بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Reconstruction after Pancreaticoduodenectomy By Maher Omar Osman Gomaha Lecturer of Surgery National Liver Institute University of Menoufiyea

3. Pancreaticoduodnectomy remains one of the most demanding operations in abdominal surgery. • Recent improved results shows: Decreased operative mortality to < 5%. Postoperative morbidity ranges from 30-44%.

4. Indications of PD include: • Periampullary carcinoma • Localized painful chronic pancreatitis in the head of the pancreas. • Major combined trauma: duodenum and pancreas. • Alternatives of PD include: • Conventional (Standard) PD (Whipple's procedure 1935), • Extended (Regional) PD (Fortner, 1973), • Pylorus Preserving PD (PPPD) (Traverso and Longmire, 1978).

5. Pancreaticoduodenectomy comprises two phases: • Resection, • Reconstruction.

6. The Standard operation involves the en bloc removal of the following: • The distal one-third of the stomach with the right half of the greater omentum, • The gallbladder, cystic and common bile duct, • The duodenum and proximal 10 cm of the jejunum, • The head of the pancreas and varying amounts of its neck and body, depending on size and site of the tumor, • The peripancreatic and hepatoduodenal lymph nodes.

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

8. (1) Management of the pancreatic Remnant • The Achilles heel in PD procedure, • Pancreaticoenterostomy is considered as the 'weak point' of PD. • Risk factors predisposing to pancreatic leakage after PD: • Advanced age, • Prolonged operation time, • Major blood loss, • Jaundice, • Soft pancreatic parenchyma, • Small pancreatic duct, • Number of operations per surgeon.

9. Options for pancreatic stump management • Non-anastomotic options, • Pancreaticojejunostomy and its varieties, • Pancreaticogastrostomy.

10. Non-anastomotic options i) Pancreatic duct ligation: • Used in the early PDs performed by Whipple, • Can be done by ligation, stapling or suturing. • Leads to inevitable pancreatic fistula in the rate of 50-100%. • Can be a logic procedure in specific circumstances: • necessity for expedient termination of the operation, • short jejunal mesentery allowing only a tension-free biliary or pancreatic anastomosis, • massive jejunal edema that would result in a tenuous anastomosis.

11. Non-anastomotic options ii) Pancreatic duct occlusion • Several biological substances can be used: • Neoprene • Ethibloc • Fibrin glue (Tissuecol). • The rate of fistula after duct occlusion was 4%(DiCarlo et al 1989), and 1.7%(Gall et al, 1989). • Gland atrophy and exocrine insufficiency are inevitable. • Should be considered for high risk anastomosis in fragile pancreatic remnants.

12. Non-anastomotic options iii) Controlled External Pancreatic Fistula • Entailed inserting a drain into the pancreatic duct and bringing it out on the skin, • Avoid high-risk pancreatoenteric anastomosis, • In about 80% of cases, the fistula will close spontaneously.

13. Non-anastomotic options iv) Total Pancreatectomy at the time of PD • Eliminates the morbidity and potential mortality of an anastomotic leak, • Establishes a complete apancreatic state with endocrine and exocrine insufficiency

14. Pancreaticojejunal Anastomosis • The traditional reconstructive method standardized by Whipple, • Several modifications have been employed: • Invagination vs Duct-to-mucosa • End-to-end vs end-to-side • The two most frequently employed techniques of PJ are: • End-to-end invagination (telescoping), • End-to-side duct-to-mucosa.

15. Pancreaticojejunal Anastomosis • In prospective/retrospective uncontrolled studies, the fistula rate was higher in the end-to-side compared with the end-to-end technique (15-17% vs 3-11%, respectively). • End-to-side anastomosis is therefore suggested in patients with a dilated pancreatic duct and firm pancreatic parenchyma. • In recent randomized studies, no statistical differences were found between the two techniques (Bassi et al, 2003).

16. Pancreaticojejunal Anastomosis Several minor modifications of the PJ have been suggested: • The injection of the duct with neoprene (DiCarlo et al, 1989). • The use of fibrin glue to seal the PJ (Kram et al, 1991). • The drainage of the PJ anastomosis (stenting vs nonstenting remains a controversy) (Roder et al, 1999). • The consideration of a second-stage PJ in high-risk patients (Kubota et al, 2000). • The use of Vicryl mesh to wrap the pancreatic stump (Pernot et al, 2001).

17. Pancreaticojejunal Anastomosis Major modifications of the PJ have also been advocated to reduce anastomotic fistula: • Sutureless pancreatic duct-to-mucosa technique (Hall et al, 1990), • The use of two Roux loops (Kingnorth et al, 1993), • The implantation into a jejunal pouch: • U-shaped pouch (Asopa et al, 2002), • J-shaped pouch (Muftuoglu and Saglam, 2003), • Binding-PJ (Peng et al, 2003).

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

19. Pancreaticogastrostomy Advantages: • Theoretically: PG is not exposed to activated proteolytic enzymes due to low pH and lack of enterokinase. • Practically: • easy to perform, • easily decompressed by a nasogastric tube and assessed by Endoscopy, • ensures a reduction in the number of anastomoses.

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

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

22. (2) Biliary-enteric anastomosis • The second step in reconstruction, • Designed as far 'down stream' from PJ, as a distance not exceeding 12 cm, • May be either: • Choledochojejunostomy, • Hepaticojejunostomy. • Performed in one-layer, mucosa-to-mucosa anastomosis.

