بسم الله الرحمن الرحيم. Reconstruction after Pancreaticoduodenectomy Maher Omar...

بسم الله بسم الله الرحمن الرحمن الرحيمالرحيم

بسم الله بسم الله الرحمن الرحمن الرحيمالرحيم

Reconstruction after Reconstruction after PancreaticoduodenectomyPancreaticoduodenectomy

Maher Omar Osman GomahaMaher Omar Osman Gomaha

Lecturer of SurgeryLecturer of SurgeryNational Liver InstituteNational Liver Institute

University of MenoufiyeaUniversity of Menoufiyea

By

Pancreaticoduodnectomy remains Pancreaticoduodnectomy remains one of the most demanding one of the most demanding operations in abdominal surgery.operations in abdominal surgery.

Recent improved results shows:Recent improved results shows:

Decreased operative mortality Decreased operative mortality

to to < 5%.< 5%.

Postoperative morbidity ranges from Postoperative morbidity ranges from 30-44%.30-44%.

Indications of PD include:Indications of PD include: Periampullary carcinomaPeriampullary carcinoma Localized painful chronic pancreatitis in the Localized painful chronic pancreatitis in the

head of the pancreas.head of the pancreas. Major combined trauma: duodenum and Major combined trauma: duodenum and

pancreas.pancreas.

Alternatives of PD include:Alternatives of PD include: Conventional (Standard) PD Conventional (Standard) PD (Whipple's (Whipple's

procedure 1935),procedure 1935), Extended (Regional) PD Extended (Regional) PD (Fortner, 1973),(Fortner, 1973), Pylorus Preserving PD (PPPD)Pylorus Preserving PD (PPPD) (Traverso and (Traverso and

Longmire, 1978). Longmire, 1978).

Pancreaticoduodenectomy comprises Pancreaticoduodenectomy comprises two phases:two phases:

Resection,Resection, Reconstruction.Reconstruction.

The Standard operation involves the en bloc The Standard operation involves the en bloc removal of the following:removal of the following:

The distal one-third of the The distal one-third of the stomach with the right half of stomach with the right half of the greater omentum,the greater omentum,

The gallbladder, cystic and The gallbladder, cystic and common bile duct,common bile duct,

The duodenum and proximal The duodenum and proximal 10 cm of the jejunum,10 cm of the jejunum,

The head of the pancreas and The head of the pancreas and varying amounts of its neck varying amounts of its neck and body, depending on size and body, depending on size and site of the tumor,and site of the tumor,

The peripancreatic and The peripancreatic and hepatoduodenal lymph nodes.hepatoduodenal lymph nodes.

Reconstruction after PDReconstruction after PD

In conventional PD, all In conventional PD, all anastomoses are placed anastomoses are placed along a single Roux loop along a single Roux loop with the pancreatojejunal with the pancreatojejunal anastomosis most anastomosis most proximal, followed by proximal, followed by biliary anastomosis and biliary anastomosis and then gastrojejunostomy.then gastrojejunostomy.

(1) Management of the pancreatic (1) Management of the pancreatic RemnantRemnant

The Achilles heel in PD procedure,The Achilles heel in PD procedure, Pancreaticoenterostomy is considered as the 'weak Pancreaticoenterostomy is considered as the 'weak

point' of PD. point' of PD. Risk factors predisposing to pancreatic leakage Risk factors predisposing to pancreatic leakage

after PD:after PD: Advanced age,Advanced age, Prolonged operation time,Prolonged operation time, Major blood loss,Major blood loss, Jaundice,Jaundice, Soft pancreatic parenchyma, Small pancreatic duct,Small pancreatic duct, Number of operations per surgeon.

Options for pancreatic stump Options for pancreatic stump managementmanagement

Non-anastomotic options,Non-anastomotic options, Pancreaticojejunostomy and its Pancreaticojejunostomy and its

varieties,varieties, Pancreaticogastrostomy.Pancreaticogastrostomy.

