PAPER

Critical Analysis of a Large Series of Pancreaticogastrostomy After Pancreaticoduodenectomy
Gerard V. Aranha, MD, FRCSC; Joshua M. Aaron, BS; Margo Shoup, MD

Hypothesis: Pancreaticogastrostomy is a safe operation for a variety of periampullary conditions. Design: Retrospective review of a prospectively collected database. Setting: An academic tertiary care university hospital and a Veterans Affairs hospital. Patients: A total of 235 consecutive patients who un-

derwent pancreaticogastrostomy.
Main Outcome Measures: Indications for surgery, preoperative risk factors, intraoperative and postoperative variables, and factors that affect postoperative complications. Results: The most common initial symptoms were jaun-

noma (17.0%), duodenal carcinoma (7.2%), and chronic pancreatitis (7.2%). The median operating time was 6.5 hours. Median blood loss was 900 mL. The median intraoperative blood transfusion was 0 U. The median postoperative length of stay was 9 days. Postoperative mortality was 0.9%. The most common complications were pancreatic fistulae (13.6%), 1 of which was thought to cause 1 of 2 mortalities in this series. Pancreatic fistulae developing after pancreaticogastrostomy were significantly related to a low preoperative alkaline phosphatase level and surgery for nonpancreatic pathologic findings. The presence of a fistula significantly increased the postoperative length of hospital stay.
Conclusions: Pancreaticogastrostomy is a safe operation associated with low mortality and morbidity rates and a pancreatic fistula rate of 13.6%. It should be considered as a suitable alternative for management of the pancreatic remnant after pancreaticoduodenectomy.

dice (73.2%), weight loss (23.8%), and abdominal pain (17.0%). The 4 most common indications for surgery were pancreatic adenocarcinoma (41.3%), ampullary carci-

Arch Surg. 2006;141:574-580 creaticoduodenectomy, various techniques for managing the pancreatic remnant have been studied, including simple ligation of the pancreatic duct,4,5 occlusion of the pancreatic duct using a synthetic rubber injection or fibrin glue,6,7 optimization of the blood supply of the edge of the pancreatic remnant and meticulous placement of sutures using magnification, 8 the application of fibrin glue sealant around the pancreaticojejunal anastomosis,9 various modifications of pancreaticojejunostomy (either end-to-end or end-to-side anastomosis), 10-15 isolated Roux-en-Y pancreaticojejunostomy,16,17 and pancreaticogastrostomy.18-32 The purpose of this study is to analyze our experience with 235 pancreaticogastrostomies after pancreaticoduodenectomy studied in a retrospective manner from a prospectively collected database to determine whether pancreaticogastrostomy is a safe and effective method for managing the pancreatic remnant.

Author Affiliations: Division of Surgical Oncology, Department of Surgery, Loyola University, Stritch School of Medicine, Maywood, Ill (Drs Aranha and Shoup and Mr Aaron), and Surgical Service, Hines VA Hospital, Hines, Ill (Dr Aranha).

pancreatic remnant after pancreaticoduodenectomy continues to be a source of controversy. This controversy is fueled by the fact that leakage from the pancreaticoenteric anastomosis is responsible for a large percentage of the morbidity and mortality that follows pancreaticoduodenectomy. Trede and Schwall1 from the Mannheim Clinic in Mannheim, Germany, published data on 233 patients who had pancreaticojejunal anastomosis and reported 25 pancreatic leaks, for an incidence of 11%, and 20% of the leaks led directly to postoperative deaths. The Lahey Clinic2 and the Mayo Clinic3 reported similar findings, with 34 pancreatic leaks in 403 pancreaticoduodenectomies, for an incidence of 8%, of which 26% was related directly to postoperative deaths. Because leakage from the pancreaticoenteric anastomosis has been the leading cause of morbidity and mortality after pan-

M

ANAGEMENT OF THE

(REPRINTED) ARCH SURG/ VOL 141, JUNE 2006 574

WWW.ARCHSURG.COM

©2006 American Medical Association. All rights reserved. Downloaded From: http://archsurg.jamanetwork.com/ by a World Health Organization User on 02/14/2014

