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PubMedDate not supplied

Postoperative pancreatic fistula following distal pancreatectomy for pancreatic neoplasm; can pancreatic fistula be prevented?

BACKGROUND/AIMS: Pancreatic fistula is a potentially fatal complication in pancreatic surgery. The objective of this study was to analyze the incidence of pancreatic fistula in patients who underwent distal pancreatectomy for pancreatic neoplasm. METHODOLOGY: Forty-seven patients who underwent distal pancreatectomy for neoplasm of the pancreas at Kochi Medical School between October 1981 and December 2002 were studied. Comparative analysis was carried out to identify the correlations between the incidence of pancreatic fistula and parameters of preoperative evaluation, intraoperative procedure, and postoperative laboratory investigation. RESULTS: The incidence of pancreatic fistula in patients who underwent distal pancreatectomy for pancreatic neoplasm was 27.7%. Intraoperatively, the frequency of pancreatic fistula was significantly high in patients who underwent distal pancreatectomy without lymph node dissection and ligation of the splenic artery. No significant difference was recognized between the conventional surgical division and auto suture staple groups, however, in the ultrasonically activated scalpel (USAS) group, no pancreatic fistula was observed. A multivariate analysis revealed that independent high incidence of pancreatic fistula were 1) the situation of the tumor at pancreatic body, 2) the procedure of D2 lymph node dissection, and 3) the ligation of the root of splenic artery. In the group with the presence of pancreatic fistula, the serum amylase level on the first postoperative day was significantly higher than that in the group without fistula. CONCLUSIONS: Our findings supported that pancreatic fistula may be preventable by use of the USAS and treatment of acute pancreatitis in the early postoperative stage.

Adult↗
PubMed2005

Acute effects of a 50% partial pancreatectomy on total pancreatic and islet blood flow in rats.

OBJECTIVES: The aim of the study was to investigate how an acute increase in functional demand for insulin release affected islet blood perfusion in anesthetized rats. METHODS: We measured total pancreatic and islet blood flow with differently colored microspheres before and 30 minutes after a 50% partial pancreatectomy. RESULTS: The blood glucose concentrations increased in the animals subjected to partial pancreatectomy. The fact that serum insulin concentrations remained unaffected implies that the islets in fact doubled their output of insulin to maintain the same degree of insulinemia. Still, pancreatic islet blood flow was the same as in the sham-operated animals. Likewise, the number of perfused pancreatic islets and the flow distribution between individual islets were not influenced by the partial pancreatectomy. CONCLUSIONS: We conclude that the acute demand for insulin secretion induced by a 50% partial pancreatectomy is not necessarily associated with an acute increase in islet blood perfusion. These findings suggest that basal islet blood flow is high enough to allow for short-term changes in hormone release without simultaneous changes in blood perfusion.

Anesthesia↗
PubMedDate not supplied

[Central pancreatectomy. Indications and perisurgical results of a pancreatic tissue conservation technique].

INTRODUCTION: Proximal or distal pancreatectomy is the standard treatment for non-resectable benign pancreatic tumors. These procedures imply a radical resection as well as a significant loss of distal normal pancreatic tissue for the standard resection, which may cause an endocrine and/or exocrine pancreatic failure. PURPOSE: Report our experience in central pancreatectomy for the treatment of benign/low malignancy potential tumors in the body and neck of the pancreas by emphasizing the indications and perisurgical results. METHODS: Prospective study of patients with suspected benign tumors in the body of pancreas. SURGICAL TECHNIQUE: Resection of central pancreas through a Roux-en-Y pancreatojejunal anastomosis. RESULTS: From March 1997 to May 2005, 12 patients underwent central pancreatectomy through pancreatojejunal anastomosis. 6 benign tumors were found in the islets of Langerhans: 3 microcystic cystadenomas, 1 mucinous cystadenoma, 1 pseudopapillary solid tumor, and 1 serous cystadenoma. Morbidity rate was 33.3% with no post-surgery deaths. Pancreatic failure was not reported during follow up. CONCLUSION: Some selected cases of benign/low malignancy potential tumors may be treated with central pancreatectomy and pancreatojejunal anastomosis with acceptable morbidity levels and minimum mortality levels. The benefit from preserving the greatest extension of healthy pancreatic tissue as possible is translated into a preservation of the endocrine and exocrine functions of the pancreas.