Non-anastomotic optionsNon-anastomotic optionsi) Pancreatic duct ligation:i) Pancreatic duct ligation: Used in the early PDs performed by Whipple,Used in the early PDs performed by Whipple, Can be done by ligation, stapling or suturing.Can be done by ligation, stapling or suturing. Leads to inevitable pancreatic fistula in the rate Leads to inevitable pancreatic fistula in the rate

of of 50-100%.50-100%. Can be a logic procedure in specific Can be a logic procedure in specific

circumstances:circumstances: necessity for expedient termination of the necessity for expedient termination of the

operation,operation, short jejunal mesentery allowing only a tension-short jejunal mesentery allowing only a tension-

free biliary or pancreatic anastomosis,free biliary or pancreatic anastomosis, massive jejunal edema that would result in a massive jejunal edema that would result in a

tenuous anastomosis.tenuous anastomosis.

Non-anastomotic optionsNon-anastomotic optionsii) Pancreatic duct occlusionii) Pancreatic duct occlusion Several biological substances can be used:Several biological substances can be used:

NeopreneNeoprene EthiblocEthibloc Fibrin glue (Tissuecol).Fibrin glue (Tissuecol).

The rate of fistula after duct occlusion was The rate of fistula after duct occlusion was 4%4% (DiCarlo et al 1989),(DiCarlo et al 1989), and and 1.7%1.7% (Gall et al, (Gall et al, 1989).1989).

Gland atrophy and exocrine insufficiency are Gland atrophy and exocrine insufficiency are inevitable.inevitable.

Should be considered for high risk Should be considered for high risk anastomosis in fragile pancreatic remnants.anastomosis in fragile pancreatic remnants.

Non-anastomotic optionsNon-anastomotic options

iii) Controlled External Pancreatic Fistulaiii) Controlled External Pancreatic Fistula

Entailed inserting a drain into the Entailed inserting a drain into the pancreatic duct and bringing it out on the pancreatic duct and bringing it out on the skin,skin,

Avoid high-risk pancreatoenteric Avoid high-risk pancreatoenteric anastomosis,anastomosis,

In about In about 80%80% of cases, the fistula will close of cases, the fistula will close spontaneously.spontaneously.

Non-anastomotic optionsNon-anastomotic optionsiv) Total Pancreatectomy at iv) Total Pancreatectomy at

the time of PDthe time of PD Eliminates the morbidity Eliminates the morbidity

and potential mortality of and potential mortality of an anastomotic leak,an anastomotic leak,

Establishes a complete Establishes a complete apancreatic state with apancreatic state with endocrine and exocrine endocrine and exocrine insufficiency insufficiency

Pancreaticojejunal Anastomosis

The traditional reconstructive The traditional reconstructive method standardized by method standardized by Whipple,Whipple,

Several modifications have Several modifications have been employed:been employed: Invagination vs Duct-to-mucosaInvagination vs Duct-to-mucosa End-to-end vs end-to-sideEnd-to-end vs end-to-side

The two most frequently The two most frequently employed techniques of PJ employed techniques of PJ are:are: End-to-end invagination (telescoping),End-to-end invagination (telescoping), End-to-side duct-to-mucosa.End-to-side duct-to-mucosa.

Pancreaticojejunal AnastomosisPancreaticojejunal Anastomosis In prospective/retrospective uncontrolled In prospective/retrospective uncontrolled

studies, the fistula rate was higher in the studies, the fistula rate was higher in the end-to-side compared with the end-to-end end-to-side compared with the end-to-end technique technique (15-17% vs 3-11%, respectively).(15-17% vs 3-11%, respectively).

End-to-side anastomosis is therefore End-to-side anastomosis is therefore suggested in patients with a dilated suggested in patients with a dilated pancreatic duct and firm pancreatic pancreatic duct and firm pancreatic parenchyma.parenchyma.

In recent randomized studies, no statistical In recent randomized studies, no statistical differences were found between the two differences were found between the two techniques techniques (Bassi et al, 2003).(Bassi et al, 2003).