23. (2) Biliary-enteric anastomosis

24. (2) Biliary-enteric anastomosis • Technichal alternatives (In case when the bile duct is not dilated) • Cholecystojejunostomy, • Side-to-side anastomosis of the cystic duct with the CHD, and the resulting common orifice is anastomosed with the jejunum. • Stenting the Hepatojejunal anastomosis: • Controversial issue. • Can be achieved via: • Transhepatic stent, • T-tube choledochotomy, • Transjejunal tube exteriorized to the outside.

25. (3) Gastro-or Duodenojejunostomy • This is the final anastomosis, 50 cm distal to the biliodigestive anastomosis, • Performed as partial, two-layer, end-to-side antecolic gastrojejunostomy • Gastrointestinal fistula due to dehiscence of the gastrojejunostomy is rare.

26. (4)Vascular Reconstruction May be confronted in certain situations: • Congenital vascular anomalies, • Arteriosclerotic vascular stenosis or occlusion, • Vascular infiltration or compression by the tumor, • Iatrogenic vascular injuries. Extended pancreatic resections with venous reconstruction are feasible and may render patients free of gross tumor (Harrison et al, 2003).

27. Vascular Reconstruction In case of portal vein resection (due to tumor infiltration or iatrogenic injury), Reconstruction can be done in several ways according to the segment of vein infiltrated/resected. Reconstructive techniques of the PV: • Direct sutures (small defects), • Tangential excision with direct closure, • Tension-free end-to-end anastomosis, • Interposition reconstruction, • Mesocaval shunt.

28. Pylorus-Preserving Pancreaticoduodenectomy (PPPD) First described by Traverso and Longmire in 1978, • The antrum, the pylorus, and the first part of the duodenum are preserved, • Has the advantage of reducing postoperative morbidity without compromising adequate radicality, • Associated with a significant reduction of the operation time, the intraoperative blood loss and the consequent need for blood transfusion

29. Pylorus-Preserving Pancreaticoduodenectomy (PPPD) • Preserves the secretion of GIT hormones (gastrin, secretin, CCK)……better nutritional status, • The GIT hormones have also a trophic effect on the mucosa of the GIT and pancreas, • Protects against gastric dumping, marginal ulceration and bile-reflux gastritis.

30. Pylorus-Preserving Pancreaticoduodenectomy (PPPD) Common postoperative complications after PPPD include: • Delayed gastric emptying (12-32%), • Anastomotic ulceration (2-11%). In a recent meta-analysis study, the morbidity and mortality are similar for PPPD and standard PD (Stojadinovic et al, 2003).

31. Pancreaticointestinal Fistula • The second leading cause of morbidity after PD (proceeded by delayed gastric emptying), • Occurs in 2-24% of patients after Pancreaticoenteric anastomosis. • The major cause of postoperative mortality (20-40%), due to consequent sepsis and hemorrhage. • Defined as the drainage of > 50 ml of amylase-rich fluid per day from intraabdominal drains, on or after the 10th postoperative day.

32. Pancreaticointestinal Fistula Diagnosis: • Recognized between the 3rd and 7th postoperative day, • Drainage output increases and takes on a brownish-black color, • Signs of sepsis: tachycardia, fever, oliguria, restlessness, and abdominal tenderness.

33. Pancreaticointestinal Fistula Management: • Should be individualized, • Conservative treatment (in the absence of peritonitis, sepsis or hemorrhage), • Surgical intervention (in the presence of major complication or uncontrollable fistula) • Early 'completion pancreatectomy' before sepsis occurs…..50% of patients can be salvaged.

34. Pancreaticointestinal Fistula Octreotide treatment: • Its therapeutic value for established pancreatic fistula is not clear (conflicting data) (Sancho et al, 1995). • Its prophylactic value is also controversial: • Four European studies…..positive results (reduced overall complication rates), • Two American studies……no prophylactic benefit with increased hospital costs. • Therefore, its administration should be used selectively in patients with soft pancreatic remnant and non-dilated pancreatic ducts (Andren-Sandberg et al, 2000)

35. Conclusions (1) • Pancreaticoduodenectomy can nowadays be performed with low operative mortality (0-5%), but postoperative complications are still a common problem (30-40%). • With a proper surgical technique, devastating postoperative complications such as leakage of the pancreaticointestinal anastomosis and hemorrhage can be avoided.

36. Conclusions (2) • Numerous reconstructive methods have been suggested in the literature aiming to reduce the rates of fistulation, but none is perfect. • All these technical issues will remain controversial until prospective randomized studies become available. • The only available prospective randomized study (Yeo et al, 1995) reported no difference between PJ and PG for restoration of GIT continuity after PD

37. Conclusions (3) • Many risk factors have been reported to predispose to pancreatic leakage after PD. • Most frequently reported are: • The texture of pancreatic parenchyma, • The number of patients per surgeon. • Therefore, a standardized technique and delicate handling of the pancreatic remnant minimize the incidence of leakage.

38. In high through-put specialist centers, PD can be performed safely with low perioperative mortality and morbidity. The prophylactic administration of octreotide is still controversial. However, the technical skill and judgment of the surgeon is still more important than any pharmacological treatment; bad operations cannot be redeemed by octreotide. For cost-benefit issues, the prophylactic administration of octreotide should not be on routine basis, but for selective situations (e.g. soft pancreatic remnant). Conclusions (4)

39. Thank You