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Biomedical subjects

H A Pitt

Publications and source records attributed to H A Pitt.

At least 55 records · Page 3Linked to original sources
PubMed1996

Palliation. Surgical and otherwise.

Carcinoma of the pancreas remains a disease with a grim prognosis. The majority of patients are not resectable for cure at the time of presentation, with less than 20% of affected patients surviving 1 year after diagnosis. Because cure is unlikely for most patients, palliation of symptoms (obstructive jaundice, duodenal obstruction, and pain) is of primary importance. Obstructive jaundice is the most common presenting symptom for cancer of the pancreas and can be managed by both surgical and nonoperative techniques. Although prospective randomized studies support an early advantage to the nonoperative techniques, concern for late complications, including recurrent jaundice and duodenal obstruction, favor a surgical approach. The management of pain due to unresectable carcinoma of the pancreas remains a significant problem. A recent prospective randomized study has shown that intraoperative chemical splanchnicectomy with 50% alcohol significantly relieves or prevents pain when compared with a placebo treatment. For patients not undergoing surgery, a percutaneous celiac nerve block can be performed quickly with overall good results. The decision to perform nonoperative versus surgical palliation for pancreatic cancer is influenced by the patient's symptoms, overall health status, projected survival, and the expected procedure-related morbidity and mortality. The major advantage for surgical palliation is the ability of a single procedure to combine adequate long term palliation for all three primary symptoms of the disease. Most surgical series report acceptable hospital morbidity and mortality, and a reasonable postoperative length of hospital stay.

Cholestasis↗
PubMed1996

Pancreaticoduodenectomy for benign disease.

BACKGROUND: Surgeons are often called upon to perform pancreaticoduodenectomy for either suspicion of malignancy or symptoms due to benign disease. Perioperative morbidity and mortality following pancreaticoduodenectomy have decreased markedly over the last 2 decades. In response, many surgical centers advocate expanding the indications for pancreaticoduodenectomy to include lesions other than periampullary carcinoma. PATIENTS AND METHODS: A retrospective review of medical records for 108 patients undergoing pancreaticoduodenectomy for benign disease at The Johns Hopkins Medical Institutions over 100 months was completed. The subset of patients with a histopathologic diagnosis of chronic pancreatitis was identified and compared with patients undergoing pancreaticoduodenectomy for other benign conditions. RESULTS: The mortality rate for the present series was less than 1%. Perioperative complications, the majority of which were self-limited, occurred in 51% of patients. The most common complication was delayed gastric emptying. Pancreatic anastamotic leak occurred in 18% of patients and developed significantly more frequently in patients with benign diseases other than chronic pancreatitis (31% versus 8%, P < 0.05). CONCLUSION: Among appropriately selected patients, the rates of perioperative mortality and serious morbidity are low, and concerns about mortality and morbidity should not prevent an aggressive approach to surgical resection in patients with benign disease.

Adult↗
PubMed1996

Biliary carcinoembryonic antigen levels are a marker for cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma develops in 5% to 15% of patients with choledochal cysts, sclerosing cholangitis, and intrahepatic stones. The detection of cholangiocarcinoma in patients with premalignant biliary conditions has been difficult. Serum levels of carcinoembryonic antigen (CEA) have been neither sensitive nor specific for the diagnosis of cholangiocarcinoma. However, CEA has been shown to be present in cholangiocarcinomas by immunohistochemical staining. Therefore, we measured the level of CEA excreted in bile in patients with benign strictures, premalignant biliary diseases, and cholangiocarcinoma. PATIENTS AND METHODS: Bile was obtained from transhepatic stents in patients with benign biliary strictures (34), choledochal cysts (5), primary sclerosing cholangitis (6), intrahepatic cholelithiasis (5), and perihilar cholangiocarcinoma (25). Samples were analyzed for CEA using a solid phase, two-site immunoenzymetric assay. RESULTS: Biliary CEA levels were significantly elevated (P < 0.01) in patients with cholangiocarcinoma (50.2 +/- 5.8 ng/mL) and intrahepatic cholelithiasis (57.4 +/- 10.4 ng/mL) compared with patients with benign strictures (10.1 +/- 3.9 ng/mL). Patients with sclerosing cholangitis (21.6 +/- 3.9 ng/mL) and choledochal cysts (20.0 +/- 16.5 ng/mL) had intermediate levels. In 5 patients undergoing resection of perihilar cholangiocarcinomas, the mean biliary CEA level decreased from a preoperative level of 46.8 +/- 6.7 ng/mL to a postoperative level of 11.3 +/- 5.6 ng/mL (P < 0.02). In 4 patients with progression of cholangiocarcinoma, biliary CEA increased from a mean of 53.3 +/- 6.9 ng/mL to 98.3 +/- 12.2 ng/mL (P < 0.02) over a mean interval of 9.5 months. CONCLUSIONS: Increased levels of CEA can be detected in the bile of patients with chlolangiocarcinoma. Monitoring these levels may have a role in the management of cholangiocarcinoma as well as premalignant biliary conditions such as choledochal cysts and sclerosing cholangitis.