Pancreaticojejunal AnastomosisPancreaticojejunal Anastomosis Several minor modifications of the PJ have been Several minor modifications of the PJ have been

suggested:suggested:1.1. The injection of the duct with neoprene The injection of the duct with neoprene (DiCarlo et (DiCarlo et

al, 1989).al, 1989).2.2. The use of fibrin glue to seal the PJ The use of fibrin glue to seal the PJ (Kram et al, (Kram et al,

1991).1991).3.3. The drainage of the PJ anastomosis (stenting vs The drainage of the PJ anastomosis (stenting vs

nonstenting remains a controversy) nonstenting remains a controversy) (Roder et al, (Roder et al, 1999).1999).

4.4. The consideration of a second-stage PJ in high-risk The consideration of a second-stage PJ in high-risk patients patients (Kubota et al, 2000).(Kubota et al, 2000).

5.5. The use of Vicryl mesh to wrap the pancreatic stump The use of Vicryl mesh to wrap the pancreatic stump (Pernot et al, 2001).(Pernot et al, 2001).

Pancreaticojejunal AnastomosisPancreaticojejunal Anastomosis

Major modifications of the PJ have Major modifications of the PJ have also been advocated to reduce also been advocated to reduce anastomotic fistula:anastomotic fistula:

Sutureless pancreatic duct-to-Sutureless pancreatic duct-to-mucosa technique mucosa technique (Hall et al, 1990),(Hall et al, 1990),

The use of two Roux loops The use of two Roux loops (Kingnorth et al, 1993),(Kingnorth et al, 1993),

The implantation into a jejunal The implantation into a jejunal pouch:pouch: U-shaped pouch U-shaped pouch (Asopa et al, 2002),(Asopa et al, 2002), J-shaped pouch J-shaped pouch (Muftuoglu and Saglam, (Muftuoglu and Saglam,

2003),2003), Binding-PJ Binding-PJ (Peng et al, 2003).(Peng et al, 2003).

Series of Roux-en-Y pancreaticojejunostomy comparing Series of Roux-en-Y pancreaticojejunostomy comparing invagination and duct-to-mucosa:invagination and duct-to-mucosa:

Series Series Patients Patients number number

Technique Technique of of

anastomosisanastomosisFistula Fistula

Fistula-Fistula-related related

mortalitymortality

Overall Overall mortalitymortality

Length of Length of stay (mean stay (mean

days)days)

Machado et al, Machado et al, 19761976

15 15 InvaginationInvaginationEnd-to-endEnd-to-end

2 (13.3%)2 (13.3%)00002020

Funovics et al, Funovics et al, 1987 1987 48 48

InvaginationInvagination

En-to-side En-to-side 9 (18.7%)9 (18.7%)003 (6.2%) 3 (6.2%) Not givenNot given

Kingsnorth Kingsnorth 19941994

52 52 Duct-to-Duct-to-mucosa mucosa

00003 (5.8%) 3 (5.8%) 18.418.4

Albertson 1994Albertson 19942525


End-to-end End-to-end 00000012.212.2

Meyer et al, Meyer et al, 19971997

3535Invagination Invagination

2(5.7%)2(5.7%)004 (11.4%)4 (11.4%)Not givenNot given

Papadimitriou Papadimitriou et al 1999et al 1999109109


End-to-end End-to-end 00001 (0.9%)1 (0.9%)7.67.6

Khan et al, Khan et al, 20022002

4141Duct-to-Duct-to-mucosa mucosa

00001 (2.4%)1 (2.4%)19.619.6

PancreaticogastrostomyPancreaticogastrostomyAdvantages:Advantages: Theoretically: Theoretically: PG is not PG is not

exposed to activated exposed to activated proteolytic enzymes due to proteolytic enzymes due to low pH and lack of low pH and lack of enterokinase.enterokinase.

Practically: Practically: easy to perform, easy to perform, easily decompressed by a easily decompressed by a

nasogastric tube and nasogastric tube and assessed by Endoscopy,assessed by Endoscopy,

ensures a reduction in the ensures a reduction in the number of anastomoses.number of anastomoses.

PancreaticogastrostomyPancreaticogastrostomyDisadvantages:Disadvantages: Acid digestion of the remnant pancreas,Acid digestion of the remnant pancreas, Reflux of gastric content into the pancreatic duct.Reflux of gastric content into the pancreatic duct.Techniques:Techniques: Invagination Invagination (dunking),(dunking), Duct-to-mucosa,Duct-to-mucosa, Sutureless technique Sutureless technique (Takao et al, 1993).(Takao et al, 1993).