most patients received octreotide.175:328-329. Inc. 2005. This was done irrespective of the volume of drainage. and when the sutures were tied. drainage from the left drain was measured for amylase content. If the volume was greater than 200 mL/d.05. the patient was fed. 1990. to the anterior wall of the body of the pancreas. (REPRINTED) ARCH SURG/ VOL 141. and sutures are placed from the posteroinferior gastric wall to the posterior pancreas body.Thedrainplaced along the biliary anastomosis was removed on day 5 if there was no bile in the drain. 250 mg intravenously every 6 hours. The Figure demonstrates the completed hepaticojejunostomy. medical records.Apancreaticfistulawasdefinedasamylase-richfluidfrom the pancreatic drain with 3 times the serum amylase level on the first day after the patient eats a solid diet. the drain had eroded into the pancreaticogastrostomyanastomosisandhadtobepulledback.33 Two drains were placed: 1 to drain the hepaticojejunostomy on the right side and 1 to drain the pancreaticogastrostomy on the left side. If the amylase level was less than 125 U/L. A.” Am J Surg. operating time. In 6 (19%) of 32 patients with a pancreatic leak. After 2 solid meals. and July 31. SPSS Inc. Completed hepaticojejunostomy. on day 4. but in the last 123 patients. If the fluid was amylase rich. gastrojejunostomy. B. 1998. such as the use of prophylactic antibiotic agents. C. The patients are given a liquid diet on day 6 and.com/ by a World Health Organization User on 02/14/2014 .ARCHSURG. were also analyzed.A B C 1 cm Figure. Ill). All rights reserved. Analyses were performed using statistical software (SPSS for Windows. and units of blood transfused. All the patients received prophylactic antibiotics before surgery. the patient was sent home with the drain until the drainage decreased to less than 200 mL/d. morbidity. Patients began receiving erythromycin lactobionate. Single layers of sutures of 3-0 silk were taken from the posterosuperior gastric wall.). A gastrotomy is made. Statistical significance was set at P=. then a drain study was performed by injecting dye into the drain. A gastrotomy was made. and metoclopramide hydrochloride was added intravenously every 8 hours. If the fluid was amylase rich and the volume increased after an oral diet. procedures. METHODS PATIENT DATA We conducted a retrospective review of a prospective database of 235 patients who underwent pancreaticogastrostomy after pancreaticoduodenectomy at Loyola University Medical Center and Hines VA Hospital between June 1. Downloaded From: http://archsurg. and intraoperative data.COM ©2006 American Medical Association. Early in the series. and the amylase level was normal.A. and the placement of stents.jamanetwork. Construction of the pancreaticogastrostomy. Copyright 1998. and interviews. advanced to a postgastrectomy diet on day 7. Proton pump inhibitors were used postoperatively to prevent stress and marginal ulceration. The nasogastric tube was removed on day 5. and pancreaticogastrostomy. Delayed gastric emptying was defined as a need for nasogastric suction for more than 10 days after pancreaticoduodenectomy. if tolerated. The pancreatic remnant was mobilized for 4 cm. Chicago. clinical symptoms and signs. Reprinted with permission from Excerpta Medica.V. JUNE 2006 575 WWW. blood loss. at least 5 cm from the cut edge of the stomach. “A Technique for Pancreaticogastrostomy. with no patients having pancreaticoduodenectomy reconstructed with pancreaticojejunostomy during this period. Postoperative data. Clinical and pathologic data were obtained from the surgery database. Sutures entered the pancreas at least 2 cm from the cut edge and exited 1 cm from the cut edge. The ␹2 or Fisher exact test was used when appropriate. and then sutures were placed from the posteroinferior gastric wall to the posterior body of the pancreas. from Aranha GV. Sutures are placed from the posterosuperior gastric wall to the anterior pancreas body. and if the volume did not change. All the patients who underwent pancreaticogastrostomy after pancreaticoduodenectomy were operated on by the same surgeon (G. the drain was removed if the volume was 200 mL/d or less. Data obtained for each patient included demographics. and pancreaticogastrostomy. at least 1 to 2 cm of the pancreas was invaginated into the stomach without a stent. and the use of octreotide. preoperative laboratory values. octreotide was not used. the patient was sent home on an oral diet. including pathologic findings. endoscopy. gastrojejunostomy. and then the drain was removed. mortality. including computed tomography (CT). SURGICAL TECHNIQUE All the patients underwent classic pancreaticoduodenectomy with distal gastrectomy.

