Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1995 Jun;221(6):635–648. doi: 10.1097/00000658-199506000-00003

Optimal management of the pancreatic remnant after pancreaticoduodenectomy.

S G Marcus 1, H Cohen 1, J H Ranson 1
PMCID: PMC1234686  PMID: 7794068

Abstract

OBJECTIVE: The authors evaluated methods of operative management of the pancreatic remnant after pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Despite reductions in mortality after pancreaticoduodenectomy, leakage from the pancreatic remnant still may cause significant morbidity. Patients with small, unobstructed pancreatic ducts or soft, friable pancreata are at particularly high risk. Although numerous surgical techniques have been described to avoid such complications, no single method is suitable for all patients. METHODS: The authors retrospectively reviewed the medical records of 114 consecutive patients who underwent pancreaticoduodenectomy. Sixty-nine patients were men (61%) and 45 were women (39%), with median age 66 years. Underlying disease was malignant in 87 (76%) and benign in 27 (24%). Patients were divided into groups based on risk for postoperative pancreatic fistula and on the operative management of the pancreatic remnant. Sixty-eight patients underwent end-to-side pancreaticojejunostomy, 13 of whom were high risk (group 1A) and 55 of whom were low risk (group 1B). Thirty-seven patients, all high risk, had either pancreatic duct closure by oversewing (N = 19, group 2) or end-to-end pancreaticojejunal invagination (N = 18, group 3). Nine patients underwent total pancreatectomy (group 4). Morbidity related to prolonged pancreatic drainage (PPD) of greater than 20 days was determined. RESULTS: Overall incidence of PPD was 17% and caused the only death. Patients considered high risk for postoperative pancreatic fistula had a 36% incidence of PPD compared with 2% in patients considered low risk (p < 0.0001). Prolonged pancreatic drainage frequency related to the method of pancreatic remnant management was as follows: group 1A, 15%; group 1B, 2%; group 2, 79%; and group 3, 6% (p < 0.001 for group 2 vs. other groups). No serious sequelae followed PPD in 15 patients (79%); however, 4 patients required reoperation for pseudocyst or abscess drainage; one in group 1A (who died) and three in group 2. Multivariate analysis revealed that operative technique (oversewing of the pancreatic duct) and male sex were significant factors predisposing a patient to the development of PPD. CONCLUSION: After pancreaticoduodenectomy, pancreatic remnant management by end-to-side pancreaticojejunostomy appeared safe in low-risk patients. In high-risk patients, end-to-end pancreaticojejunal invagination was the safest option. Morbidity was greatest after pancreatic duct closure without anastomosis.