Retrospective studies comparing between PG and PJ Retrospective studies comparing between PG and PJ for restoration of continuity after PDfor restoration of continuity after PD

Reference Reference Total no. of Total no. of patientspatients

ReconstructionReconstructionPancreatic fistula Pancreatic fistula (PF)(PF)

Kim et al, 1997Kim et al, 19978686PJ…….38PJ…….38

PG……48PG……48

PF for PJ….15.8%PF for PJ….15.8%

PF for PG….2.1%PF for PG….2.1%

Arnaud et al, 1999Arnaud et al, 1999171171PJ…….91PJ…….91

PG……80PG……80

PF for PJ…..13%PF for PJ…..13%


Takano et al, 2000Takano et al, 2000142142PJ……..69PJ……..69

PG…….73PG…….73


PF for PG…..0%PF for PG…..0%

Schlitt et al, 2001 Schlitt et al, 2001 441441PJ……..191PJ……..191

PG…….250PG…….250

PF for PJ…..12.6%PF for PJ…..12.6%

PF for PG…..2.8%PF for PG…..2.8%

Aranha et al, 2003Aranha et al, 2003214214PJ…….97PJ…….97

PG……177PG……177


PF for PG …..12%PF for PG …..12%

Oussoultzoglow et al, Oussoultzoglow et al, 20042004

250250PJ…….83PJ…….83

PG……167 PG……167

PF for PJ…..20.4%PF for PJ…..20.4%


(2) Biliary-enteric anastomosis(2) Biliary-enteric anastomosis

The second step in reconstruction,The second step in reconstruction, Designed as far 'down stream' from Designed as far 'down stream' from

PJ, as a distance not exceeding 12 cm,PJ, as a distance not exceeding 12 cm, May be either:May be either:

Choledochojejunostomy,Choledochojejunostomy, Hepaticojejunostomy.Hepaticojejunostomy.

Performed in one-layer, mucosa-to-Performed in one-layer, mucosa-to-mucosa anastomosis.mucosa anastomosis.


Technichal alternatives (Technichal alternatives (In case when the bile duct In case when the bile duct is not dilated) is not dilated) Cholecystojejunostomy,Cholecystojejunostomy, Side-to-side anastomosis of the cystic duct with the Side-to-side anastomosis of the cystic duct with the

CHD, and the resulting common orifice is anastomosed CHD, and the resulting common orifice is anastomosed with the jejunum. with the jejunum.

Stenting the Hepatojejunal anastomosis:Stenting the Hepatojejunal anastomosis: Controversial issue.Controversial issue. Can be achieved via:Can be achieved via:

Transhepatic stent,Transhepatic stent, T-tube choledochotomy,T-tube choledochotomy, Transjejunal tube exteriorized to the outside.Transjejunal tube exteriorized to the outside.

(3) Gastro-or Duodenojejunostomy(3) Gastro-or Duodenojejunostomy

This is the final anastomosis, 50 cm distal This is the final anastomosis, 50 cm distal to the biliodigestive anastomosis,to the biliodigestive anastomosis,

Performed as partial, two-layer, end-to-Performed as partial, two-layer, end-to-side antecolic gastrojejunostomyside antecolic gastrojejunostomy

Gastrointestinal fistula due to dehiscence Gastrointestinal fistula due to dehiscence of the gastrojejunostomy is rare.of the gastrojejunostomy is rare.

(4)(4) Vascular ReconstructionVascular Reconstruction May be confronted in certain situations:May be confronted in certain situations:1.1. Congenital vascular anomalies,Congenital vascular anomalies,2.2. Arteriosclerotic vascular stenosis or occlusion,Arteriosclerotic vascular stenosis or occlusion,3.3. Vascular infiltration or compression by the tumor,Vascular infiltration or compression by the tumor,4.4. Iatrogenic vascular injuries.Iatrogenic vascular injuries.