8) 40 (17. Two of the patients had hemorrhage from the gastrojejunal anastomosis that was controlled with endoscopic means.Table 1.0) 15 (6. 21-90 years.9%) (Table 3).(%) 68 (21-90) 145 (61. RESULTS Patient characteristics and preoperative risk factors are listed in Table 1.3) 172 (73.1) 5 (2.jamanetwork.4) 12 (5. The most common initial symptoms included jaundice (73.com/ by a World Health Organization User on 02/14/2014 .0%).5 g/dL) were given parenteral or enteral nutrition for 10 to 14 days before surgery. weight loss (23.2) 14 (6.5) 8 (3. Median blood loss was 900 mL (range.6) 14 (6) 14 (6) 13 (5. and chronic pancreatitis (7.3) 9 (3.9%) and were treated with percutaneous transhepatic stenting of the anastomosis.413. 2007500 mL). All the patients underwent preoperative CT.3%).ARCHSURG. 191 patients underwent pancreaticoduodenectomy without mortality.4) 98 (41. No. Bile leaks occurred in 2 patients (0.3) 18 (7. Postoperative Complications Complication Mortality Pancreatic leak Intra-abdominal abscess Delayed gastric emptying Wound infection Cardiac complications Small intestinal obstruction Pulmonary complications Hemorrhage Gastric leak Bile leak Reexploration Miscellaneous Patients.1) 17 (7.1) 4 (1. One patient died of acute respiratory distress syndrome on the 45th postoperative day.8) Table 3. Contained leaks from the gastrojejunostomy occurred in 3 patients (1. duodenal carcinoma (7. parenteral nutrition was necessary for fistula closure. 5-83 days).9) 3 (1. and all resolved with conservative measures. Indications for Pancreaticoduodenectomy Pathologic Finding Adenocarcinoma Ampullary carcinoma Duodenal carcinoma Chronic pancreatitis Common bile duct cancer Mucinous cystadenoma Neuroendocrine Intraductal papillary mucinous neoplasm Serous cystadenoma Cystic adenocarcinoma Other Patients.7) Abbreviations: COPD. Aside from the 2 deaths.7) 40 (17. Patients who were considered malnourished (ie. All the patients with intra-abdominal abscess were treated with either intraoperatively placed drains or new percutaneous drains by means of interventional radiology.0) 17 (7. and the median intraoperative transfusion was 0 U (range. JUNE 2006 576 a massive upper gastrointestinal hemorrhage. There were 145 men and 90 women (median age. and the other 2 had pseudoaneurysms. chronic obstructive pulmonary disease. *Data are given as number (percentage) of patients except where indicated otherwise.2%). Hemorrhage occurred in 4 patients (1.4%) of these 32 patients. One pseudoaneurysm was controlled at our institution (Loyola University Medical Center) with interventional radiology using coil embolization. diabetes mellitus.9) 19 (8. Preoperative risk factors included hypertension.COM ©2006 American Medical Association. Only 1 patient had to return to surgery for closure of the fistula. median (range).80-24. GERD. WWW.8%). Median weight loss was 6.2) 56 (23. Delayed gastric emptying occurred in 14 patients (6. The second patient died at an outside institution of (REPRINTED) ARCH SURG/ VOL 141. In 11 (34.7) 3 (1.0) 38 (16.6) 2 (0. (%) 2 (0.9) 32 (13.2) 17 (7.0 hours).2) 28 (11. with resolution of the problem. Downloaded From: http://archsurg. y Sex Male Female Jaundice Weight loss Epigastric or back pain Itching Hypertension Coronary artery disease Diabetes mellitus Previous cancer COPD or asthma Atrial fibrillation Hypothyroid GERD Peripheral vascular disease Peptic ulcer disease No. No.2) 15 (6. The other patient died at an outside institution of massive upper gastrointestinal bleeding and is presumed to have had a pseudoaneurysm. (%) 97 (41. 3. ampullary carcinoma (17. Thirty-day and in-hospital mortality occurred in 2 patients (0. atrial fibrillation. Most of the 32 fistulae closed with maintenance of drains and continued oral intake. chronic obstructive pulmonary disease or asthma.6%) and was the most common morbidity. range. 0-7 U).3%).2%). previous cancer. The median operating time was 6. The 4 most common indications for pancreaticoduodenectomy were pancreatic adenocarcinoma (41.7%).1) 10 (4. An intra-abdominal abscess occurred in 14 patients (6.0%).0) 10 (4. and 142 (60. and abdominal pain (17.0) 6 (2. peptic ulcer. Characteristics and Preoperative Risk Factors of 235 Patients* Characteristic Age. 68 years.0%).7) 90 (38.3) 40 (17. hypothyroidism.2%). and pancreatitis. Octreotide was used after surgery in 112 patients and was not used in 123 patients.4) 5 (2.3) Table 2. and none required surgery.9) 16 (6. peripheral vascular disease. A pancreatic fistula occurred in 32 patients (13. gastroesophageal reflux disease. Indications for pancreaticoduodenectomy based on pathologic findings are given in Table 2.0%) and wound infections in 13 (5.5%). All rights reserved. The median postoperative hospital stay was 9 days (range. coronary artery disease.75 kg (range.8) 7 (3.3) 2 (0.75 kg).5 hours (range. 1.9) 21 (8.4%) had biliary stents placed via endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. This occurred in fewer than 10 patients. albumin level Ͻ2.