Adolescent↗
PubMed2006

[A novel technique for the closure of the pancreatic remnant using jejunal serosa following distal pancreatectomy].

Postoperative complication rate after distal pancreatectomy is as high as 10-30% in the published literature. Intraabdominal abscess formation and pancreatic fistula are the most common and clinically relevant complications, and they are thought to depend on surgical technique and skills. Using a novel method, we covered the pancreatic stump with the serosal surface of the first jejunal loop. Our aim was to compare the efficacy of this new technique to the traditional "stapling and handsewn suturing" method in terms of postoperative complication rate. Between 2002 and 2005, 50 patients, who underwent distal pancreatectomy, were randomized prospectively into two groups. In the first group of patients (n=23) the remnant of the pancreas was closed by the novel technique using the serosal surface of the first jejunal loop. In the second group (n=27) the pancreatic stump was closed in the traditional way using a combination of stapler and handsewn suture method. The incidence of postoperative pancreatic fistula and/or intra-abdominal abscess formation were compared using Fischer's test. Pancreatic fistula was defined as a loss of greater than 100 ml fluid drainage beyond postoperative day 5. We found a significantly lower postoperative complication rate using the novel technique compared to the traditional way to cover the pancreatic stump after distal pancreatectomy (8.7% vs. 33% (P = 0.0458). However, there was no significant difference in postoperative hospital stay. We concluded that using the serosal surface of the first jejunal loop is a simple, quick and secure method of closure of the proximal pancreas in terms of surgical practicability. This new technique significantly decreases the rate of postoperative fistula or abscess formation after distal pancreatectomy.

Abdominal Abscess↗
PubMed1978

Total pancreatectomy for acute hemorrhagic pancreatitis. A case report.

A patient with acute hemorrhagic pancreatitis treated successfully with total pancreatectomy is reported. Total pancreatectomy is rarely indicated in acute hemorrhagic pancreatitis as suggested by only one surviving patient in the literature so far. Though near total pancreatectomy remains the best surgical treatment in patients with acute hemorrhagic pancreatitis dying from the disease because of failure of nonoperative treatment, total pancreatectomy may be considered as an alternative if circumstances so indicate.

Acute Disease↗
PubMed1993

Medial pancreatectomy for tumors of the neck of the pancreas.

BACKGROUND: The surgical treatment of benign tumors of the pancreas usually consists of enucleation or formal pancreatectomy. Nonetheless, enucleation is not always feasible, and extended pancreatectomies may result in impaired endocrine and exocrine function. METHODS: For these reasons we proposed a limited resection centered on the neck of the pancreas with complete excision of the tumor. The cephalic section was sutured, and a Roux-en-Y jejunal loop was anastomosed to the distal section of the pancreas. Fourteen patients were operated on by this technique. The tumors were mainly cystadenomas (n = 6) and endocrine tumors (n = 4). The other lesions were one epithelial cyst, one necrotic pseudocyst, one Castleman disease, and one cystadenocarcinoma diagnosed after surgery on histologic examination. RESULTS: No patients died. Two patients underwent reoperation: one for a postoperative acute pancreatitis and one for a pancreatic fistula. All patients were followed up from 4 months to 8 years. No patients had exocrine insufficiency or diabetes mellitus. CONCLUSIONS: Medial pancreatectomy does not carry a higher operative risk than formal pancreatectomy and avoids extensive pancreatic resection when enucleation is not feasible.

Acute Disease↗
PubMedDate not supplied

Surgical technique, curability and postoperative quality of life in an extended pancreatectomy for adenocarcinoma of the pancreas.

BACKGROUND/AIMS: In the treatment of adenocarcinoma of the pancreas, we have succeeded in both decreasing the locoregional recurrence and improving the patient's survival by adding a wide range of lymphatic and connective tissue clearance to the conventional pancreatectomy. The present paper shows the detailed techniques of this procedure and the factors associated with long-term survival to provide a better understanding of the indications and limitations. MATERIALS AND METHODS: The postoperative survival rate in association with the background factors of the tumor and the quality of life is analyzed in 62 patients who received an extended pancreatectomy of ductal carcinoma of the pancreas. In this procedure, a wide range of lymphatic and connective tissue clearance was cleared in addition to the pancreatectomy, skeletonizing the major vessels. RESULTS: The long-term survivors had the following background factors: tumor diameter 4 cm or less; no nodal involvement or involvement limited to the immediate region of the tumor (n1-group); PV/SMV-invasion was absent or slight (2 cm or less in length and hemilateral). Long-term survival was rarely expected for any patients who had more advanced factors. Since removing the nerve plexi and connective tissues skeletonize major vessels, most patients did not recover their health easily within one post-operative year. CONCLUSION: While our extended pancreatectomy is the most promising procedure at present, providing the candidate is appropriate, its indication should be carefully selected because of the patient's quality of life and cost-performance.