Adult↗
PubMed1996

Surgery for pancreatic tumors during pregnancy: a case report and review of the literature.

Seven cases of surgery of pancreatic tumors during pregnancy have been reported in the literature. Six of the cases resulted in live term births. The patient discussed herein, a 37-year-old para 2-0-0-2 white female, had surgery for the removal of a pancreatic mass at 20 2/7 weeks' gestation. No intraoperative complications occurred, and both mother and fetus appeared to have done well. The postoperative course was complicated by pseudomembranous enterocolitis caused by C. difficile, which was treated with antibiotics. Despite treatment, diarrhea continued, and the patient was readmitted to the hospital for hydration and further antibiotics at 27 weeks. Three days after admission, the fetus was noted to have poor biophysical testing and a caesarean delivery was performed. The infant was found to have a large intracerebral hemorrhage, which most likely occurred antenatally, and life support was discontinued shortly after birth. We conclude from this that surgery for a pancreatic mass in pregnancy should be approached cautiously, and the risk to both the mother and fetus should be considered.

Adult↗
PubMed1996

Pyogenic hepatic abscess. Changing trends over 42 years.

OBJECTIVE: The authors document changes in the etiology, diagnosis, bacteriology, treatment, and outcome of patients with pyogenic hepatic abscesses over the past 4 decades. SUMMARY BACKGROUND DATA: Pyogenic hepatic abscess is a highly lethal problem. Over the past 2 decades, new roentgenographic methods, such as ultrasound, computed tomographic scanning, direct cholangiography, guided aspiration, and percutaneous drainage, have altered both the diagnosis and treatment of these patients. A more aggressive approach to the management of hepatobiliary and pancreatic neoplasms also has resulted in an increased incidence of this problem METHODS: The records of 233 patients with pyogenic liver abscesses managed over a 42-year period were reviewed. Patients treated from 1952 to 1972 (n = 80) were compared with those seen from 1973 to 1993 (n = 153). RESULTS: From 1973 to 1993, the incidence increased from 13 to 20 per 100,000 hospital admissions (p < 0.01. Patients managed from 1973 to 1993 were more likely (p < 0.01) to have an underlying malignancy (52% vs. 28%) with most of these (81%) being a hepatobiliary or pancreatic cancer. The 1973 to 1993 patients were more likely (p < 0.05) to be infected with streptococcal (53% vs. 30%) or Pseudomonas (30% vs. 9%) species or to have mixed bacterial and fungal 26% vs. 1%) infections. The recent patients also were more likely (p < 0.05) to be managed by percutaneous abscess drainage (45% vs. 0%). Despite having more underlying problems, overall mortality decreased significantly (p < 0.01) from 65% (in 1952 to 1972 period) to 31% (in 1973 to 1993 period). The reduction was greatest for patients with multiple abscesses (88% vs. 44%; p < 0.05) with either a malignant or a benign biliary etiology (90% vs. 38%; p < 0.05). Mortality was increased (p < 0.02) in patients with mixed bacterial and fungal abscesses (50%). From 1973 to 1993, mortality was lower (p = 0.19) with open surgical as opposed to percutaneous abscess drainage (14% vs. 26%). CONCLUSIONS: Significant changes have occurred in the etiology, diagnosis, bacteriology, treatment, and outcome patients with pyogenic hepatic abscesses over the past 4 decades. However, mortality remains high, and proper management continues to be a challenge. Appropriate systemic antibiotics and fungal agents as well as adequate surgical, percutaneous, or biliary drainage are required for the best results.