ARCHSURG.7%) developed a fistula. h Յ6.3%). This patient was taken back to the operating room.08 . The third patient who had a second surgery was the one who had surgical closure of a persistent pancreatic fistula 3 months after surgery. More recently. Of 813 patients who underwent pancreaticogastrostomy.5 Octreotide therapy Yes No Intraoperative blood transfusion Yes No Estimated blood loss. In a meta-analysis of WWW. Used infrequently initially. At exploration.001 . and postoperative variables in relation to fistula formation.5 Ͼ6. mL Յ1000 Ͼ1000 Preoperative stent Yes No Preoperative ERCP or PTC Yes No Alkaline phosphatase. The proximity of the pancreas to the posterior wall of the stomach allows for potentially less tension on the anastomosis. and the drain remnant was found in the wound just after the anterior fascia was opened. In all of these patients. the stomach does not contain enterokinase. Age. Several theoretical physiologic and technical advantages to performing pancreaticogastrostomy have been described.9%) of 123 patients who developed a fistula without octreotide administration.43 . g/dL Յ3 Ͼ3 Pancreatic pathologic findings Yes No Hospital stay. preoperative biliary stenting. a benefit not possible with a pancreaticojejunal anastomosis. However. median (range).com/ by a World Health Organization User on 02/14/2014 . and this was not significant compared with the 11 (8. duration of surgery. y Ͻ70 Ն70 Duration of surgery. a pancreatic fistula was associated with a doubling in the median length of hospital stay. COMMENT Table 4. therefore. A lack of enzyme activation may prevent autodigestion of the anastomosis. In this case. U/L Յ110 Ͼ110 Albumin. Intraoperative. 3 (0. In the first patient. 9 (34. Of the 26 patients. Also.24-32 It is well-known that leakage from the pancreaticojejunal anastomosis and its consequences are the leading causes of mortality after pancreaticoduodenectomy.005 Ͻ. 32 (4.4%) were thought to be the primary cause of death. Preoperative. use of octreotide. preoperative endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Of the 112 patients receiving octreotide. percutaneous transhepatic cholangiography. Table 4 lists certain preoperative.09 . the pancreatic duct was simply oversewn and the gastrotomy closed. *Data are given as number (percentage) of patients except where otherwise indicated. pancreaticogastrostomy has been used much more frequently in the past 20 years. All rights reserved. PTC. Of these fistulae. which is required for the conversion of trypsinogen to trypsin and the subsequent activation of other proteolytic enzymes. JUNE 2006 577 pancreatic enzymes are inactivated by the acidic gastric fluid. intraoperative blood loss.6%) died after the second operation.92 . Further impetus to the success of the operation was provided by Mackie et al37 in 1975. patients who had pancreatic adenocarcinoma and pancreatic pathologic abnormalities had a much lower incidence of pancreatic fistula than those who had other types of pathologic abnormality. Yeo et al38 reported on 650 consecutive pancreaticoduodenectomies performed at The Johns Hopkins Hospital.COM ©2006 American Medical Association. and when the pancreatic drain was removed.30 65 (81) 138 (89) 128 (90) 75 (82) 127 (89) 76 (82) 49 (86) 154 (87) 46 (74) 157 (91) 44 (90) 159 (85) 135 (91) 68 (78) 9 (5-34) 15 (19) 17 (11) 15 (10) 17 (18) 15 (11) 17 (18) 8 (14) 24 (13) 16 (26) 16 (9) 5 (10) 27 (15) 13 (9) 19 (22) 18 (7-83) . 12 (10. Data from the late 1970s and early 1980s confirm this. This patient survived. A review of the world literature on pancreaticogastrostomy from 1946 to 1997 by Mason39 seems to confirm the safety of pancreaticogastrostomy. patients with elevated alkaline phosphatase levels had a significantly lower incidence of postoperative pancreatic fistula than those whose alkaline phosphatase level was not elevated.35 Waugh and Clagett36 at the Mayo Clinic were the first to use pancreaticogastrostomy in the clinical setting in 1946. less tension on the pancreaticogastrostomy anastomosis.001 Abbreviations: ERCP. therefore.10 .0%) developed pancreaticocutaneous fistulae. The excellent blood supply to the stomach wall is favorable to anastomotic healing. intraoperative.0%) required repeated surgery. Nasogastric decompression provides for continuous emptying of the stomach and.A second operation was required in 3 patients (1. endoscopic retrograde cholangiopancreatography. Pancreaticogastrostomy became a reality when Tripodi and Sherwin34 first reported successful transplantation of the pancreas into the stomach in 1934.15 . the surgery was for peritonitis.29 .jamanetwork. They noted that 26 patients (4. and a preoperative albumin level of 3 g/dL had no effect on fistula formation. and the thickness of the stomach wall holds sutures well.28 A physiologic advantage is believed to be that (REPRINTED) ARCH SURG/ VOL 141. Downloaded From: http://archsurg. death could be directly related to leakage from the pancreaticojejunal anastomosis. This finding was confirmed by Person and Glenn. Finally. the alkaline and pancreatic secretions may aid in preventing marginal ulceration. it was severed. and Postoperative Variables in Patients With vs Without a Pancreatic Fistula* No Fistula (n = 203) 113 (84) 90 (89) 110 (89) 93 (83) 94 (84) 109 (89) Fistula (n = 32) 21 (16) 11 (11) 13 (11) 19 (17) 18 (16) 14 (11) P Value Characteristic Age. intraoperative blood transfusion. reentry into the abdomen was not necessary. d . it was found that the pancreatic remnant had separated completely from the stomach. In addition. In addition. The second patient had a drain included in the closure of the fascia.

