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PubMed2006

Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: a review of the literature and critical reappraisal of the implicated pathomechanism.

Pylorus-preserving pancreaticoduodenectomy (PPPD) is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying (DGE) comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/Medline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy (PD) vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported (but not yet tested in large-scale studies) modification, that is, PPPD with antecolic duodenojejunostomy.

Duodenal Neoplasms↗
PubMed2006

Is delayed gastric emptying so terrible after pylorus-preserving pancreaticoduodenectomy? Prevention and management.

AIM: To explore some operative techniques to prevent the occurrence of delayed gastric emptying (DGE) after pylorus-preserving pancreaticoduodenectomy (PPPD). METHODS: One hundred and eighty-six patients in a single medical center who accepted PPPD were retrospectively studied. The incidence of DGE was investigated and the influence of some operative techniques on the prevention of DGE was analyzed. RESULTS: During the operative process of PPPD, the methods of detached drainage of pancreatic fluid and bile and gastric fistulization were used. Postoperatively, six patients suffered DGE among the 186 cases; the incidence was 3.23% (6/186). One of them was complicated with intraabdominal infection at the same time, and two with pancreatic leakage. CONCLUSION: Appropriate maneuvers during operation are essential to avoid postoperative DGE in PPPD. The occurrence of DGE is avoidable. It should not be used as an argument to advocate hemigastrectomy in PPPD.

Adult↗
PubMedDate not supplied

Double pylorus.

We report a 55-year-old man presenting with postprandial epigastric pain and vomiting. Barium meal study suggested two openings from the stomach to the duodenum. Endoscopy revealed double pylorus with chronic duodenal ulcer, suggesting the second opening as an acquired one.

Barium Sulfate↗
PubMed1999

Comparison of pylorus-preserving and classic pancreaticoduodenectomy.

BACKGROUND: The authors present their recent experience with the treatment of periampullary lesions to compare the surgical technique, safety and prognosis between pylorus-preserving pancreaticoduodenectomy (PPPD) and classic pancreaticoduodenectomy (CPD). METHODS: Prospective data from 100 patients with periampullary lesions treated with either PPPD or CPD between January, 1991, and June, 1997, were evaluated, including demographic data, surgical technique, surgical risk and prognosis. RESULTS: There were 35 patients treated with PPPD and 65 treated with CPD. The operating time was significantly shorter in the PPPD group (9.3 +/- 0.3 hours) than in CPD (10.4 +/- 0.3 hours). The average overall blood loss was 1,275 +/- 71 ml, with no statistical difference between PPPD and CPD groups. The overall complication rate was 56%, with 54% in the PPPD group and 57% in the CPD group (p = 0.755). The overall mortality was 4%, with 0% in the PPPD group and 6.2% in CPD (p = 0.655). There was no statistical difference in survival time for overall periampullary cancers between the PPPD and CPD groups (median = 28.0 vs 26.5 months, p = 0.393). The difference in survival time was still of no significance between the PPPD and CPD groups when the periampullary cancers were further stratified into pancreatic head cancer and nonpancreatic periampullary cancer. CONCLUSIONS: Morbidity and mortality of PPPD did not exceed that of CPD, and the prognosis after PPPD was not compromised in patients with periampullary cancer. PPPD, with a shorter operating time, can be a safe and effective alternative to CPD in the treatment of periampullary lesions.

Ampulla of Vater↗
PubMedDate not supplied

Influence of vagal pyloric branches on gastric acid secretion and gastrointestinal motility in patients following a pylorus preserving pancreatoduodenectomy.

BACKGROUND/AIMS: The authors evaluated the influence of the vagal pyloric branches on the gastrointestinal function in patients who underwent a pylorus preserving pancreatoduodenectomy (PPPD). METHODOLOGY: Twenty-seven patients with pancreatobiliary and duodenal diseases underwent a PPPD between 1991 and 1994. We analyzed several variables including the daily volume of gastric juice, days of gastric suctioning, start of diet, gastric acid, and gastrin levels. In addition, a gastric emptying scintigram and gastrointestinal manometry were measured. These variables were compared between two groups, namely, those with retained superior pyloric branches of the vagus nerve (preserved group: n = 14), and those without these branches (non-preserved group: n = 13). RESULTS: There were no significant differences in basal acid output, maximum acid output, or plasma gastrin levels between the preserved group and the non-preserved group. In addition, a gastric emptying scintigram demonstrated no difference between the two groups. Finally, on gastrointestinal manometry, there was no significant difference between the two groups during gastric and jejunal phase III activity of migrating motor complex. CONCLUSIONS: Preservation of the vagal pyloric branches did not influence gastric exocrine and endocrine secretion, nor did it effect the gastric emptying of patients who underwent a PPPD.