Age Distribution↗
PubMed1996

Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer?

OBJECTIVE: The authors define the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma. BACKGROUND: Decreases in perioperative morbidity and mortality and improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma have clearly established a role for this operation when performed with curative intent. However, most surgeons remain hesitant to perform pancreaticoduodenectomy unless surgical margins are widely clear, choosing rather to perform palliative biliary and gastric bypass. METHODS: A single-institution retrospective review was performed comparing the outcome of 64 consecutive patients undergoing pancreaticoduodenectomy for pancreatic carcinoma with gross or microscopic evidence of adenocarcinoma at the surgical resection margins, and 62 consecutive patients found to be unresectable at the time of laparotomy because of local invasion without evidence of metastatic disease (stage III). Combined biliary and gastric bypass were performed in 87% of patients not resected. RESULTS: The two groups were similar with respect to age, gender, race, and presenting symptoms. The hospital mortality rate was identical in both groups (1.6%). Fifty-eight percent of patients undergoing pancreaticoduodenectomy had an uncomplicated postoperative course compared with 68% of patients undergoing palliative bypass (not significant). The length of postoperative hospital stay after pancreaticoduodenectomy was 18.4 days, which was significantly longer (p < 0.05) than for patients undergoing palliative bypass (15.0 days). The overall actuarial survival (Kaplan-Meier) was improved significantly in patients undergoing pancreaticoduodenectomy (p < 0.02). Postoperative chemotherapy and radiation therapy improved survival in both groups. CONCLUSIONS: Pancreaticoduodenectomy can be performed with a similar perioperative morbidity and mortality and only a minimal increase in hospital stay when compared with traditional surgical palliation. Pancreaticoduodenectomy with postoperative chemotherapy and radiation therapy is associated with improved long-term survival when compared with patients treated with surgical bypass. These data support the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma and with local residual disease.

Adenocarcinoma↗
PubMed1996

Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors.

OBJECTIVE: The objective of this article is to introduce a simple method for classifying cholangiocarcinomas and to apply this system to analyze a large number of patients from a single institution. SUMMARY BACKGROUND DATA: For the past 2 decades, most western reports on cholangiocarcinoma have separated intrahepatic from extrahepatic tumors and have subclassified this latter group into proximal, middle, and distal subgroups. However, "middle" lesions are uncommon and are managed most often either with hilar resection or with pancreatoduodenectomy. The spectrum of cholangiocarcinoma, therefore, is best classified into three broad groups: 1) intrahepatic, 2) perihilar, and 3) distal tumors. These categories correlate with anatomic distribution and imply preferred treatment. METHODS: The records of all patients with histologically confirmed cholangiocarcinoma who underwent surgical exploration at The Johns Hopkins Hospital over a 23-year period were reviewed. RESULTS: Of 294 patients with cholangiocarcinoma, 18 (6%) had intrahepatic, 196 (67%) had perihilar, and 80 (27%) had distal tumors. Age, gender, race, and associated diseases were similar among the three groups. Patients with intrahepatic tumors, by definition, were less likely (p < 0.01) to be jaundiced and more likely (p < 0.05) to present with abdominal pain. The resectability rate increased with a more distal location (50% vs. 56% vs. 91%), and resection improved survival at each site. Five-year survival rates for resected intrahepatic, perihilar, and distal tumors were 44%, 11%, and 28%, and median survival rates were 26, 19, and 22 months, respectively. Postoperative radiation therapy did not improve survival. In a multivariate analysis resection (p < 0.001. hazard ratio 2.80), negative microscopic margins (p < 0.01, hazard ratio 1.79), preoperative serum albumin (p < 0.04, hazard ratio 0.82), and postoperative sepsis (p < 0.001, hard ratio 0.27) were the best predictors of outcome. CONCLUSIONS: Cholangiocarcinoma is best classified into three broad categories. Resection remains the primary treatment, whereas postoperative adjuvant radiation has no influence on survival. Therefore, new agents or strategies to deliver adjuvant therapy are needed to improve survival.

Bile Duct Neoplasms↗
PubMed1996

Current management of patients with perihilar cholangiocarcinoma.