Extended pancreatic resections with venous reconstructionExtended pancreatic resections with venous reconstructionare feasible and may render patients free of gross tumorare feasible and may render patients free of gross tumor(Harrison et al, 2003).(Harrison et al, 2003).

Vascular ReconstructionVascular Reconstruction In case of portal vein resection (due to In case of portal vein resection (due to

tumor infiltration or iatrogenic injury), tumor infiltration or iatrogenic injury), Reconstruction can be done in several Reconstruction can be done in several ways according to the segment of vein ways according to the segment of vein infiltrated/resected. infiltrated/resected.

Reconstructive techniques of the PV:Reconstructive techniques of the PV: Direct sutures (small defects),Direct sutures (small defects), Tangential excision with direct closure,Tangential excision with direct closure, Tension-free end-to-end anastomosis,Tension-free end-to-end anastomosis, Interposition reconstruction,Interposition reconstruction, Mesocaval shunt.Mesocaval shunt.

Pylorus-Preserving Pylorus-Preserving Pancreaticoduodenectomy (PPPD)Pancreaticoduodenectomy (PPPD)

First described by Traverso and First described by Traverso and Longmire in Longmire in 19781978,,

The antrum, the pylorus, and The antrum, the pylorus, and the first part of the duodenum the first part of the duodenum are preserved,are preserved,

Has the advantage of reducing Has the advantage of reducing postoperative morbidity postoperative morbidity without compromising without compromising adequate radicality,adequate radicality,

Associated with a significant Associated with a significant reduction of the operation time, reduction of the operation time, the intraoperative blood loss the intraoperative blood loss and the consequent need for and the consequent need for blood transfusionblood transfusion


Preserves the secretion of Preserves the secretion of GIT hormones (gastrin, GIT hormones (gastrin, secretin, CCK)……better secretin, CCK)……better nutritional status,nutritional status,

The GIT hormones have also The GIT hormones have also a trophic effect on the a trophic effect on the mucosa of the GIT and mucosa of the GIT and pancreas,pancreas,

Protects against gastric Protects against gastric dumping, marginal dumping, marginal ulceration and bile-reflux ulceration and bile-reflux gastritis.gastritis.


Common postoperative complications after Common postoperative complications after PPPD include:PPPD include:

Delayed gastric emptying Delayed gastric emptying (12-32%),(12-32%), Anastomotic ulceration Anastomotic ulceration (2-11%).(2-11%).

In a recent meta-analysis study, the In a recent meta-analysis study, the morbidity and mortality are similar for morbidity and mortality are similar for PPPD and standard PD PPPD and standard PD (Stojadinovic et al, (Stojadinovic et al, 2003). 2003).

Pancreaticointestinal FistulaPancreaticointestinal Fistula The second leading cause of morbidity after The second leading cause of morbidity after

PD (proceeded by delayed gastric emptying),PD (proceeded by delayed gastric emptying), Occurs in Occurs in 2-24%2-24% of patients after of patients after

Pancreaticoenteric anastomosis.Pancreaticoenteric anastomosis. The major cause of postoperative mortality The major cause of postoperative mortality

(20-40%),(20-40%), due to consequent sepsis and due to consequent sepsis and hemorrhage.hemorrhage.

Defined as the drainage of Defined as the drainage of > 50 ml> 50 ml of amylase- of amylase-rich fluid per day from intraabdominal drains, rich fluid per day from intraabdominal drains, on or after the 10th postoperative day.on or after the 10th postoperative day.

Pancreaticointestinal FistulaPancreaticointestinal Fistula

Diagnosis:Diagnosis: Recognized between the 3rd and 7th Recognized between the 3rd and 7th

postoperative day,postoperative day, Drainage output increases and takes on a Drainage output increases and takes on a

brownish-black color,brownish-black color, Signs of sepsis: tachycardia, fever, oliguria, Signs of sepsis: tachycardia, fever, oliguria,

restlessness, and abdominal tenderness.restlessness, and abdominal tenderness.