Adult↗
PubMedDate not supplied

Duplication cyst of the pylorus--a rare cause of gastric outlet obstruction in the newborn.

Duplication cysts of the pylorus are the rarest of alimentary tract duplications with very few reported cases. We present such a cyst in a neonate presenting with gastric outlet obstruction. We have also reviewed the literature and outlined the theories of origin, modes of presentation, diagnosis and the surgical procedures. Even though several modes of surgery have been described, it is best to individualize the surgical option in each case. The results depend on the nature and site of duplication, complications and the associated anomalies.

Cysts↗
PubMedDate not supplied

Pylorus-preserving Kausch-Whipple resection: the successor of the classical Kausch-Whipple in chronic pancreatitis.

Chronic pancreatitis can be a debilitating disease. Resection for complicated disease and in those patients with intractable pain is a major component of therapy. There are potentially important physiological advantages with the pylorus preserving Kausch-Whipple (P-KW) compared to the standard Kausch-Whipple (KW) resection but further prospective studies are required to show this unequivocally. The Beger's operation also represents a significant theoretical advance. Indeed it permits resection in a proportion in whom a PP-KW or KW would not be possible technically because of severe fibrosis around the intra-pancreatic portal venous system. Although we have adopted the Beger's operation on our unit, large comparative studies are required against the KW and PP-KW procedures to properly establish its value. The hidden malignancy is an important issue, which undermines the routine use of the Beger's operation.

Chronic Disease↗
PubMed1999

Purely laparoscopic pylorus-preserving gastrectomy with extraperigastric lymphadenectomy for early gastric cancer: a case and technical report.

For the purpose of prevention of postgastrectomy syndrome and a less invasive and yet curative oncological resection, a purely laparoscopic pylorus-preserving gastrectomy with extraperigastric lymphadenectomy was performed for a patient with early gastric cancer located in the middle third of the stomach. The patient's postoperative course was uneventful. During his postoperative recovery, the patient experienced very little pain and used analgesic medication only one time. This operation appeared to be oncologically adequate. As of the seventh postoperative month, the patient never experienced dumping syndrome or alkaline reflux gastritis. This procedure is technically feasible and an excellent option because of its reduced surgical invasiveness and better postoperative quality of life.

Adenocarcinoma↗
PubMed1975

Beta-adrenergic mechanisms and ulcer formation in pylorus-ligated rats.

The importance of beta-adrenergic receptor activity for ulcer formation was studied. In rats fasted for 48 hours, ulcers in the rumen were produced constantly after 17 hours of pyloric ligation. d,1,Propranolol in doses of 1 to 30 mg/kg given 4 times during 12 hours caused a dose-dependent inhibition of ulcer formation. The ulcero-protective potency of d,1,propranolol was about 20 times that of d,propranolol. No explanation of the ulcero-protective effect was observed when the gastric acid secretion was studied after 17 hours. Serum gastrin concentration after 17 hours of ligation was in all animals less than 5 pmol per liter, i.e. below one-third of the normal fasting value. For all pharmacological effects apart from beta-adrenergic blockage, d,1, and d,propranolol do not differ, while the results presented here suggest that intact beta-adrenergic receptor activity is important for the development of gastric ulcers in the pylorus-ligated rat. The mechanism behind the ulcero-protective effect of beta-adrenergic blockage remains to be solved.

Animals↗
PubMed2002

Non-stented pancreaticogastrostomy after pylorus-preserving pancreaticoduodenectomy.