Despite the overall advances in the ability to diagnose and treat patients with perihilar cholangiocarcinoma, the prognosis for patients with this malignancy remains poor. Further improvements in the survival of patients with perihilar cholangiocarcinoma will come with the early diagnosis of these lesions. New molecular techniques should improve our ability to screen high-risk patients, such as those with primary sclerosing cholangitis, hepatolithiasis, choledochal cysts, and ulcerative colitis. Improvements in diagnostic CT scanning, duplex ultrasonography, and MRI will enhance our ability to noninvasively stage patients with perihilar cholangiocarcinoma. Complete surgical resection remains the only curative treatment for malignancies of the biliary tract. Aggressive surgical approaches are likely to continue, and the challenge remains being able to perform these procedures safely in jaundiced and sometimes septic patients. For those patients with unresectable lesions, the optimal form of palliation, whether operative or nonoperative, remains to be defined. Finally, advances in adjuvant chemotherapy and radiotherapy will be required to further improve the overall prognosis of patients with perihilar cholangiocarcinoma.

Bile Duct Neoplasms↗
PubMed1995

Biliary nonmucin glycoproteins in patients with and without gallstones.

Total protein, mucin, and specific nonmucin glycoproteins are proposed pronucleating agents in cholesterol gallstone pathogenesis. However, characterization of specific nonmucin glycoproteins in patients with and without gallstones is unknown. Furthermore, nonmucin glycoproteins may be qualitatively different in patients with and without gallstones. Total protein and total and specific nonmucin glycoproteins were studied in gallbladder bile of 43 patients with cholesterol gallstones and 13 patients without gallstones. Patients with cholesterol gallstones had higher concentrations of both total protein and nonmucin glycoproteins than that observed in control patients (P < 0.05). SDS gel electrophoresis of nonmucin glycoproteins demonstrated an 84-kDa protein that was present significantly more often in patients with cholesterol gallstones (87% vs 8%, P < 0.05). Proposed 130- and 42-kDa pronucleating and 120-kDa anti-nucleating nonmucin glycoproteins were present in similar percentages in gallstone and control bile. Moreover, gallbladder bile of patients with the 84-kDa protein nucleated 50% faster than model bile and > 100% faster than that of patients without this protein (P < 0.05). The currently described gallbladder pronucleating and anti-nucleating proteins are found with equal frequency in cholesterol gallstone and control patients. However, an 84-kDa protein is found more commonly in gallstone patients and was associated with a shortened crystal observation time. Thus, this glycoprotein may be important in cholesterol gallstone pathogenesis.

Adult↗
PubMed1995

Hypercalcemia decreases bile flow and increases biliary calcium in the prairie dog.

BACKGROUND: Biliary calcium is known to play an important role in the pathogenesis of gallstones. Calcium salts are present in all pigment gallstones and are also present in the core of most, if not all, cholesterol gallstones. METHODS: The effects of acute hypercalcemia on bile flow and biliary calcium secretion were examined in 22 prairie dogs during intravenous taurocholate infusion (0, 1.0, 2.25, and 4.5 mumol/kg/min). RESULTS: Bile flow was linearly correlated with bile acid output in both control (y = 7.62x + 13.5, r = 0.98) and hypercalcemic (y = 7.00x + 10.4, r = 0.96) animals. At lower bile acid outputs (< 3.0 mumol/kg/min), biliary ionized calcium output per increment bile acid output was significantly increased in hypercalcemic animals (0.016 versus 0.011 mumol Ca++ mumol taurocholate, p < 0.001). Bile ionized calcium concentrations approximated Gibbs-Donnan predicted values only at low bile flow rate. CONCLUSIONS: Hypercalcemia decreases bile flow and increases biliary ionized calcium concentration in the prairie dog. These effects favor the precipitation of calcium salts in bile.

Animals↗
PubMed1995

Dietary fish oil inhibits cholesterol monohydrate crystal nucleation and gallstone formation in the prairie dog.

