pancreaticojejunostomy vs. pancreaticogastrostomy after pancreaticoduodenectomy

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pancreaticojejunostomy vs. pancreaticogastrostomy
after pancreaticoduodenectomy

• Ri b86401095 ???

Reference J. of clinical gastroenterology 2001
31(3)11-8 World J of Surg. 2001 25567-71 World
J of Surg. 2000 2486-91 Annals of Surgery. 1995
222(4)580-8.
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Trend of Whipple mortality

• Before 1980 5-y survival 5-6
• After 1980 op mortality rate lt5

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Whipple better prognostic factors

• Small tumor lt2cm
• Histologically negative surgical margins
• Negative locoregional lymph nodes
• No vessel invasion of the tumor
• More experienced surgeon
• gt40 5-year survival rate

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pancreaticojejunostomy

• The pancreatic remnant is invaginated into
  jejunum to prevent leakage in an end-to-end
  fashion

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Complications of Whipple 40-50
Sabiston 16th edition 2001
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Leading complications

• Delayed gastric emptying
• Healing failure of pancreatic anastomosis
• Incidence 10-20
• ? pancreatic fistula formation
• ? intra-abdominal abscess
• ? hemorrhage
• ? wound infection
• Mortality rate 40-50
• Account for gt50 of post-Whipple mortality
• Somatostatin limited use

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Ways to prevent pancreatic leakage
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pancreaticogastrostomy

• Pylorus-preserving operation
• Hemigastrectomy

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pancreaticogastrostomy

• Direct visualization with anterior gastrostomy
• Posterior approach from outside

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Advantages of pancreaticogastrostomy
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Other statistical data of PG (1) 16.5
complication rate

• Loyola medical center 102 consecutive PG
  1986-1998

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Other statistical data of PG (2)

• Pancreatic leak rate after PG 0-14
• John Hopkins the only randomized prospective
  study
• 1993-1995, 145 patients
• Pancreatic leak rate 11.7
• No significant difference between PG PJ
• Univariable logistic regression ampullary or
  duodenal disease, surgical volume, pancreatic
  texture, operation time, and intraoperative red
  blood cell transfusions,

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Physiologic studies of Whipple

• After Whipple, gt50 of exocrine gland are
  resected, gt20 of patients will experience
  increased fecal fat and weight loss in 1 year.
• Measure chemotrypsin activity with
  N-benzoyl-L-tyrosyl-p-amiobenzoic acid and PABA
• Pre-operative significantly depressed
• Post-op slowly recovery of function
• 1 year post-op normalizing
• Excellent residual exocrine activity
• Importance of ductal drainage

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Physiologic studies of PG

• Animal study
• Mild increase in basal gastric pH
• No change in
• Maximal gastric output
• Gastrin, secretin secretion
• Gastric pH response to gastrin, secretin
• Pre- post-prandial hormone level and pH
• Neurohormonal relationship between stomach,
  pancreas, duodenum is maintained

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Physiologic studies of PG human study 3 y after
WhipplePG

• Normal circadian rhythm of gastrin/secretin
• Fasting serum gastrin 93.5/-20.3 73.9/-8.2
• Fasting serum secretin 84.1/-6.4 73.6/-5.0
• Basal gastric pH still lt3
• Amylase, lipase, chemotrypsin activity are
  present in the stomach when pHgt3
• Amylase, lipase, chemotrypsin are normally
  activated in the small intestine
• Decreased amylase, lipase, chemotrypsin level in
  stool
• Normal 882/-234
• PG 151/-20
• PJ 136/-25
• Chronic pancreatitis 58

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Physiologic studies of PG
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Physiologic studies of PG
Gastric pH 24 hours study
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Physiologic studies of PG GI motility

• No post-op patients have normal jejunal motility
  pattern during the fasted or fed status.
• PG did yield a more normal-like tracing
• Timing of arrivals of biliary and pancreatic
  secretions?

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Conclusion

• PG is better, or at least not worse than PJ
• Complications
• Pancreatic leakage
• There are no untoward physiologic effects of
  invaginating the pancreatic stump into the
  stomach, specifically in relation to gastric pH,
  pancreatic enzyme activity, and GI motility.