Pancreaticojejunostomy after Pancreatic Head Resections
Acta Universitatis Tamperensis, No. 1564
By Mickael Parviainen
Tampere University Press
Distributed by Coronet Books
$77.50 Paper Original
This study addresses early and long-term complications that may be linked to technical problems of pancreaticojejunostomy. Given the importance of the leakage of the pancreaticojejunostomy in increasing postoperative mortality and morbidity, a study was performed in which it was found that biliary leakage usually occurs together with pancreatic leakage. This gave rise to a hypothesis of a possible common aetiologic factor, which may be postoperative pancreatitis.
To investigate the effect of surgeon and hospital volume on postoperative morbidity and mortality, a nation-wide study was performed including 33 Finnish hospitals, where resections of the head of the pancreas (average 2.1 resections per year per hospital) were performed during a five-year period (1990-1994). There were 98 surgeons performing these resections (average 0.7 resections per year per surgeon). Most of the complications that resulted in death were a result of technical problems. Both surgeon and hospital volume affected postoperative morbidity and mortality. To reduce postoperative morbidity, mortality and hospital stay pancreatic head surgery needs to be centralized in fewer hospitals with adequate perioperative care and performed by surgeons professing special interest in pancreatic surgery. Long-term results, however, were related to the nature of the disease.
Given that most patients undergoing resection of the pancreatic head show severe signs of pancreatic insufficiency, a dynamic secretin-stimulated magnetic resonance cholangiopancreatography (D-MRCP) examination was performed to examine whether these symptoms were a result of anastomotic stricture or due to malfunction of the pancreatic gland. This study was performed on 26 patients who 3-76 (median 52) months earlier had undergone pancreaticoduodenectomy with end-to-end invaginated anastomosis, which was the method of choice in the 1990s. All those patients had severe exocrine insufficiency as measured by faecal elastase-1. D-MRCP failed in three patients, but revealed severe glandular malfunction in seven patients (30 %), total obstruction of the pancreaticojejunostomy in five patients (22 %), partial obstruction in six patients (26 %) and an open anastomosis in five patients (22 %), these five patients having the highest faecal elastase-1 values. Better long-term functional results may require better surgical technique.
To study postoperative quality of life in patients who had undergone pancreaticoduodenal resection, 15D, a generic instrument was used which enabled comparison of the results to healthy population. In the early stage (24 months postoperatively), postoperative health-related quality of life was significantly poorer than in general population, but there was no difference in the late stage (110 months postoperatively).
As a possible solution to protect the pancreaticojejunal anastomosis, biodegradable, barium sulphate containing stents were manufactured to be inserted in the pancreatic duct during the operation. The degradability of these stents was followed-up in vitro in different pH and enzyme milieus and the stents were tested in vivo in two pilot patients. Degradation of the stents occurred after 24-52 weeks of incubation. Alkaline milieu together with the presence of pancreatic enzyme degraded the stents twice as fast as when either alkaline milieu or enzymes alone were present. In the milieu resembling pancreatic juice barium sulphate had no effect on the degradation time. Neither of the pilot patients experienced any postoperative complications.
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