Adenocarcinoma↗
PubMed1996

[Pancreatectomy for intraductal papillary mucinous tumor of the pancreas].

Twelve cases of pancreatectomy for intraductal papillary-mucinous tumor of the pancreas operated between August 1985 and February 1996 are reported. Mean age of the patients was 57.6 years (range: 25 to 77 years). Two of them were female and 10 were male. Ten patients underwent a pylorus preserving pancreaticoduodenectomy, one patient a segmental isthmic pancreatectomy and one other a left pancreatectomy. Histologic examination of the operative specimen showed benign ademomatosis with severe dysplasia in 3 cases, intramucosal or microinvasive carcinoma in 7 cases and invasive carcinoma in 2 cases. Two patients died during the period of follow-up, one at 20 months from metastases, the other one at 33 months accidentally. The 10 remaining patients were alive and disease-free with a follow-up of 3 to 93 months (mean time of follow-up: 38 months). Pancreatectomy is indicated without delay as soon as the diagnosis of this uncommon tumor is obtained.

Adenocarcinoma, Mucinous↗
PubMed2000

Experimental study on liver regeneration after simultaneous partial hepatectomy and pancreatectomy.

In this study, we performed hepatectomy and pancreatectomy to assess the physiological contribution of the pancreas, especially in terms of endocrine function to hepatic regeneration. Group 1 Wistar rats underwent 70% hepatectomy and group 2 rats underwent 70% hepatectomy plus 50% pancreatectomy. The time course assessment of liver regeneration rates obtained by Fishback's formula demonstrated a difference in rates between the two groups as early as day 3 or day 7 after surgery. Since levels of both PCNA-positive cells and serum transforming growth factor-alpha (TGF-alpha) were significantly higher in the hepatectomy only group, we could prove the difference of liver regeneration between the two groups. We have concluded that pancreatectomy retards the liver regeneration initiation processes occurring from 24 h to 3 days after evisceration. Glucagon-insulin molar ratios most significantly differed between the two groups 3 days after evisceration in the present study. This result was due to increased glucagon level of group 2 at day 3 after evisceration. Our findings suggest that 50% partial pancreatectomy inhibits the rate of hepatic regeneration, thereby altering the supply of pancreatic hormones, especially glucagon.

Journal Article↗
PubMed2005

Persistent hyperinsulinemic hypoglycemia of infancy (PHHI): Long-term outcome following 95% pancreatectomy.

OBJECTIVE: To evaluate the outcome of neonates and infants with persistent hyperinsulinemic hypoglycemia of infancy (PHHI) who had undergone 95% pancreatectomy, with special emphasis on development of diabetes mellitus (DM). METHODS: Ten infants diagnosed according to the established criteria of PHHI, and who had undergone 95% pancreatectomy, were followed for a period ranging from 1-20 years (mean 13(4/12) years). A retrospective analysis of their data was carried out with special emphasis on growth and development, glycemic control, neurological status and school performance. The data on weight, glycemic control and daily insulin requirement were compared with a control group of ten children with type 1 DM (DM1), matched for age and sex. RESULTS: All ten children ultimately developed DM; three of them immediately following pancreatectomy and the remainder after a variable period ranging from 7(1/4)-11(1/2) years (mean: 8(11/12) years). Data on their weight, HbA1c levels and daily insulin requirements when compared to ten children with DM1 showed no statistically significant difference in these biological variables. All the children, with the exception of one who sustained subarachnoid hemorrhage, cerebral edema and seizures in the neonatal period, were neurologically and developmentally normal. None exhibited clinical manifestations of pancreatic exocrine deficiency. CONCLUSION: 95% pancreatectomy is an effective treatment modality in PHHI not responding to medical treatment. In our experience; recurrence of hypoglycemia following surgery is uncommon and responds well to medical treatment. There is a high risk of secondary DM in these children; however, the serious risk of brain damage and neurological abnormalities could be avoided by early surgical intervention. Children in this study did not show any signs or symptoms of malabsorption.