BACKGROUND: We hypothesized that neutralization of the gastric acidity by alkaline pancreatic secretion via a non-stented pancreaticogastrostomy after pylorus-preserving pancreaticoduodenectomy (non-stented PPPD-PG) might provide protection against marginal or stress ulcer. Surgical risk of non-stented pancreaticogastrostomy was also assessed to clarify the importance of stenting in pancreatic anastomosis. METHODS: From January 1997 to December 2000, 54 patients with resectable periampullary lesions were included for non-stented PPPD-PG. Gastric pH and amylase levels were measured on the postoperative day 7. Surgical risks including pancreatic leakage, morbidity and mortality were also assessed. RESULTS: Patients undergoing the non-stented PPPD-PG presented significantly higher gastric levels of pH and amylase than healthy patients as controls (median pH 5.0 vs 2.8, p = 0.007; and median amylase 7,660 vs 21 IU/L, p = 0.031). Among the patients undergoing the non-stented PPPD-PG, low gastric pH and amylase levels were associated with high gastric drainage group > or = 600 c.c./day. However, only 1 of the 18 patients with low gastric amylase level (high gastric drainage group) developed significant steatorrhea and needed replacement of concentrated pancreatic enzymes. There were 18 (33.3%) complications and 1 (1.8%) mortality. The cause of death was cardiac arrythmia, not related to operation. Gastric atonia was the most common complication (18.5%), followed by wound infection, intraabdominal abscess, and intraabdominal bleeding in 2 patients (5.6%) individually. No pancreatic leakage or ulcer-related complication occurred after non-stented PPPD-PG. CONCLUSIONS: Experience of no pancreatic leakage in our 54 non-stented PPPD-PG implies that stenting of pancreaticogastrostomy might not be crucial in prevention of pancreatic leakage and ductal occlusion. Moreover, non-stented PPPD-PG can increase gastric pH and amylase levels, which might be beneficial in protection against marginal ulceration.

Adult↗
PubMed1976

Manometric studies of the human pylorus.

The human gastroduodenal junction was investigated by means of simultaneous measurements of pressure and potential difference between skin and mucosa. An accurate and circumferentially sensitive miniature transducer assembly failed to reveal a zone of elevated pressure at the gastroduodenal junction of 8 fasting, healthy, young subjects. Additional studies were carried out with a six-lumen perfused catheter system, in which three of the pressure-transmitting catheters had openings arranged circumferentially at the same axial level. Measurements of pressure and potential difference were obtained basally during intraduodenal infusion of hydrochloric acid and after intraduodenal instillation of olive oil. In only 1 of 10 subjects was a tonic elevation in pressure recorded simultaneously by all three leads at the gastroduodenal junction. The normal human pylorus, therefore, is not reliably demonstrable as a high pressure zone.

Adult↗
PubMedDate not supplied

Pylorus-preserving pancreatoduodenectomy associated with longitudinal pancreatojejunostomy for treatment of chronic pancreatitis.

Patients with chronic pancreatitis presenting with lesions at the head of the pancreas and in the uncinate process associated with duct dilatation at the body and tail of the gland are inadequately treated by partial pancreatic head resection or by standard pancreatic drainage procedures. A new technique for the surgical treatment of this form of chronic pancreatitis, based on the performance of a pylorus-preserving pancreaticoduodenectomy associated with a longitudinal pancreatojejunostomy, is proposed herein. Nine patients with chronic pancreatitis were operated on according to this technique with no postoperative complications or mortality. Complete symptom control was achieved in all patients. Follow-up periods varied from one month to five years.

Chronic Disease↗
PubMedDate not supplied

Pylorus-preserving pancreaticoduodenectomy without homologous blood transfusion in a Jehovah's witness with pancreatic cancer: report of a case.

A case of successfully treated pancreatic cancer without homologous blood transfusion in a Jehovah's witness is reported. The patient was a 60-year-old Japanese man and he was diagnosed with pancreatic cancer. Based on the patient's informed consent, human recombinant erythropoietin (12000 IU/day), saccharated ferric oxide (60 mg/day), and 25% human serum albumin (100 mL/day) were administrated for 7 consecutive days prior to the operation. As a result, the hemoglobin level increased by 1.6 g/dL during the week, pylorus-preserving pancreaticoduodenectomy was performed on June 5, 1998. We used a technique of transfusing diluted autologous blood, hypervolemic hemodilution, and a cell-saver device for autologous transfusion during the operation. The operation took 10 hours and 35 minutes, blood loss was 600 mL, and the hemoglobin level at the end of surgery was 12.0 g/dL. He had an uneventful postoperative course, and was discharged on the 31st postoperative day. Although there have been numerous reports on surgery without homologous blood transfusion in Jehovah's witnesses, many of the cases of major surgery have involved cardiovascular procedures. However, major digestive surgery may be feasible in more Jehovah's witnesses if adequate alternative treatments and strict nutritional management are carefully implemented, as in our case.

Blood Transfusion↗
PubMed2003

[A case of advanced gastric cancer showing pylorus stenosis with multiple liver metastases, that respond remarkably to neoadjuvant chemotherapy of combined TXL and low-dose FP].