9%) occurred. hemorrhage. This has also been reported by other researchers. 1977. repeated surgery is also low. reexploration was required in 3 patients (1. was discharged from the hospital with a drain on the ninth postoperative day. only 2 deaths (0. Pancreatic fistula complicating pancreatectomy for malignant disease. JUNE 2006 578 creatic fistula increases the length of the postoperative hospital stay.49 Delayed gastric emptying occurred in only 6. FRCSC. These patients should undergo immediate CT angiography. The complications of pancreatectomy. 2006. One death was due to acute respiratory distress syndrome and occurred 45 days after the operation.46 In the present series. Downloaded From: http://archsurg. intraabdominal abscesses. No autopsy was performed.1 proton pump inhibitors are used after surgery.48. parenteral nutrition was needed only in patients who had persistent high-volume fistulae. EMS Bldg.5%). Here.55:531-536.com/ by a World Health Organization User on 02/14/2014 . Ghosh BC. Yeo et al41 published the only prospective randomized trial of pancreaticogastrostomy vs pancreaticojejunostomy after pancreaticoduodenectomy. Pancreaticogastrostomy remains a viable option for management of the pancreatic remnant after pancreaticoduodenectomy.9%) had albumin levels of 3 g/dL or less.43 with pancreaticojejunal anastomosis revealed a reexploration rate of 3% to 4%.41 the surgeon’s experience and pancreaticoduodenectomy performed for nonpancreatic pathologic findings were strongly associated with pancreatic fistula formation. Papachristou DN.3%). Bartoli et al40 also suggested that pancreaticogastrostomy was safer than pancreaticojejunostomy. Mayo Clin Proc. In the present study. and is published after peer review and revision. he returned to the emergency department where. fistula formation was significantly related to pancreaticoduodenectomy performed for nonpancreatic pathologic findings. Accepted for Publication: January 14. REFERENCES 1. of which 34% of the mortality was related directly to leakage from the pancreaticojejunal anastomosis. Calif. In the present study.45. Trede M. In this study. Mortality is low. blood rushed out of his mouth and nose. was found by Lin et al47 to be significantly associated with pancreatic fistula. Five days after discharge. Metoclopramide is used to prevent impaired gastric motility after duodenectomy and reflux secondary to gastric stasis. death was due to leakage at the pancreaticojejunal anastomosis. Rancho Mirage. this study. 2. Because partial pancreatectomy can have an ulcerogenic effect. 5. and in 3 of these 5 patients. resulting in immediate death. Late bleeding in a patient who has had pancreaticoduodenectomy. Kiernan PD.0%) and wound infections occurred in 13 (5. there was no difference in the mortality and morbidity whether the stomach or jejunum was anastomosed to the pancreatic remnant. and other complications of pancreatic fistulae. wound infections. We can only conjecture that this death was due to a pseudoaneurysm as a result of a leak from the pancreaticogastrostomy. Intraabdominal abscesses are mainly due to leakage from the pancreaticoenteric anastomosis. Stritch School of Medicine. The soft texture of the pancreas. and all 3 survived. after undergoing CT. Edis AJ. Maywood. Attempted curative resection of ductal carcinoma of the pancreas: review of Mayo Clinic experience. Aranha.edu). The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript. 2160 S First Ave. In conclusion. 2005. Ann Surg. Huvos AG. WWW. 1988.49 Leaks from the hepaticoenteric and gastroenteric anastomosis cause fewer intraabdominal abscesses.COM ©2006 American Medical Association.ARCHSURG. However. Braasch JW. In the article by Yeo et al. according to his family members. 4. All intra-abdominal abscesses were managed successfully with maintenance of intraoperatively placed drains or new percutaneous drains. In addition. it has an effect on the motility of the entire stomach in addition to increasing the tone of the lower esophageal sphincter. Room 1103236. Loyola University. Department of Surgery. Surg Gynecol Obstet. only 49 patients (20.44 5 (5%) of 97 patients undergoing pancreaticojejunostomy needed reexploration. Correspondence: Gerard V. In addition. shows the safety of pancreaticogastrostomy. bile leaks. Gray BN. In a previous study. Ligation versus implantation of the pancreatic duct after pancreaticoduodenectomy. Goldsmith HS. In addition.42 Recent published large series38. as seen in this study and others. Schwall G.pancreatic fistula after pancreaticoduodenectomy. 1981. Intra-abdominal abscess occurred in 14 patients (6. the use of metoclopramide after surgery may have also helped. Although metoclopramide increases the tone and amplitude of the antral stomach. Intra-abdominal abscesses are thought to be associated with increased mortality. 3. and cardiac complications are also low. there was no correlation with fistula formation and patients having an albumin level of 3 g/dL or less.49 This was not true in this series. Therefore.0% of patients in this series. Previous Presentation: This paper was presented at the 113th Scientific Session of the Western Surgical Association. All rights reserved. In the same study. 1980. We believe that this is due to the fact that we perform a classic pancreaticoduodenectomy that includes a distal gastrectomy. Fortner JG. although we did not have sufficient information on the texture of the pancreatic remnant. repeated operations.44 reexploration was not required in 117 patients undergoing pancreaticogastrostomy. Taylor WF. which is the largest study of pancreaticogastrostomy in the literature.68:238-240. Am J Surg. The second death can be related to leakage from the pancreaticogastrostomy because this patient. as seen in nonpancreatic pathologic abnormalities. he was found unconscious by a family member and was taken by ambulance to another institution.jamanetwork.49 There are several reasons why delayed gastric emptying occurs in patients undergoing pancreaticoduodenectomy. is often due to pseudoaneurysms. patientswithelevatedalkalinephosphataselevelswerefound to have a significantly lower incidence of fistula after pancreaticoduodenectomy in our series. further supporting the safety of pancreaticogastrostomy. Previous studies have attempted to define the cause of fistula formation after pancreaticoduodenectomy. IL 60153 (garanha@lumc. The development of a pan(REPRINTED) ARCH SURG/ VOL 141.207: 39-47. with embolization if a pseudoaneurysm is demonstrated. especially one who has had a leak. 1971. November 9. delayed gastric emptying.132:87-92. MD.133:480-484. Considerations that lower pancreaticoduodenectomy mortality. who had a pancreaticoduodenectomy for an ampullary carcinoma. 1951-1975. followed by conventional angiography. Br J Surg.