BACKGROUND: Epidemiologic studies suggest that populations consuming a diet rich in fish oil have lower rates of both atherosclerotic heart disease and gallstones. The mechanisms underlying this inhibitory effect on cholesterol gallstone formation remain unclear. We therefore studied the effect of dietary fish oil on bile composition and cholesterol precipitation in an animal model of gallstone disease. METHODS: Adult male prairie dogs were fed a standard control diet (n = 12) or a lithogenic 1.2% cholesterol diet (n = 16). One half of the animals in each group had their diet supplemented with concentrated fish oil. RESULTS: After 14 days animals receiving the cholesterol diet all developed biliary cholesterol monohydrate crystals and gallstones. When fish oil was added to this high cholesterol diet, solid cholesterol crystal precipitation and gallstone formation were completely inhibited. This inhibition of gallstone formation was accompanied by a significant decrease in biliary calcium and total protein concentration. Microscopic cholesterol liquid crystals were evident in the bile of all of the animals fed the cholesterol plus fish oil diet. Dietary fish oil also significantly prolonged cholesterol monohydrate crystal observation time in animals receiving the lithogenic diet. CONCLUSIONS: These data suggest that dietary fish oil exerts a potent antilithogenic effect on cholesterol gallstone disease and may induce a stable liquid crystalline phase retarding nucleation.

Animals↗
PubMed1995

Bilirubin inhibits calcium carbonate precipitation in gallbladder bile.

BACKGROUND: Previous studies have shown that human bile contains one or more factors that inhibit the precipitation of calcium carbonate from supersaturated solutions of calcium chloride and sodium bicarbonate. Lower concentrations of this factor have been observed in the gallbladder bile of patients with calcified gallstones. We hypothesized that gallbladder bile contains factors that inhibit calcium carbonate and these factors are present in varying concentrations in normal persons and in patients with cholesterol gallstones with and without calcium carbonate. METHODS: Gallbladder bile of patients without gallstones (n = 8) and of patients with cholesterol gallstones containing either calcium carbonate (n = 8) or other calcium salts (n = 8) was assayed for calcium carbonate inhibition. Individual components of bile (bilirubin, phospholipid, bile salts, and albumin) were tested in different concentrations in the same assay system. In addition, samples of model bile were tested. RESULTS: An inhibitory factor for calcium carbonate precipitation was present within all human gallbladder bile, irrespective of the absence, presence, or type of gallstones. The addition of a bilirubin-albumin solution to a supersaturated solution of calcium chloride and sodium bicarbonate entirely blocked precipitation of calcium carbonate from solution. In addition, serial dilutions of bilirubin exhibited a linear response between bilirubin concentration and inhibitory effect. Model bile and phospholipid dissolved in sodium taurocholate also exhibited a modest inhibitory effect on calcium carbonate precipitation. CONCLUSIONS: We conclude that bilirubin, cholesterol, and phospholipids incrementally interfere with calcium carbonate precipitation in supersaturated solutions through the preferential formation of a soluble calcium complex.

Bile↗
PubMed1995

Curative treatment for pancreatic neoplasms. Standard resection.

In the mid-1990s pancreatoduodenectomy can be performed at regional referral centers with an operative mortality of 1% to 2%. In addition, a number of centers around the world are now reporting 5-year survivals between 20% and 30% for patients with resected pancreatic cancer. In recent years a debate has continued as to the proper extent of resection for these patients, in part because numerous resective and reconstructive options are available. In broad terms, operations can be categorized as "standard" or "radical." In general, standard operations tend to have lower postoperative morbidity and mortality. Multiple factors influence postoperative survival, including intraoperative blood loss, perioperative transfusions, type of operation, hospital mortality, tumor biology, and adjuvant therapy. Among these parameters, tumor biology is the most important by multivariate analysis. Recent data suggest that the quality of survival is better with standard operations and best with the pylorus-preserving pancreatoduodenectomy. Nevertheless, debate will continue about the proper extent of resection until a well-controlled randomized trial has addressed this issue.

Blood Loss, Surgical↗
PubMed1995

Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients.

