ObjectiveThis meta-analysis aimed to systematically evaluate the feasibility and the safety of total laparoscopic pancreatoduodenectomy (TLPD) by comparing it with open pancreatoduodenectomy (OPD).MethodsWe searched the relative domestic and international data bases systematically, such as the Cochrane Library, Medline Database, SCI, CBM, VIP-data, CNKI-data, and WanFang Data. We selected case control studies or cohort studies, and used the Review Manager 5.3 to perform statistical analysis.ResultsIn total, thirteen single-center retrospective case-control studies were included, totally 808 patients involved, and there were 401 cases in the TLPD group and 407 cases in the OPD group. There were no significant difference in terms of the cumulative morbidity, incidence of the Clavien Ⅲ-Ⅴ complication, pancreatic fistula, B/C pancreatic fistula, biliary fistula, postoperative hemorrhage, pulmonary infection, and gastric emptying delay, as well as the ratio of secondary operation, mortality of perioperative period, the ration of R0 resection, and the number of lymph nodes dissected between the 2 groups (P>0.05). Although the operative time was significant longer, TLPD had significant superiority in terms of the amount of bleeding and blood transfusion during operation, the hospital stays after operation, the bowel function recovery time, the time to restart eating, and the time to reactivate (P<0.05).ConclusionIn terms of the relative complications and the parameters of oncology such as the ration of R0 resection, the number of lymph nodes dissected, both of the procedures are safe and feasible, while TLPD is more favorable to control operative bleeding and accelerate rehabilitation.
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 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 investigate the clinical effect of “Double R” pancreatojejunostomy in laparoscopic pancreaticoduodenectomy (LPD).MethodsThe clinical data of 20 patients underwent “Double R” pancreaticojejunostomy in the LPD from November 2018 to December 2019 in this hospital were collected retrospectively. The duration of pancreaticojejunostomy, incidence of postoperative pancreatic fistula, incidence of other complications, mortality, length of stay, and other clinical outcomes were analyzed.ResultsThere were 5 males and 6 females. The age was (56±10) years old. The body mass index was (22.6±4.4) kg/m2. The LPDs were successfully performed in all 20 patients, no patient transferred to the laparotomy, and no patient died within 30 d. There were 6 patients with papillary adenocarcinoma of the duodenum, 5 patients with adenocarcinoma of the lower part of the common bile duct, 2 patients with adenocarcinoma of the pancreatic duct, 3 patients with serous cystadenoma of the pancreatic head, 2 patients with intraductal papillary myxoma of the main pancreatic duct of the pancreatic head, 1 patient with duodenal adenoma with high grade intraepithelial neoplasia, 1 patient with metastatic renal clear cell carcinoma of the pancreatic head, 5 patients with soft pancreas, 12 patients with medium texture, 3 patients with hard texture. The diameter of distal pancreatic duct was (2.1±1.7) mm. The operative time was (380±69) min, the duration of pancreaticojejunostomy was (29±15) min, the intraoperative blood loss was (180±150) mL, the postoperative time of anal exhaust (2.2±0.8) d, postoperative time of fluid intake (3.5±1.1) d, postoperative time of half fluid intake (5.5±0.7) d, postoperative time of hospitalization (14±10) d. There were 3 complications in 2 patients, one of which suffered the pulmonary infection, the other suffered the delayed gastric emptying and gastrointestinal anastomosis bleeding, no bile leakage and abdominal hemorrhage happened. There were 2 cases of pancreatic fistula after the operation, all of them were biochemical pancreatic fistula.Conclusions“Double R” pancreaticojejunostomy method has some advantages of convenient operation, short operation time, and low incidence of pancreatic fistula. However, due to the limited sample size, its safety and feasibility still need to be verified by larger samples and more institutions.
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.
Objective To investigate the effect of common iliac vein allograft replacing the portal vein-superior mesenteric vein transition area invaded by pancreatic cancer. Methods The clinical data of a patient with pancreatic cancer admitted to the Beijing Tsinghua Changgung Hospital in December 2021 who underwent pancreaticoduodenectomy combined with common iliac vein allograft replacing the junction of portal vein, superior mesenteric vein and splenic vein were analyzed retrospectively. The patient was a 77-year-old man who complained of “epigastric pain for 1 month and pancreatic mass was found for 1 week”. After admission, the patient was diagnosed with pancreatic cancer through inspection, and then the surgery was required. Preoperative examination and intraoperative exploration confirmed that the junction of portal vein, superior mesenteric vein, and spleen vein was invaded by tumor. In addition, the length of the invaded vessels measured by preoperative 3D reconstruction image was 5.5 cm, and the distance between the broken end of portal vein and the broken end of superior mesenteric vein measured was 4.5 cm during the operation. After tumor and vessels were resected, vascular anastomosis could not be performed directly. After accurate evaluation, pancreaticoduodenectomy combined with common iliac vein allograft replacing the junction of portal vein, superior mesenteric vein and splenic vein was performed. The operative time was 11 h, and the intraoperative blood loss was 400 mL. After the operation, the routine treatment was performed in ICU and was transferred to the general ward on the 7th day. Postoperative laboratory tests were performed to monitor liver function changes routinely, and imaging examination were was performed to monitor portal venous system blood flow. Results Postoperative complications such as biliary fistula, pancreatic fistula, hemorrhage, infection and thrombosis were not occurred. Postoperative pathological diagnosis: pancreatic ductal adenocarcinoma, medium-low differentiation. Enhanced CT reexamination on the 2nd and 13th day after the operation showed that the blood flow at the junction of portal vein, superior mesenteric vein and splenic vein of the common iliac vein allograft was unobstructed, and there was no stenosis or thrombosis at each anastomosis. Conclusions The application of common iliac vein allograft replacing the portal vein-superior mesenteric vein transition area invaded by pancreatic cancer is safe and feasible. The short-term efficacy is satisfactory, and long-term prognosis remains to be further observed.