Murr MM. Shepherd JA. Minn: Dr Aranha and his colleagues have been proponents of the use of pancreaticogastrostomy for reconstruction following pancreaticoduodenectomy for a number of years. Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? results of a prospective randomized trial. 32. Pancreaticogastrostomy: experimental transplantation of the pancreas into the stomach. Weber J-C. Wells C. Cameron JL. Ann Surg. Pancreaticogastrostomy: a further evaluation. Hermreck AS. 12. Misra M. Surg Clin North Am. Tripodi AM. The hypothesis in this retrospective analysis of prospectively collected data is that pancreaticogastrostomy is a safe reconstruction for a variety of periampullary conditions. Yeo CJ. Lancet. Pancreaticoduodenectomy and pancreaticogastrostomy: a fiveyear survival with notes on the metabolism. Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy Arch Surg. Gibbon N. Sohn TA.COM ©2006 American Medical Association. 197:223-232.18:363-369. Pancreatico-gastrostomy in pancreatico-duodenal resection for carcinoma of the head of the pancreas or the papilla of vater. Pancreaticogastrostomy: preferred reconstruction for Whipple resection. 20. 1998. Consolidation of a friable pancreas for pancreaticojejunal anastomosis. Pancreaticogastrostomy as reconstruction for pancreaticoduodenectomy: review. Strauch GO. 1995. Pancreaticogastrostomy: a safe drainage procedure after pancreaticoduodenectomy. is the largest reported to date. 2004. Seenu V. Lancet. Restoration of continuity following pancreaticoduodenectomy. Thayer SP. 30.25:567-571. 46. JUNE 2006 579 WWW. 17. World J Surg. Downloaded From: http://archsurg.8:701-705. 27. Strasberg SM. Ihse I.199:198-203. Nakano H. Willams JG. Arch Surg. Vilgrain V.14:183-186. 1993. Clagett OT. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Ann Surg. 1946. Dr Aranha pointed out in his presentation.23:221-226. Br J Surg. Management of complications following pancreaticoduodenectomy. which may allow for lack of tension on the anastomosis. Eng M. 10. 2001.jamanetwork. 2000. Ann Surg. Purse-string pancreaticojejunostomy following pancreatic resection. DISCUSSION Michael B. 40. J Am Coll Surg. 1958. I am sure.3:54-60. Surgery. Oper Tech Gen Surg.8:766-774. 1999. 1995. Am J Surg. Am J Surg. Pancreaticoduodenectomy with occlusion of the residual stump with Neoprene injection. 14. Smyrniotis B. et al. Pancreaticogastrostomy after subtotal pancreatectomy for cancer. Mackie JA. Sakorafas GH. 13. 2004. Rochester. 1997. 24. Suc B. Aranha GV. Resected adenocarcinoma of the pancreas: 616 patient results. Anticancer Res.207:253-256. Axelson J. Golts E. Bramhall SR. Fingerhut A. 1939. Pancreaticogastrostomy following pancreaticoduodenectomy. All rights reserved. unlike a jejunal limb. Ford RS. Fotopoulos AC.20:224-232. Stented versus nonstented pancreaticojejunostomy after pancreaticoduodenectomy: a prospective study.139:327-335. White SA. J Surg Res. 33. outcomes and prognostic indicators. Surgery. Delayed hemmorrhage after pancreaticoduodenectomy. 2004. J Gastrointest Surg. J Am Coll Surg.226:248-260. Pickleman J. Mokadam NA. Neoptolemos JP. Hodul P. Ann Surg. Freiss H.44:299-302. 2003. Arch Surg. 9. The morbidity and mortality rates in this series are commendable. 15. 229:41-48. Pancreaticogastrostomy. 1985. Jott JW. 1999. et al. et al. Cameron JL. Icard P. Szecseny A. Ingebrigtsen R. Chiesa R. Hodul PJ. Farnell. Pancreaticogastrostomy. 2004. Park D. 16. 1997. J Gastrointest Surg. Bachi V. Problems of reconstruction during pancreatoduodenectomy. Pancreatic leak occurred in 13. Eid A. Oussoultzoglou E. Millbourn E. O’Neil S. Cameron JL. et al. 35. many of whom report outstanding results comparable to those we have heard from Dr Aranha today. Sauvanet A. 1997. Arch Surg. 2003. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Tihanya T. Thomson SR. 2002. 49. et al. Sohn TA. There were only 2 postoperative deaths. 1999. Pancreatic fistula and relative mortality in the malignant disease after pancreaticoduodenectomy: review and statistical meta-analysis regarding 15 years of literature. 116:12-27. Papadimitriou JD. et al. et al. Glenn F. 132:296-299. Garcea G. Kapur BML. Sherwin CF.54:122-125.199:186-191. The mean length of stay was 9 days. Sutton CD. 1990. 