OBJECTIVE: This single-institution study examined the outcome after pancreaticoduodenectomy in patients with adenocarcinoma of the head of the pancreas. SUMMARY OF BACKGROUND DATA: In recent years, pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has been associated with decreased morbidity and mortality and, in some centers, 5-year survival rates in excess of 20%. METHODS: Two hundred one patients with pathologically verified adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy at The Johns Hopkins Hospital between 1970 and 1994 were analyzed (the last 100 resections were performed between March 1991 and April 1994). This is the largest single-institution experience reported to date. RESULTS: The overall postoperative in-hospital mortality rate was 5%, but has been 0.7% for the last 149 patients. The actuarial 5-year survival for all 201 patients was 21%, with a median survival of 15.5 months. There were 11 5-year survivors. Patients resected with negative margins (curative resections: n = 143) had an actuarial 5-year survival rate of 26%, with a median survival of 18 months, whereas those with positive margins (palliative resections; n = 58) fared significantly worse, with an actuarial 5-year survival rate of 8% and a median survival of 10 months (p < 0.0001). Survival has improved significantly from decade to decade (p < 0.002), with the 3-year actuarial survival of 14% in the 1970s, 21% in the 1980s, and 36% in the 1990s. Factors significantly favoring long-term survival by univariate analyses included tumor diameter < 3 cm, negative nodal status, diploid tumor DNA content, tumor S phase fraction < 18%, pylorus-preserving resection, < 800 mL intraoperative blood loss, < 2 units of blood transfused, negative resection margins, and use of postoperative adjuvant chemotherapy and radiation therapy. Multivariate analyses indicated the strongest predictors of long-term survival were diploid tumor DNA content, tumor diameter < 3 cm, negative nodal status, negative resection margins, and decade of resection. CONCLUSIONS: The survival of patients with pancreatic adenocarcinoma treated by pancreaticoduodenectomy is improving. Aspects of tumor biology, such as DNA content, tumor diameter, nodal status and margin status, are the strongest predictors of outcome.

Actuarial Analysis↗
PubMed1995

Perihilar cholangiocarcinoma. Postoperative radiotherapy does not improve survival.

OBJECTIVE: The aims of this analysis were to determine prospectively the effects of surgical resection and radiation therapy on the length and quality of survival as well as late toxicity in patients with perihilar cholangiocarcinoma. BACKGROUND: Retrospective analyses have suggested that adjuvant radiation therapy improves survival in patients with perihilar cholangiocarcinoma. However, in these reports, patients receiving radiotherapy tended to have smaller, often resectable tumors, and were relatively fit. In comparison, patients who have not received radiotherapy often had unresectable tumors, metastatic disease, or poor performance status. METHODS: From 1988 through 1993, surgically staged patients with perihilar cholangiocarcinoma and 1) no evidence of metastatic disease, 2) Karnofsky score > 60, 3) no prior malignancy or radiotherapy, and 4) a patent main portal vein were analyzed. Fifty patients were stratified by resection (n = 31) versus operative palliation (n = 19) and by radiation (n = 23) versus no radiotherapy (n = 27). RESULTS: Patients undergoing resection had smaller tumors (1.9 +/- 2.8 vs. 2.4 +/- 2.1 cm, p < 0.01) that were less likely to invade the hepatic artery (3% vs. 42%, p < 0.05) or portal vein (6% vs. 53%, p < 0.05). Multiple parameters that might have affected outcome were similar between patients who did and did not receive radiation therapy. Resection improved the length (24.2 +/- 2.5 vs. 11.3 +/- 1.0 months, p < 0.05) and quality of survival. Radiation had no effect on the length (18.4 +/- 2.9 vs. 20.1 +/- 2.4 months) or quality of survival or on late toxicity. CONCLUSIONS: This analysis suggests that in patients with localized perihilar cholangiocarcinoma, resection prolongs survival whereas radiation has no effect on either survival or late toxicity. Thus, new agents or strategies to deliver adjuvant therapy are needed to improve survival in these patients.

Bile Duct Neoplasms↗
PubMed1995

A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy.

OBJECTIVE: The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula. SUMMARY BACKGROUND DATA: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications. METHODS: Between May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rich fluid on or after postoperative day 10. RESULTS: The pancreaticogastrostomy (n = 73) and pancreaticojejunostomy (n = 72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (17/145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatic fistula was associated with a significant prolongation of postoperative hospital stay (36 +/- 5 vs. 15 +/- 1 days) (p < 0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p < 0.05). A multivariate logistic regression analysis revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the resected specimen. CONCLUSIONS: Pancreatic fistula is a common complication after pancreaticoduodenectomy, with an incidence most strongly associated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than pancreaticojejunostomy or is associated with a lower incidence of pancreatic fistula.

Anastomosis, Surgical↗