Objective To investigate the effect of sarcopenia on postoperative complications in patients undergoing pancreaticoduodenectomy（PD）. Methods The data of 225 patients who underwent pancreaticoduodenectomy in the Nanjing Hospital Affiliated to Nanjing Medical University (Nanjing First Hospital) from March 2012 to February 2020 were retrospectively analyzed. The total area of the skeletal muscle was measured by CT images at the level of the third lumbar vertebra for the diagnosis of sarcopenia. The patients were divided into sarcopenia group and non-sarcopenia group. The clinical data and surgical complications were compared between the two groups to explore the relationship between sarcopenia and postoperative complications. Results Compared with the non-sarcopenia group, the patients in the sarcopenia group were older and had lower hemoglobin concentration, lower serum albumin concentration, and higher total bilirubin levels (P<0.05). The incidences of clinically relevant pancreatic fistula (grade B and C fistula), pulmonary infection, atelectasis and hypoxemia in the sarcopenia group were significantly higher than those in the non-sarcopenia group (P<0.05). The length of ICU stay and perioperative mortality in the sarcopenia group were significantly higher than those in the non-sarcopenia group (P<0.05). Multivariate analysis showed that sarcopenia, preoperative total bilirubin level, pancreatic duct diameter and pancreatic texture were independent risk factors for clinically relevant pancreatic fistula (P<0.05). Sarcopenia, intraoperative blood loss and postoperative abdominal infection were independent risk factors for pulmonary complications after PD (P<0.05). Conclusions Sarcopenia is an independent risk factor for increased incidence of clinically relevant pancreatic fistula and pulmonary complications after PD. Strengthening perioperative nutritional therapy and rehabilitation exercise in patients with sarcopenia is of great significance to reduce postoperative complications of PD.
ObjectiveTo compare surgical safety and postoperative efficacy of total mesopancreas excision (TMpE) with pancreaticoduodenectomy (PD) and standard PD (Whipple).MethodsA total of 123 patients underwent PD in the Affiliated Hospital of Southwest Medical University from August 2013 to December 2017 were included, including 47 patients with pancreatic head carcinoma and 76 patients with periampullary carcinoma, then were divided into a TMpE group and a Whipple group respectively. The operative time, intraoperative blood loss, postoperative hospitalization time, postoperative recovery time of gastrointestinal function, postoperative complications, and postoperative survival of patients with the same site between the Whipple group and the TMpE group were retrospectively compared.Results① There were no significant differences in the baseline data between the TMpE group and the Whipple group in the pancreatic head carcinoma and periampullary carcinoma (P>0.05). ② For the patients with pancreatic head carcinoma, there were no significant differences in the operative time, postoperative hospitalization time, and postoperative gastrointestinal function recovery time between the TMpE group and the Whipple group (P>0.05), but the intraoperative blood loss in the TMpE group was significantly higher than that in the Whipple group (P=0.038); For the patients with periampullary carcinoma, the above indexes had no significant differences between the TMpE group and the Whipple group (P>0.05). ③ The total incidence of complications in the TMpE group was significantly higher than that in the Whipple group for the patients with pancreatic head carcinoma (χ2=6.595, P=0.010), which had no significant difference between the TMpE group and the Whipple group for the patients with periampullary carcinoma (P>0.05). ④ The cumulative survival curve in the TMpE group was better than that in the Whipple group for the patients with pancreatic head carcinoma (χ2=9.597, P=0.002), which had no significant difference between the TMpE group and the Whipple group for the patients with periampullary carcinoma (χ2=0.844, P=0.358).ConclusionsFor patients with pancreatic head cancer, comparing with standard Whipple, although TMpE PD increases intraoperative blood loss and overall incidence of complications, it could significantly improve long-term survival and there are no significant differences in postoperative recovery time and operative safety between Whipple and TMpE; For patients with periampullary carcinoma, there are no significant differences in surgical safety, long-term survival rate, and survival time between TMpE and Whipple.