Congenital Hyperinsulinism↗
PubMed1980

Fluorophotometry. III. Streptozocin-treated rats and rats with pancreatectomy.

To determine whether elevated vitreous fluorescence levels are a result of a direct ocular toxic effect of streptozocin or a consequence of the diabetic state, we compared hyperglycemic streptozocin- and insulin-treated or non-insulin-treated rats, hyperglycemia rats with pancreatectomy, and normal rats. Streptozocin, 65 mg/kg, was injected intravenously in one group of hooded rats, and pancreatectomy was performed on another group of hooded rats. Eight to 16 days later, fluorescein sodium, 16.6 mg/kg, was injected in the femoral vein of 21 hyperglycemic rats and 18 normal animals. One hour later, the aqueous, vitreous, and plasma fluorescence levels were measured using fluorophotometry. We did not find a significant difference between vitreous fluorescence levels of the hyperglycemic streptozocin- and insulin-treated or non-insulin-treated and normal rats. Moreover, we did not find a significant difference between the vitreous fluorescence of hyperglycemic rats with pancreatectomy and normal rats.

Animals↗
PubMed1983

Persistent leucine sensitivity following partial pancreatectomy and diazoxide treatment. Therapeutic response.

Hyperinsulinemic hypoglycemia secondary to nesidioblastosis persisted in a 4-year-old girl despite a 95% pancreatectomy and high-dose diazoxide treatment. Current literature suggests that dietary treatment, specifically protein restriction, of patients who are receiving diazoxide is ineffective and that further surgical pancreatectomy is required. However, in this patient, marked leucine sensitivity was demonstrated and a subsequent reduction in leucine intake eliminated hypoglycemia and the need for total or nearly total pancreatectomy. Therefore, dietary alteration should be considered in some patients with hyperinsulinism as an adjunct to other medical treatment.

Child, Preschool↗
PubMed2004

Completion pancreatectomy for postoperative peritonitis after pancreaticoduodenectomy: early and late outcome.

HYPOTHESIS: Completion pancreatectomy in patients with pancreatic leakage associated with postoperative peritonitis after pancreaticoduodenectomy is a viable salvage procedure. DESIGN: Retrospective analysis from a cohort of consecutive patients admitted between January 1, 1989, and December 31, 1999, for postoperative peritonitis originating from pancreaticojejunostomy leakage. SETTING: Tertiary referral center with surgical intensive care unit specializing in the treatment of intra-abdominal sepsis. PATIENTS: Eight consecutive patients with postoperative peritonitis originating from pancreaticojejunostomy after pancreaticoduodenectomy, with a mean Acute Physiology and Chronic Health Evaluation II score of 18.6. We excluded patients with pancreatic fistulas or abscesses amenable to percutaneous drainage or other conservative treatment. INTERVENTION: Completion pancreatectomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and long-term outcome, which was assessed by interview. RESULTS: Three patients died in the postoperative period: 2 required early reoperation during the postoperative period and died of hemorrhage and sepsis, and 1 died of multiorgan failure without reoperation. Recurrence of carcinoma was responsible for late death of 2 other patients. CONCLUSIONS: Postoperative peritonitis after pancreaticoduodenectomy still has high mortality; however, completion pancreatectomy may represent the only means to achieve source control of infection in cases of postoperative peritonitis.

Adenocarcinoma↗
PubMed1982

Near-total pancreatectomy in persistent infantile hypoglycemia.

To prevent the devastating effects of hypoglycemia on the CNS of the infant, persistent infantile hypoglycemia should be recognized early and treated promptly. To avoid mental retardation, surgical intervention should not be considered as a last resort. When an insulinoma is identified at surgery, subtotal pancreatectomy is adequate in achieving normoglycemia. However, the most common cause of insulin excess in infancy appears to be islet cell hyperplasia or nesidioblastosis, both diffuse processes. In these patients, subtotal pancreatectomy is often ineffective in achieving normoglycemia. Near-total pancreatectomy, retaining the spleen and duodenum, is a safe procedure, well tolerated by infants and children, and should be considered early for the correction of hypoglycemia of infancy that is not readily controlled by medical intervention.

