bzw. der A. mesenterica superior freigelegt oder auch vorgeschädigt wurden [30][31][32] [25,33,34]. Andere Autoren sehen aufgrund der hohen Mortalität späterer Revisionseingriffe das primär operative Vorgehen eher problematisch [35].…”

A Simple, Secure and Universal Pancreaticojejunostomy following Pancreaticoduodenectomy

“…Twenty-five patients (50 %) received no blood transfusion. The consistency of the pancreatic remnant was hard in 12 patients (24 %) and normal in 38 patients (76 % mortality [7,8,23] the pacreatic duct, and secured with a suture of 3-0 chromic catgut. The nasogastric tube was pulled through the jejunum via a stab wound in both sides of the jejunum, which was 10 to 15 cm distal to the hepaticojejunostomy, and was brought out extraabdominally.…”