19.15:297-298. pancreatic fistula was correlated with the consistency of the pancreas and is consistent with large series that one sees reported for pancreaticoduodenectomy. Jaeck D.75:913-924. Dubois F. 7. which may prevent marginal ulceration. Aranha GV. A comparison of pancreaticogastrostomy and pancreaticojejunostomy following pancreatiocduodenectomy. 2001. Pancreaticogastrostomy. 1989.222:580-592. Pancreaticogastrostomy: an ideal complement to pancreatic head resection with preservation of the pylorus in the treatment of chronic pancreatitis. for a mortality rate of 0. Arch Surg. 45. Waugh JM.ARCHSURG. Creech S. Lillemoe KD. to my knowledge. Raill TS.11: 1831-1848. 39. Ann Surg. 1934.2:270-271.177:340-341. Buchler MW. Muggia-Sullam M. Lancet. 1999. Six hundred fifty consecutive pancreatiocduodenectomies in the 1990s: pathology. Moon HJ. et al. Aranha GV. These results are outstanding and are comparable to results obtained in other high-volume centers employing more conventional reconstruction techniques consisting of either invagination or ductto-mucosa pancreaticojejunostomy. Pontiroli AE. J Gastrointest Surg.16:389-392. 42. J Am Coll Surg. 36. Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy. 8. Yeo CJ. 43. Cameron JL. Nagorney DM. Langfeldt E. The merits of these advantages. Bartoli FG. 1995. Dig Surg. Stein HJ. the superb blood supply to the stomach. World J Surg. 26. Person EC Jr. Choi SH.28:345-346. 18. Mason GR. 11. Pancreaticogastrostomy for reconstruction of pancreatic stump after pancreaticoduodenectomy for ampullary carcinoma. 2004. Acta Chir Scand.4:567-579. 1972. 44. Also. Sibert A. Ann Surg. Drebin JA. Pierce GE. Experimental transplantation of the pancreas into the stomach. 1956. 28.1:589-590. Flautner L. Bigourdan J-M. randomized fash- (REPRINTED) ARCH SURG/ VOL 141. Pancreaticogastrostomy following pancreaticoduodenectomy. Silverstone M. 21. 2004. can be debated by proponents of pancreaticojejunal reconstruction. Risk factors and outcomes in post-pancreaticoduodenectomy pancreaticocutaneous fistula. Dill-Russell AS. Lin JW. et al. 1975. 48. complications and outcomes.237:57-65. 2001.134:135-139. Resection of the duodenum and head of pancreas for carcinoma: an analysis of thirty cases. Dig Surg.1: 588-589. Creech S. which may facilitate healing of the anastomosis. World J Surg. Yeo CJ. Zero mortality after 152 consective pancreaticoduodenectomies with pancreaticogastrostomy.6% and delayed gastric emptying in only 6.0% of patients. Rhoads JE. 2004. Delcore R. 22. 31. Pikarsky AJ. Cameron JL. Their experience with 235 consecutive patients undergoing pancreaticogastrostomy for a variety of indications. Pancreatic reconstruction has been analyzed in a prospective.8:951-959. Balsiger BM. J Gastrointest Surg.108:641-647. and nasogastric decompression. Br J Surg. 2003.150:608-611. Goel AK. 8:733-741. 1991. Madiba TE. Denys A. J Gastrointest Surg. 1952. 1952. Bachellier P. Pickleman JR. Kim YI. The theoretic physiologic and technical advantages espoused by proponents of pancreaticogastrostomy include lack of enzyme activation and alkaline milieu in the stomach. Sarr MG. and only 3 patients required reoperation. Oh D. Maher MM. 25. 29.181:541-545. Heo JS. which may distend with a pancreaticojejunostomy. Thomas JH.194:746-760. Belghiti J. Dig Surg. Munoz-Bongrand N. I believe that Dr Aranha and his colleagues’ data support their conclusions that pancreaticogastrostomy is a safe alternative to pancreaticojejunostomy. et al.176:274-278. Pancreaticoduodenectomy. Kim MP. Jacobs W. The use of pancreatogastrostomy after blunt traumatic pancreatic transection: a complete and efficient operation. Bottcher KA. Dig Surg. An end-to-end pancreaticojejunostomy using a mechanical purse-string device. MD.7:672-682. Lillemoe KD. Yeo CJ. Arnone GB.9%. Warshaw AL. Roder JD. Di Carlo V.176:16-18. Hansson L. Isolated Roux-loop pancreaticojejunostomy: a series of 61 patients with zero postoperative pancreaticoenteric leaks.82:158-165. Landen S. 34.com/ by a World Health Organization User on 02/14/2014 . Am J Surg.39:530-550. 37. 1988. 41. Ravera G. 1998. Yeo CJ. 1999. 23. Pancreaticogastrostomy.6. 1952. Subtotal pancreaticoduodenectomy: use of a defunctionalized loop for pancreatic stump drainage. Pancreaticogastrostomy after pancreatoduodenectomy: a retrospective study of 28 patients.13: 105-111. Prospective trial of a blood supply– based technique of pancreaticojejunostomy: effect on anastomotic failure in the Whipple procedure. Morris DM. Msika S. Ann Surg. J Am Coll Surg. Aranha GV. 38. 47. J Gastrointest Surg.

