pancreaticojejunostomy vs. pancreaticogastrostomy after pancreaticoduodenectomy - PowerPoint PPT Presentation

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pancreaticojejunostomy vs. pancreaticogastrostomy after pancreaticoduodenectomy

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pancreaticojejunostomy vs. pancreaticogastrostomy. after ... J. of clinical gastroenterology 2001 31(3):11-8. World J of Surg. 2001 25: ... prandial hormone ... – PowerPoint PPT presentation

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Title: pancreaticojejunostomy vs. pancreaticogastrostomy after pancreaticoduodenectomy


1
pancreaticojejunostomy vs. pancreaticogastrostomy
after pancreaticoduodenectomy
  • Ri b86401095 ???

Reference J. of clinical gastroenterology 2001
31(3)11-8 World J of Surg. 2001 25567-71 World
J of Surg. 2000 2486-91 Annals of Surgery. 1995
222(4)580-8.
2
Trend of Whipple mortality
  • Before 1980 5-y survival 5-6
  • After 1980 op mortality rate lt5

3
Whipple better prognostic factors
  • Small tumor lt2cm
  • Histologically negative surgical margins
  • Negative locoregional lymph nodes
  • No vessel invasion of the tumor
  • More experienced surgeon
  • gt40 5-year survival rate

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pancreaticojejunostomy
  • The pancreatic remnant is invaginated into
    jejunum to prevent leakage in an end-to-end
    fashion

7
Complications of Whipple 40-50
Sabiston 16th edition 2001
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Leading complications
  • Delayed gastric emptying
  • Healing failure of pancreatic anastomosis
  • Incidence 10-20
  • ? pancreatic fistula formation
  • ? intra-abdominal abscess
  • ? hemorrhage
  • ? wound infection
  • Mortality rate 40-50
  • Account for gt50 of post-Whipple mortality
  • Somatostatin limited use

9
Ways to prevent pancreatic leakage
10
pancreaticogastrostomy
  • Pylorus-preserving operation
  • Hemigastrectomy

11
pancreaticogastrostomy
  • Direct visualization with anterior gastrostomy
  • Posterior approach from outside

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Advantages of pancreaticogastrostomy
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Other statistical data of PG (1) 16.5
complication rate
  • Loyola medical center 102 consecutive PG
    1986-1998

15
Other statistical data of PG (2)
  • Pancreatic leak rate after PG 0-14
  • John Hopkins the only randomized prospective
    study
  • 1993-1995, 145 patients
  • Pancreatic leak rate 11.7
  • No significant difference between PG PJ
  • Univariable logistic regression ampullary or
    duodenal disease, surgical volume, pancreatic
    texture, operation time, and intraoperative red
    blood cell transfusions,

16
Physiologic studies of Whipple
  • After Whipple, gt50 of exocrine gland are
    resected, gt20 of patients will experience
    increased fecal fat and weight loss in 1 year.
  • Measure chemotrypsin activity with
    N-benzoyl-L-tyrosyl-p-amiobenzoic acid and PABA
  • Pre-operative significantly depressed
  • Post-op slowly recovery of function
  • 1 year post-op normalizing
  • Excellent residual exocrine activity
  • Importance of ductal drainage

17
Physiologic studies of PG
  • Animal study
  • Mild increase in basal gastric pH
  • No change in
  • Maximal gastric output
  • Gastrin, secretin secretion
  • Gastric pH response to gastrin, secretin
  • Pre- post-prandial hormone level and pH
  • Neurohormonal relationship between stomach,
    pancreas, duodenum is maintained

18
Physiologic studies of PG human study 3 y after
WhipplePG
  • Normal circadian rhythm of gastrin/secretin
  • Fasting serum gastrin 93.5/-20.3 73.9/-8.2
  • Fasting serum secretin 84.1/-6.4 73.6/-5.0
  • Basal gastric pH still lt3
  • Amylase, lipase, chemotrypsin activity are
    present in the stomach when pHgt3
  • Amylase, lipase, chemotrypsin are normally
    activated in the small intestine
  • Decreased amylase, lipase, chemotrypsin level in
    stool
  • Normal 882/-234
  • PG 151/-20
  • PJ 136/-25
  • Chronic pancreatitis 58

19
Physiologic studies of PG
20
Physiologic studies of PG
Gastric pH 24 hours study
21
Physiologic studies of PG GI motility
  • No post-op patients have normal jejunal motility
    pattern during the fasted or fed status.
  • PG did yield a more normal-like tracing
  • Timing of arrivals of biliary and pancreatic
    secretions?

22
Conclusion
  • PG is better, or at least not worse than PJ
  • Complications
  • Pancreatic leakage
  • There are no untoward physiologic effects of
    invaginating the pancreatic stump into the
    stomach, specifically in relation to gastric pH,
    pancreatic enzyme activity, and GI motility.
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