Title: pancreaticojejunostomy vs. pancreaticogastrostomy after pancreaticoduodenectomy
1pancreaticojejunostomy vs. pancreaticogastrostomy
after pancreaticoduodenectomy
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.
2Trend of Whipple mortality
- Before 1980 5-y survival 5-6
- After 1980 op mortality rate lt5
3Whipple 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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6pancreaticojejunostomy
- The pancreatic remnant is invaginated into
jejunum to prevent leakage in an end-to-end
fashion
7Complications of Whipple 40-50
Sabiston 16th edition 2001
8Leading 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
9Ways to prevent pancreatic leakage
10pancreaticogastrostomy
- Pylorus-preserving operation
- Hemigastrectomy
11pancreaticogastrostomy
- Direct visualization with anterior gastrostomy
- Posterior approach from outside
12Advantages of pancreaticogastrostomy
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14Other statistical data of PG (1) 16.5
complication rate
- Loyola medical center 102 consecutive PG
1986-1998
15Other 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,
16Physiologic 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
17Physiologic 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
18Physiologic 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
19Physiologic studies of PG
20Physiologic studies of PG
Gastric pH 24 hours study
21Physiologic 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?
22Conclusion
- 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.