ObjectiveTo systematically evaluate the effect of different enteral nutrition timing on patients with pancreaticoduodenectomy.MethodsPubMed, Embase, The Cochrane Library, Web of Science, CBM, CNKI, WanFang Data, and VIP databases were searched to collect RCTs for nutritional support in pancreaticoduodenectomy patients. The search time was established until March 1 2019. After two independent investigators conducted literature screening, data extraction, and evaluation of the risk of bias in the included studies, a meta-metabolic analysis was performed using the R 3.5.3 software gemtc package, JAGS 3.4.0, and Revman software.ResultsA total of 8 RCTs were included, for a total of 825 patients. The results of reticular meta-analysis showed that there was no significant difference in the duration of hospitalization for patients with pancreaticoduodenectomy, between the enteral nutrition supported at different timing. The results of the ranking probability map suggested that preoperative enteral nutrition was a better option for supporting nutrition in patients with pancreaticoduodenectomy, secondly, timing to give was 24–48 hours after operation.ConclusionsAccording to the results of mesh meta-analysis and probabilistic ranking, the nutritional status of patients is corrected before surgery, and the effect of enteral nutrition is better than other nutritional support methods. Secondly, enteral nutrition should be given at 24–48 hours after operation in combination with ESPEN and ERAS recommendations.
ObjectiveTo understand the adverse effects of perioperative red blood cells (RBC) transfusion on patients after pancreaticoduodenectomy (PD) so as to provide ideas for reducing postoperative complications and improving prognosis. MethodThe relevant literatures at home and abroad in recent years about studies of perioperative RBC transfusion on postoperative complications (focusing on pancreatic fistula and infection) and prognosis of patients with PD were reviewed. ResultsThe rates of postoperative complications and perioperative RBC transfusion after PD were still higher. The perioperative RBC transfusion might increase the rate of postoperative complications, promote early tumor recurrence, and shorten the disease-free survival and overall survival. At present, with the progress of technology, the perioperative RBC transfusion rate was decreasing. At the same time, with the accelerated development of new blood transfusion technologies such as freeze-drying and refrigeration, the decline rate was still expected to be increased. ConclusionsPerioperative RBC transfusion in PD might have adverse effects on postoperative complications and prognosis. Although further research is still needed to explore its necessary connection, this adverse effect needs to be paid enough attention in clinical practice. Early identification of risk factors, strict transfusion indications and minimizing amount or concentration of RBC transfusion might help to avoid or reduce RBC transfusion and minimize its adverse effects.
ObjectiveTo compare the effectiveness of antecolic duodenojejunostomy (ADJ) and retrocolic duodenojejunostomy (RDJ) after pylorus-preserving pancreaticoduodenectomy (PPPD). MethodsRandomized controlled trials (RCTs) of ADJ versus RDJ after PPPD were searched in Cochrane Library, PubMed database, Embase database, Web of Science, Chinese biomedicine database, CNKI database, VIP database, and Wanfang database from inception to April 2014, as well as Google. After quality assessment of RCTs according to the Cochrane Handbook for Systematic Reviews of Interventions Version, Meta analysis was performed by RevMan 5.1 software. ResultsFour RCTs of 462 patients in total were included in this Meta-analysis. The results of Meta-analysis showed that, there were no significant differences in the operation time (MD=14.02, 95% CI:-41.42-69.46, P=0.62), incidence of postoperative complications (RR=1.09, 95% CI:0.81-1.48, P=0.56), incidence of delayed gastric emptying (RR=0.63, 95% CI:0.31-1.28, P=0.20), incidence of pancreatic fistula (RR=1.13, 95% CI:0.72-1.75, P=0.60), incidence of abdominal abscess (RR=0.92, 95% CI:0.54-1.58, P=0.77), and mortality (RR=0.61, 95% CI:0.24-1.60, P=0.32) between ADJ group and RDJ group. ConclusionsThe effectiveness of ADJ is similar with RDJ after PPPD, so the reconstruction way after PPPD can be routed according to the surgeon's preference.