Pancreaticointestinal FistulaPancreaticointestinal Fistula

Management:Management: Should be individualized,Should be individualized, Conservative treatment (in the absence of Conservative treatment (in the absence of

peritonitis, sepsis or hemorrhage),peritonitis, sepsis or hemorrhage), Surgical intervention (in the presence of major Surgical intervention (in the presence of major

complication or uncontrollable fistula)complication or uncontrollable fistula) Early 'completion pancreatectomy' before Early 'completion pancreatectomy' before

sepsis occurs…..sepsis occurs…..50%50% of patients can be of patients can be salvaged.salvaged.

Pancreaticointestinal FistulaPancreaticointestinal FistulaOctreotide treatment:Octreotide treatment: Its therapeutic value for established pancreatic Its therapeutic value for established pancreatic

fistula is not clear (conflicting data)fistula is not clear (conflicting data) (Sancho et al, (Sancho et al, 1995).1995).

Its prophylactic value is also controversial: Its prophylactic value is also controversial: 1.1. Four European studies…..positive results (reduced Four European studies…..positive results (reduced

overall complication rates),overall complication rates),2.2. Two American studies……no prophylactic benefit with Two American studies……no prophylactic benefit with

increased hospital costs.increased hospital costs. Therefore, its administration should be used Therefore, its administration should be used

selectively in patients with soft pancreatic selectively in patients with soft pancreatic remnant and non-dilated pancreatic ducts remnant and non-dilated pancreatic ducts (Andren-Sandberg et al, 2000)(Andren-Sandberg et al, 2000)

Conclusions (1)Conclusions (1) Pancreaticoduodenectomy can Pancreaticoduodenectomy can

nowadays be performed with low nowadays be performed with low operative mortality operative mortality (0-5%),(0-5%), but but postoperative complications are still a postoperative complications are still a common problem common problem (30-40%).(30-40%).

With a proper surgical technique, With a proper surgical technique, devastating postoperative devastating postoperative complications such as leakage of the complications such as leakage of the pancreaticointestinal anastomosis and pancreaticointestinal anastomosis and hemorrhage can be avoided.hemorrhage can be avoided.

Conclusions (2)Conclusions (2) Numerous reconstructive methods have Numerous reconstructive methods have

been suggested in the literature aiming to been suggested in the literature aiming to reduce the rates of fistulation, but none is reduce the rates of fistulation, but none is perfect. perfect.

All these technical issues will remain All these technical issues will remain controversial until prospective randomized controversial until prospective randomized studies become available.studies become available.

The only available prospective randomized The only available prospective randomized study study (Yeo et al, 1995)(Yeo et al, 1995) reported no reported no difference between PJ and PG for difference between PJ and PG for restoration of GIT continuity after PDrestoration of GIT continuity after PD

Conclusions (3)Conclusions (3) Many risk factors have been reported Many risk factors have been reported

to predispose to pancreatic leakage to predispose to pancreatic leakage after PD. after PD.

Most frequently reported are:Most frequently reported are: The texture of pancreatic parenchyma,The texture of pancreatic parenchyma, The number of patients per surgeon.The number of patients per surgeon.

Therefore, a standardized technique Therefore, a standardized technique and delicate handling of the pancreatic and delicate handling of the pancreatic remnant minimize the incidence of remnant minimize the incidence of leakage.leakage.

Conclusions (4)Conclusions (4) In high through-put specialist centers, PD can be In high through-put specialist centers, PD can be

performed safely with low perioperative performed safely with low perioperative mortality and morbidity. mortality and morbidity.

The prophylactic administration of octreotide is The prophylactic administration of octreotide is still controversial. However, the technical skill still controversial. However, the technical skill and judgment of the surgeon is still more and judgment of the surgeon is still more important than any pharmacological treatment; important than any pharmacological treatment; bad operations cannot be redeemed by bad operations cannot be redeemed by octreotide.octreotide.

For cost-benefit issues, the prophylactic For cost-benefit issues, the prophylactic administration of octreotide should not be on administration of octreotide should not be on routine basis, but for selective situations (e.g. soft routine basis, but for selective situations (e.g. soft pancreatic remnant).pancreatic remnant).

بسم الله الرحمن الرحيم. Reconstruction after Pancreaticoduodenectomy Maher Omar...

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