Modified Heidelberg technique of pancreatic anastomosis postpancreaticoduodenectomy – 10 years of experience

Abstract

Context: Pancreatic fistula has forever been a dreaded complication after pancreatic anastomosis (PA). We present a retrospective analysis of 10 years of experience with the Modified Heidelberg technique (MHT) that has been recently described. Aim: The aim of the study is to establish postoperative pancreatic fistula (POPF) rates after MHT. Settings and Design: This is a retrospective observational study carried out at a tertiary cancer center in South India in the Department of Surgical Oncology. Subjects and Methods: Two hundred and eight consecutive patients who underwent pancreaticoduodenectomy (PD) and PA with MHT for a variety of proximal pancreatic lesions from January 2008 to February 2018 were included in this study. The incidence of POPF was recorded by the International Study Group on Pancreatic Fistula 2005 and 2016 definitions. Statistical Analysis Used: Epidemiological and clinical data are expressed in ratios and percentage and presented in table format. Results: Between January 2008 and March 2016, 186 patients underwent PD, and MHT was used for PA. Five (2.7%) patients developed Grade A POPF whereas Grades B and C were seen in three (1.6%) patients each with one death. Between April 2016 and February 2018, 22 patients underwent PD. Two patients (9%) had biochemical leak whereas none of them developed clinically relevant POPF. No deaths were recorded in this period. Overall, Grade B and Grade C POPF rates were 1.4% each, whereas 30-day mortality was 0.4%. Conclusions: Results of this study indicate that MHT is a safe, reliable, easy to learn, and adopt technique of pancreatic reconstruction after PD.

Post operative pancreatic fistula rate following pancreaticojejunostomy with Heidelberg technique versus classical duct to mucosa technique: a comparative study

“…In a French RCT comparing stented versus no stent group, the CR-POPF rate was 25% and 36% respectively. 9 In another recent study by Zhang et al found no difference in the incidence of complications according to the Clavien-Dindo grades or the rate of CR-POPF after PD. 10 A recent Cochrane systematic review found the role of stents in decreasing CR-POPF after PD was uncertain due the fact that benefit of stenting in pancreatic anastomosis is not supported by high quality evidence.…”

Centralisation of Pancreatoduodenectomy in India: Where Do We Stand?

“…Only 1 article [25] mentioned percentage of patients receiving neoadjuvant treatment in their cohort; likewise, 3 articles [25,39,42] reported percentage of patients undergoing vascular resection, 1 article [34] reported the stage distribution of the study cohort and 4 articles [25,26,34,42] reported the survival after PD. Different centres have different predilections for pancreato-enteric reconstruction like pancreato-gastrectomy [14,30] and duct to mucosa or Blumgart's pancreato-jejunostomy [30,31,40,41,44].…”

“…A total of 36 unique series [9–44] from 24 institutes across India were identified after excluding 18 series [45–62] due to overlap of cases from the same author and institution. Figure 1 depicts the consort chart of the study methodology.…”

“…Surgeons and primary care physicians also stand to benefit from development of centres of excellence for PD Kaman et al [19] Sunil et al [34] Vinchurkar et al [36] Govil et al [42] Patra et al [10] Singhal et al [13] Shah et al [14] Samaddar et al [17] Kaman et al [18] Jakhmola et al [21] Reddy et al [26] Govil et al [27] Pal et al [28] Mishra et al [31] Tampi et al [32] Krishna et al [35] Pamecha et al [38] Jain et al [39] Chowdappa et al [40] Nikhil et al [43] Gupta et al [44] Ray et al [9] Barreto et al [11] Perwaiz et al [12] Palanivelu et al [16] Kurumboor et al [20] Rammohan et al [22] Sivaraj et al [23] Rajarathinam et al [24] Shrikhande et al [25] Gangavatiker et al [29] Singh et al [30] Mansukhani et al [33] Manipadam et al [37] Tewari et al [ as they can focus more intently on problems that are more commonly encountered in their practice than invest their time in a disease that is infrequent. The surgeons at dedicated units develop better understanding of the disease process, anatomy and anatomic anomalies, thereby achieving more proficiency, and become better equipped to take complex clinical decisions.…”

Reduction of pancreatic leak rate after pancreaticoduodenectomy by changing anastomotic and drainage techniques: a long-term single center experience

“…12 Other authors confirmed the safety and reliability of the Heidelberg technique and its modification in such cases. 20 In cases of complicated acute pancreatitis, the concept of continued irrigation and passive drainage following surgical debridement decreased mortality and necrosectomies.…”