ObjectiveTo investigate the efficacy of different methods of reducing jaundice in patients with low malignant obstructive jaundice undergoing pancreaticoduodenectomy. Methods A retrospective analysis was performed on the clinicopathological data of patients admitted to the Department of Hepatobiliary Surgery of The Affiliated Hospital of Guizhou Medical University from January 2014 to June 2020 who were considered to have low malignant obstructive jaundice before operation and confirmed by postoperative pathological examination as pancreatic cancer, ampulla cancer, duodenal cancer or carcinoma of the lower segment of the common bile duct. Patients were devide into percutaneous transhepatic cholangial drainage (PTCD) group and endoscopic retrograde biliary drainage (ERBD) group according to preoperative biliary drainage (PBD) methods. In order to reduce selection bias, SPSS propensity matching module was used for propensity score matching analysis. The age, basic diseases (hypertension, diabetes), biochemical indexes, time of reduction of jaundice, total hospitalization time, and postoperative complications of PBD and pancreaticoduodenectomy were compared between the 2 groups. Then, the patients were divided into pancreatic cancer group and non-pancreatic cancer group (including ampulla cancer, duodenal carcinoma and lower common bile duct carcinoma) by tumor type, and compared the effect of two groups of patients receiving different PBD methods. Results A total of 84 patients, 43 males and 41 females, were included in this study, 58 (69.0%) patients with PTCD and 26 (31.0%) patients with ERBD. After PBD the serum total bilirubin, direct bilirubin, γ-glutamyl transferase, and alkaline phosphatase of the PTCD and the ERBD groups patients were lower than before PBD, the differences were statistically significant (P<0.05). Alanine aminotransferase did not change significantly before and after PBD with PTCD (P>0.05), but decreased significantly after PBD with ERBD (P<0.05). Aspartate aminotransferase did not change significantly before and after PBD with ERBD (P>0.05), but decreased significantly after PBD with PTCD(P<0.05). The PBD time and total hospitalization time of the ERBD group were shorter than those of the PTCD group, the differences were statistically significant (P<0.05). The incidences of PBD related complications (cholangitis and pancreatitis) in the ERBD group were higher than those the PTCD group, and the incidence of bleeding in the ERBD group was lower than that the PTCD group, but the differences were not statistically significant (P>0.05). In the patients with pancreatic cancer group, the PBD time by ERBD was shorter than that of the receiving PTCD, the difference was statistically significant (P=0.006). In the non-pancreatic cancer group, the total hospitalization time and PBD time of patients receiving ERBD were shorter than those receiving PTCD, and the differences were statistically significant (P<0.05). In all patients, the median survival time of PTCD group (14 months) was shorter than that in ERBD group (18 months), P=0.002; pancreatic cancer group (12 months) was shorter than non-pancreatic cancer group (16 months), P=0.034; in non-pancreatic cancer group, ERBD group (20 months) was longer than PTCD group (15 months), P=0.008. Conclusions ERBD can shorten the waiting time of operation and hospital stay as compared with PTCD, and has a longer median survival time. It can be used as the first choice for PBD in patients with low malignant obstructive jaundice.
【Abstract】 Objective To investigate the origin, prevention and treatment of postoperative complications and death rate after pancreaticoduodenectomy （PD）. Methods Retrospective study on the clinical materials of complications and death rate was done on 106 cases of PD performed in our hospital during July 1985 to December 2002. Results In this group, 37 cases (34.91%) had postoperative complications, and the incidence rate of severe complications was 19.81% (21/106), the death rate was 10.38% (11/106). Compared between the two groups with preoperative bilirubin gt;342 μmol/L and ≤342 μmol/L, the incidence of total complications increased evidently (P＜0.05), and the bleeding amount，infusion amount and operation time in those with complications or dead ones were evidently higher than those without complications (P＜0.05). Conclusion The safty and resectability of PD has improved evidently in recent years but good skills, careful operation, the experience of the operatior and careful perioperative treatment and nursing are of crucial importance to reduce the complications and death rate.