Adenoma↗
PubMed1983

Islet cell autotransplantation after subtotal pancreatectomy.

Six patients, ranging in age from 28 to 41 years, five men and one woman, underwent 80% to 95% pancreatectomy for chronic pancreatitis, with subsequent autotransplantation of pancreatic fragments. The technique for isolation of pancreatic fragments containing islets of Langerhans was extrapolated from previous experimental work. The follow-up period ranged from one to 25 months. Normal or near-normal carbohydrate metabolism was observed in each patient after the autotransplantation procedure; however, only two patients were insulin independent at 25 and 20 months. One patient died one month after pancreatectomy and autotransplantation of disseminated intravascular coagulation, and another died at three months of surgical complications and sepsis. The remaining two patients were alive and insulin dependent at nine and 25 months. Further developments in islet cell autotransplantation techniques are necessary to achieve, if possible, an insulin-independent status and avert surgically induced diabetes mellitus after total or subtotal pancreatectomy.

Adult↗
PubMed1980

Ligation of the pancreatic duct in pancreatectomy.

This study was undertaken to determine the safety of duct ligation in pancreatic surgery. Duct ligation was performed in 43 patients after pancreaticoduodenectomy and in 108 patients after distal pancreatectomy; 33 patients had a pancreaticojejunostomy after a pancreaticoduodenectomy. All procedures were performed between 1965 and 1975; the analysis was retrospective. The mortality and morbidity for the duct ligation group after pancreaticoduodenectomy were 19 per cent and 77 per cent and after distal pancreatectomy were 4 per cent and 9 per cent respectively. After pancreaticoduodenectomy with pancreaticojejunostomy the mortality was 18 per cent with a morbidity of 33 per cent. It is concluded that distal pancreatectomy with duct ligation is a relatively safe procedure, while after pancreaticoduodenectomy the morbidity is significantly reduced (P less than 0.001) by a pancreaticojejunostomy.

Duodenum↗
PubMed1985

Conservative pancreatectomy.

By convention, resection of the proximal pancreas includes the distal stomach (and duodenum) and resection of the distal pancreas includes the spleen. In 28 patients the stomach and spleen were preserved to minimize functional disability. In 13 patients with proximal pancreatectomy (7 men, median age 39 years) the pylorus and first 3 cm of duodenum were preserved. Indications were chronic pancreatitis (n = 9) and localized neoplasia (ampulla 2, duodenum 1, insulinoma 1). One patient died (aged 81 years), and 2 required re-operation for a pancreatic abscess or stenosed choledochojejunostomy. The 12 survivors are well at a median of 1.25 years (range 0.25-3.25 years). In 15 patients with distal pancreatectomy (6 men, median age 44 years) the spleen was preserved. Indications were islet cell tumour in 2 and chronic abdominal pain in 13,9 of whom had an isolated dorsal pancreas and 6 of whom had histological evidence of chronic pancreatitis. Recovery was uneventful apart from 2 patients with a fluid collection in the lesser sac, 1 needing percutaneous aspiration. In the absence of gross inflammatory adherence, partial pancreatectomy need not entail removal of the adjacent stomach or spleen.

Adult↗
PubMed1987

Duodenum-preserving total pancreatectomy for end stage chronic pancreatitis.

The classical Whipple procedure for chronic pancreatitis has been associated with significant long term postoperative morbidity. The pylorus-preserving procedure of Longmire has reduced but not eliminated the long-term morbidity. Preservation of the whole duodenum with total pancreatectomy has been introduced for the treatment of patients with end-stage chronic pancreatitis after favourable experience with this procedure in infants for nesidioblastosis. Fourteen patients with chronic pancreatitis have had a total pancreatectomy with preservation of the duodenum and the bile duct. All patients are still alive (median follow-up 9.5 months) and none suffered major complications in the perioperative period. One patient developed a biliary stricture at 3 months, requiring biliary reconstruction. Six of the patients have returned to full-time work; nine require no analgesia. All patients require pancreatic enzyme replacement, and all patients have gained weight postoperatively. Diabetic control is satisfactory with a twice daily insulin regime. Duodenum-preserving total pancreatectomy is feasible in the adult without mortality or high morbidity; early experience suggests that preserving the duodenum improves gastrointestinal function with easier control of the diabetes.

Adult↗