We report a 65-year-old man with advanced gastric cancer that showed a remarkable response to treatment with a new combination of paclitaxel (TXL) and low-dose 5-fluorouracil and cisplatin (FP) as neoadjuvant chemotherapy (NAC). The patient was admitted to our hospital complaining of epigastric discomfort. Endoscopic examination revealed type 3 advanced gastric cancer, which was confirmed to be adenocarcinoma by biopsy. Tumor markers of serum carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP) were elevated to 768.7 ng/ml and 2,782.8 U/ml, respectively. Computed tomography (CT) showed multiple liver metastases, and metastases to group 3 lymph nodes. After three courses of NAC, the CEA and AFP levels decreased to 245.0 ng/ml and 754.0 U/ml, respectively. Computed tomography revealed marked reduction of the primary tumor, liver metastases, and lymph nodes. Shrinkage of the primary tumor was also shown by gastrography and endoscopy. Distal gastrectomy was then performed because of pylorus stenosis. The resected specimen showed tub 2, pSS, pN3, ly2, v2 and Grade 2 histological responses. About half of the nodal metastatic lesions were degenerated. The patient is doing well and undergoing treatment with hepatic arterial infusion chemotherapy as an outpatient. TXL + low-dose FP as NAC may be one of the new tactics against advanced gastric cancer.

Aged↗
PubMed1992

Evidence for the involvement of nitric oxide in the electrically induced relaxations of human lower esophageal sphincter and distal pylorus.

The aim of the present study was to investigate in vitro the effect of NG-nitro-L-arginine methyl ester (L-NAME), a nitric oxide (NO) synthase inhibitor, on neurogenic relaxation of human lower esophageal sphincter (LES) and distal pylorus (DP) circular muscle strips induced by electrical field stimulation (EFS). Muscle strips obtained from 5 patients who underwent total gastrectomy were suspended in 10-ml organ baths containing Krebs solution for recording isometric tension. L-NAME (30 microM) reduced the amplitude of the EFS-induced relaxation by 85 +/- 9% (N = 3) in the LES and by 52 +/- 16% (N = 3) in the DP but did not affect sodium nitroprusside-induced relaxation. L-Arginine (300 microM) partially reversed the L-NAME inhibition in the LES and totally in the DP. These findings suggest a role for L-arginine-derived NO in the nerve-mediated NANC relaxation of the human LES and DP.

Adult↗
PubMed2005

[Effect of ileocecum interposition graft as pylorus replacement on glycometabolism].

OBJECTIVE: To evaluate the application of ileocecum interposition (ii) graft as pylorus replacement in alimentary reconstruction. METHODS: Twenty- one minipigs were randomly divided into three groups: sham operation group (control group), B - i group and ii group. The levels of blood glucose were measured by quick blood glucose testing of paper at 0, 30, 60, 90, and 120 minutes of oral glucose after 60 and 120 post- operative days to compare gastric emptying of liquid feeds. RESULTS: Two months after operation,the peak of blood glucose was (7.8+/- 1.0)mmol/ L, (7.1+/- 0.8)mmol/ L, (4.1+/- 0.4)mmol/ L in B - i, ii group and control group respectively, there were significant differences between the two operation groups and control group (P< 0.01). Four months after operation, the peak of blood glucose was (6.9+/- 1.0) mmol/ L, (5.2+/- 0.8)mmol/ L, (4.2+/- 0.5)mmol/ L, respectively, there was no significant difference between ii group and control group (P > 0.05),but there were significant differences between both of the above two groups and B - i group (P< 0.01). CONCLUSION: The ileocecum interposition graft can offer specific advantages over current reconstruction procedures.

Animals↗
PubMed1991

[Cephalic duodenopancreatectomy with pylorus preservation. An experience of 52 surgically-treated cases].

From february, 1985, to december, 1990, we carried out 52 pylorus preserving duodenopancreatecomies (41 times for cancerous lesions, 11 times for chronic pancreatitits). Our current observations suggest that PPDP is better than the conventional Whipple's procedure as far as nutrition and digestion are concerned, this being confirmed by digestive and endocrine functional tests. The procedure also has the advantage of being confined to the supramesocolic level, thus being less traumatising and more rapidly carried out. Postoperative nutrition and digestion are less disturbed, owing to the conservation of the gastroduodenal functional entity. The endocrine potential of the pancreas seems also to benefit from this procedure.

Adult↗