Objective To explore the feasibility of clinical application of hepatic artery （HA） or proper hepatic artery （PHA） anastomosing with superior mesenteric artery （SMA） and internal iliac vein （IIV） anastomosing with superior mesenteric vein （SMV） or portal vein （PV） in the extended pancreaticoduodenectomy combined with vascular resection．Methods The HA，PHA，SMA， SMV， PV， and IIV were dissected on 20 adult corpses， and the length， thickness，and lumen diameter of blood vessels were measured and compared with the results of multislice spiral CT scan，magnetic resonance angiography，or color Doppler in 25 patients with pancreatic head carcinoma．The extended pancreaticoduodenectomy was carried out on 5 patients of pancreatic head carcinoma with vascular invasion according to the mathcing results，and the reconstructions of HA or PHA with SMA and IIV with SMV or PV were performed．Results According to autopsy，HA-PHA was （5.50±1.50） cm in length，（0.20±0.01） mm in thickness，（5.02±1.32） mm in lumen diameter；and SMA was （4.00±1.00） cm in length，（0.21±0.01） mm in thickness，（6.05±1.06） mm in lumen diameter．The lumen diameter of left IIV，right IIV，and PV or SMV was （11.06±0.16） mm，（11.10±0.13） mm，and （11.56±0.20） mm，respectively．The thickness of left IIV，right IIV，and PV or SMV was （0.10±0.01） mm，（0.10±0.02） mm，and （0.10±0.02） mm，respectively．The multislice spiral CT scan，magnetic resonance angiography，color Doppler，and selective arteriography in vivo showed that the thickness and lumen diameter of HA-PHA and SMA were wider （0.1 mm and 0.3 mm） than those of the autopsy results，and there were no statistic significances （P＞0.05），but the length of HA-PHA was longer （1－2 cm） than that of SMA，and there was statistic significance （P＜0.05）. The survival of 5 patients with extended pancreaticoduodenectomy combined with PHA or SMA and IIV-PV/SMV resection and reconstruction was longer than that of palliative surgery patients or giving-up patients at the same period，and no long-term complications occurred．Conclusions The vascular invasion of pancreatic head carcinoma is not an absolute contraindication of radical pancreaticoduodenectomy．The survival of 5 patients with vascular invasion of pancreatic head carcinoma in this group is prolonged by extended pancreaticoduodenectomy combined with vascular resection and reconstruction as compared with palliative surgery group at the same period．HA，PHA，and IIV are the best autologous vascular alternative materials without more complications． Being familiar with regional anatomy will guide the surgeons in extended pancreaticoduodenectomy.
ObjectiveTo discuss the current status and progress of delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD).MethodThe related researches about DGE after PD in recent year were searched and reviewed.ResultsThe etiology and pathogenesis of DGE had not yet been fully elucidated. There were various risk factors, such as the surgical trauma, advanced age, diabetes, and with other abdominal complications. The pylorus preserving PD didn’t increase the risk of DGE. The pylorus ring resection, anterior colon, Braun anastomosis, and minimally invasive surgery were beneficial for reducing DGE. Although there was no obvious progress in the treatment of DGE at home and abroad, the majority of patients could be cured by the symptomatic conservative treatment.ConclusionsPrevention is a main strategy for DGE after PD. Application of enhanced recovery after surgery might be a key to solve problem in clinical, but further research is needed.
ObjectiveTo analyze the risk factors for pancreatic fistula following pancreaticoduodenectomy. MethodThe clinical data of 150 patients underwent pancreaticoduodenectomy in this hospital from January 2011 to January 2014 were reviewed, and the potential factors for pancreatic fistular were evaluated by both univariate and multivariate analysis. ResultsThe incidence of pancreatic fistula was 12.7% (19/150). Univariate analysis results showed that the age, preoperative high bilirubin level, texture of the remnant pancreas, diameter of wirsung, operative time were associated with pancreatic fistula following pancreaticoduodenectomy (P < 0.05). Multivariate logistic regression analysis results revealed that the texture of the remnant pancreas, diameter of wirsung, and operative time were the inde-pendent risk factors (P < 0.05) for pancreatic fistula following pancreaticoduodenectomy. ConclusionsTexture of the remnant pancreas, diameter of wirsung, operative time are independent risk factors for pancreatic fistula following pancreaticoduodenectomy. Rich experience and skilled surgical procedures could effectively reduce the incidence of pancreatic fistula.