in my practice I reconstruct using the duct-tomucosa technique.222:580-592). Heretofore. Motilin is concentrated in the duodenum. However. Erythromycin. but it was significantly lower in those with pancreaticogastrostomy than in those who have pancreaticojejunostomy. We did have 2 patients who had recurring attacks of pancreatitis. like you in many cases. We have continued to do this despite the Baltimore data. Presumably with a leak following pancreaticogastrostomy. suggesting that acid does inactivate amylase. (REPRINTED) ARCH SURG/ VOL 141. watching what is going on. the gastric mucosa may grow over the end of the pancreatic duct. We have not as of yet. a pancreaticogastrostomy is suggested in the management of pancreatic remnant because the remnant can be observed for changes by an endoscopic ultrasound. we send the patient home with the drain until the fistula closes. it doesn’t matter whether one does pancreaticogastrostomy or pancreaticojejunostomy. Overall. I think one of the reasons that we do not have the same incidence of delayed gastric emptying is because we do the classic Whipple. I will continue to feed the patient. 40% of patients with pancreaticogastrostomy were taking enzymes for more than 1 year after their Whipple procedure. My question is. I get a drain study. Dr Aranha’s rich experience reported today and the surgical literature support the observation that either of these anastomotic techniques are excellent for reconstruction with comparable safety. at which time we remove the drain. we are having a lot of difficulty finding the pancreatic duct in the stomach because it seems like they lose it. Fewer than 5 patients have had to stay in the hospital and receive total parenteral nutrition. and this is due to the poor prognosis of many patients undergoing the operation. My feeling has al- ways been that diabetes occurred because the duct became obstructed.ARCHSURG.0% incidence of delayed gastric emptying? Dr Aranha: You asked about whether I have studied the pancreatic duct. 1995. and therefore. In patients who have a Whipple procedure for an intraductal papillary mucinous neoplasm. In this situation. your question about erythromycin and Reglan as prokinetic agents. MD. and therefore. is a motilin agonist. We studied 88 patients who had a pancreaticogastrostomy and 44 patients with pancreaticojejunostomy. As the indications for pancreaticoduodenectomy have broadened and pancreatic surgeons are operating on more patients with cystic neoplasms. All rights reserved. If the amount of fluid from the drain increases. JUNE 2006 580 WWW. we did an upper GI [gastrointestinal] endoscopy and gave them secretin. Downloaded From: http://archsurg. the durability of pancreatic anastomosis has not been a high priority. Then after that. This leads me to my first question for Dr Aranha and that has to do with patency of the anastomosis and preservation of endocrine and exocrine function. 6 patients had the pancreatic drain erode into the anastomosis. the prognosis is improving and patients are living for a longer period of time. and I wondered if Dr Aranha has any experience with assessing patency and durability of his anastomosis and preservation of endocrine and exocrine function? Second. and we were able to identify the duct. Are you able to feed these patients and are you able to dismiss them from the hospital.com/ by a World Health Organization User on 02/14/2014 . the morbidity and mortality was no different in pancreaticogastrostomy vs pancreaticojejunostomy. 60% had stopped taking pancreatic enzymes. I was impressed with your low incidence of delayed gastric emptying. loss of motilin is thought to be the reason for delayed gastric emptying that occurs more in the pylorus-preserving Whipple procedure. Koep. once it is well controlled. I am in the process of getting IRB [institutional review board] approval to do such a study.COM ©2006 American Medical Association. there is extravasation from the stomach. What really matters is that it is done well. and in their study. The drain was pulled back. South Africa. Your second question was in regard to patients with intraductal papillary mucinous neoplasms. Phoenix. how do we treat leaks? If I have a leak from the pancreaticogastrostomy. I believe that over time. Early on we can do it up to about a year. Ariz: The real advantage of this drainage is access to the pancreas. In other words. your protocol for postoperative management included both erythromycin on day 4 and Reglan [metoclopramide hydrochloride] on day 5 when the NG [nasogastric] tube was removed. and the leak was closed. one needs to get a CT scan to make sure that there is no abscess that has to be drained. In the manuscript. we can access that pancreatic duct. Patients who had the pancreaticogastrostomy took pancreatic enzymes for a longer period than those who had the pancreaticojejunostomy. but I do have quality-of-life studies that we presented recently in Durban. The question of whether you have been able to access this so far is really critical. On these patients. the Johns Hopkins group also supports pancreaticogastrostomy. We have not as of yet. The amount of pancreas one removes may result in a decrease of pancreatic polypeptide. Of the 23 leaks that we had. whether it is papillary disease in the pancreatic duct or whether it is pancreatitis. patients with pancreaticogastrostomy have more steatorrhea.jamanetwork. The incidence of diabetes was 9% overall. There are other reasons for patients getting diabetes. Lawrence J. at the International Surgical Society Week. and should a leak concur. and this may make the liver resistant to insulin. If the patient can eat and the volume does not go up. Your second question was. I am comfortable feeding the patients and then ultimately dismissing them even with the leak persisting. To what extent do you feel that this pharmacologic regimen is responsible for your very low 6. unfortunately. We have tried to do this. Finally. is this something we are going to be able to do? Do you think that we will be able to access the anastomosis long term and know what is happening to the pancreatic duct and to exocrine function? Dr Aranha: You asked if we have studied the patency of the pancreatic duct after a pancreaticogastrostomy. but this has not been studied in a prospective fashion. or do you have to wait until it is completely healed? Last. as most of you know.ion by Yeo et al (Ann Surg. but I have not been able to prove this with endoscopic studies. The anastomosis with pancreaticogastrostomy is easily accessible endoscopically. Also. where it is essential to be able to get access to that pancreatic duct as time goes on.