ObjectiveTo explore the safety and feasibility of the uncinate-process-first superior mesenteric artery (SMA) right posterior approach in laparoscopic pancreaticoduodenectomy (LPD). MethodsThe clinical data of 5 patients admitted to the Second Affiliated Hospital of Chongqing Medical University from December 2022 to May 2023 were retrospectively analyzed, all patients underwent uncinate-process-first SMA right posterior approach during LPD. ResultsAll 5 cases of LPD with uncinate-process-first SMA right posterior approach were successfully completed. The operative time was (366±51) min, the intraoperative blood loss was (140±42) mL, and the postoperative hospital stay was (11±2) days. All the postoperative pathological findings reached R0 resection. None of the 5 patients suffered from biliary leakage, bleeding, or gastrointestinal empties, and 2 patients suffered from biochemical fistula, the postoperative follow-up time was (7±2) months, and there was no recurrence during the follow-up period. ConclusionThe uncinate-process-first SMA right posterior approach is a safe and feasible surgical approach, especially for tumors with no obvious vascular invasion and diameter ≤2 cm.
Objective To summarize preliminary experience of laparoscopic pancreaticoduodenectomy for periampullary carcinoma. Method The clinical data of patients with periampullary carcinoma underwent laparoscopic pancreaticoduodenectomy from July 2016 to September 2016 in the Shengjing Hospital of China Medical University were analyzed retrospectively. Results Two patients underwent complete laparoscopic pancreaticoduodenectomy, 2 patients underwent laparoscopic resection and anastomosis assisted with small incision open. The R0 resection and duct to mucosa pancreaticojejunal anastomosis were performed in all the patients. The operative time was 510–600 min, intraoperative blood loss was 400–600 mL, postoperative hospitalization time was 15–21d, postoperative ambulation time was 6–7 d. Three cases of pancreatic fistula were grade A and all were cured by conservation. No postoperative bleeding, delayed gastric emptying, intra-abdominal infection, and bile leakage occurred. The postoperative pathological results showed that there was 1 case of pancreatic head ductal adenocarcinoma, 1 case of cyst adenocarcinoma of pancreas uncinate process, 1 case of papillary carcinoma of duodenum, and 1 case of terminal bile duct carcinoma. Conclusion The preliminary results of limited cases in this study show that laparoscopic pancreaticoduodenectomy has been proven to be a safe procedure, it could reduce perioperative cardiopulmonary complications, its exhaust time, feeding time, and postoperative ambulation time are shorter, but its operative complications could not be reduced.
ObjectiveTo summarize of clinical application and progress of duodenum-preserving pancreatic head resection (DPPHR).MethodThe relevant literatures published recently at domestic and abroad about the clinical application and progress of DPPHR were collected and reviewed.ResultsFor the benign lesions, low-grade malignancies and borderline tumors of the head of pancreas, the DPPHR could achieve the same expected therapeutic effect as the classical pancreatoduodenectomy. The DPPHR could reserve the continuity of stomach and duodenum while resecting lesions and improve the symptoms of patients, reduce the reconstruction of digestive tract and the resection of pancreas and surrounding tissues as much as possible, and retain the pancreas-intestinal axis, which was more in line with the physiology of human beings.ConclusionsAt present, DPPHR is worthy of further development and promotion in department of pancreas surgery, but current studies only focus on occurrence of short-term complications after operation. Because patients with benign diseases of pancreatic head have better prognosis and longer survival time after operation, we should pay attention to the long-term complications such as diarrhea, anemia and reflux cholangitis. More clinical studies need in future to be demonstrated superiority of DPPHR in clinical efficacy and to evaluate occurrence of long-term complications and their impact on quality of life of patients with DPPHR by comprehensive analysis of multiple evaluation indicators.
ObjectiveTo summarize the current status and update of the use of medical imaging in risk prediction of pancreatic fistula following pancreaticoduodenectomy (PD).MethodA systematic review was performed based on recent literatures regarding the radiological risk factors and risk prediction of pancreatic fistula following PD.ResultsThe risk prediction of pancreatic fistula following PD included preoperative, intraoperative, and postoperative aspects. Visceral obesity was the independent risk factor for clinically relevant postoperative pancreatic fistula (CR-POPF). Radiographically determined sarcopenia had no significant predictive value on CR-POPF. Smaller pancreatic duct diameter and softer pancreatic texture were associated with higher incidence of pancreatic fistula. Besides the surgeons’ subjective intraoperative perception, quantitative assessment of the pancreatic texture based on medical imaging had been reported as well. In addition, the postoperative laboratory results such as drain amylase and serum lipase level on postoperative day 1 could also be used for the evaluation of the risk of pancreatic fistula.ConclusionsRisk prediction of pancreatic fistula following PD has considerable clinical significance, it leads to early identification and early intervention of the risk factors for pancreatic fistula. Medical imaging plays an important role in this field. Results from relevant studies could be used to optimize individualized perioperative management of patients undergoing PD.