Full text

PDF
635

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Aston S. J., Longmire W. P., Jr Management of the pancreas after pancreaticoduodenectomy. Ann Surg. 1974 Mar;179(3):322–327. doi: 10.1097/00000658-197403000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bartoli F. G., Arnone G. B., Ravera G., Bachi V. Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature. Anticancer Res. 1991 Sep-Oct;11(5):1831–1848. [PubMed] [Google Scholar]
  3. Baumel H., Huguier M., Manderscheid J. C., Fabre J. M., Houry S., Fagot H. Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery. Br J Surg. 1994 Jan;81(1):102–107. doi: 10.1002/bjs.1800810138. [DOI] [PubMed] [Google Scholar]
  4. Braasch J. W., Gray B. N. Considerations that lower pancreatoduodenectomy mortality. Am J Surg. 1977 Apr;133(4):480–484. doi: 10.1016/0002-9610(77)90135-0. [DOI] [PubMed] [Google Scholar]
  5. Brooks J. R., Brooks D. C., Levine J. D. Total pancreatectomy for ductal cell carcinoma of the pancreas. An update. Ann Surg. 1989 Apr;209(4):405–410. doi: 10.1097/00000658-198904000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Brooks J. R., Culebras J. M. Cancer of the pancreas. Palliative operation, Whipple procedure, or total pancreatectomy? Am J Surg. 1976 Apr;131(4):516–520. doi: 10.1016/0002-9610(76)90167-7. [DOI] [PubMed] [Google Scholar]
  7. Büchler M., Friess H., Klempa I., Hermanek P., Sulkowski U., Becker H., Schafmayer A., Baca I., Lorenz D., Meister R. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg. 1992 Jan;163(1):125–131. doi: 10.1016/0002-9610(92)90264-r. [DOI] [PubMed] [Google Scholar]
  8. Cameron J. L., Pitt H. A., Yeo C. J., Lillemoe K. D., Kaufman H. S., Coleman J. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg. 1993 May;217(5):430–438. doi: 10.1097/00000658-199305010-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Crist D. W., Sitzmann J. V., Cameron J. L. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg. 1987 Sep;206(3):358–365. doi: 10.1097/00000658-198709000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Cullen J. J., Sarr M. G., Ilstrup D. M. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management. Am J Surg. 1994 Oct;168(4):295–298. doi: 10.1016/s0002-9610(05)80151-5. [DOI] [PubMed] [Google Scholar]
  11. Delcore R., Thomas J. H., Pierce G. E., Hermreck A. S. Pancreatogastrostomy: a safe drainage procedure after pancreatoduodenectomy. Surgery. 1990 Oct;108(4):641–647. [PubMed] [Google Scholar]
  12. Di Carlo V., Chiesa R., Pontiroli A. E., Carlucci M., Staudacher C., Zerbi A., Cristallo M., Braga M., Pozza G. Pancreatoduodenectomy with occlusion of the residual stump by Neoprene injection. World J Surg. 1989 Jan-Feb;13(1):105–111. doi: 10.1007/BF01671167. [DOI] [PubMed] [Google Scholar]
  13. Goldsmith H. S., Ghosh B. C., Huvos A. G. Ligation versus implantation of the pancreatic duct after pancreaticoduodenectomy. Surg Gynecol Obstet. 1971 Jan;132(1):87–92. [PubMed] [Google Scholar]
  14. Grace P. A., Pitt H. A., Tompkins R. K., DenBesten L., Longmire W. P., Jr Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg. 1986 Jan;151(1):141–149. doi: 10.1016/0002-9610(86)90024-3. [DOI] [PubMed] [Google Scholar]
  15. Hannoun L., Christophe M., Ribeiro J., Nordlinger B., Elriwini M., Tiret E., Parc R. A report of forty-four instances of pancreaticoduodenal resection in patients more than seventy years of age. Surg Gynecol Obstet. 1993 Dec;177(6):556–560. [PubMed] [Google Scholar]
  16. Icard P., Dubois F. Pancreaticogastrostomy following pancreatoduodenectomy. Ann Surg. 1988 Mar;207(3):253–256. doi: 10.1097/00000658-198803000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Jordan G. L., Jr Pancreatic resection for pancreatic cancer. Surg Clin North Am. 1989 Jun;69(3):569–597. doi: 10.1016/s0039-6109(16)44836-x. [DOI] [PubMed] [Google Scholar]
  18. Kojima Y., Katayama K., Note M., Shimada H., Nakagawara G. Pancreaticojejunostomy and pancreatic leakage after pancreaticoduodenectomy. Int Surg. 1992 Apr-Jun;77(2):80–83. [PubMed] [Google Scholar]
  19. Lerut J. P., Gianello P. R., Otte J. B., Kestens P. J. Pancreaticoduodenal resection. Surgical experience and evaluation of risk factors in 103 patients. Ann Surg. 1984 Apr;199(4):432–437. doi: 10.1097/00000658-198404000-00010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Matsumoto Y., Fujii H., Miura K., Inoue S., Sekikawa T., Aoyama H., Ohnishi N., Sakai K., Suda K. Successful pancreatojejunal anastomosis for pancreatoduodenectomy. Surg Gynecol Obstet. 1992 Dec;175(6):555–562. [PubMed] [Google Scholar]
  21. Miedema B. W., Sarr M. G., van Heerden J. A., Nagorney D. M., McIlrath D. C., Ilstrup D. Complications following pancreaticoduodenectomy. Current management. Arch Surg. 1992 Aug;127(8):945–950. doi: 10.1001/archsurg.1992.01420080079012. [DOI] [PubMed] [Google Scholar]
  22. Papachristou D. N., Fortner J. G. Pancreatic fistula complicating pancreatectomy for malignant disease. Br J Surg. 1981 Apr;68(4):238–240. doi: 10.1002/bjs.1800680406. [DOI] [PubMed] [Google Scholar]
  23. Roder J. D., Stein H. J., Hüttl W., Siewert J. R. Pylorus-preserving versus standard pancreatico-duodenectomy: an analysis of 110 pancreatic and periampullary carcinomas. Br J Surg. 1992 Feb;79(2):152–155. doi: 10.1002/bjs.1800790219. [DOI] [PubMed] [Google Scholar]
  24. Sarr M. G., Behrns K. E., van Heerden J. A. Total pancreatectomy. An objective analysis of its use in pancreatic cancer. Hepatogastroenterology. 1993 Oct;40(5):418–421. [PubMed] [Google Scholar]
  25. Takao S., Shimazu H., Maenohara S., Shinchi H., Aikou T. Modified pancreaticogastrostomy following pancreaticoduodenectomy. Am J Surg. 1993 Mar;165(3):317–321. doi: 10.1016/s0002-9610(05)80833-5. [DOI] [PubMed] [Google Scholar]
  26. Trede M., Schwall G. The complications of pancreatectomy. Ann Surg. 1988 Jan;207(1):39–47. doi: 10.1097/00000658-198801000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Tsao J. I., Rossi R. L., Lowell J. A. Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation. Arch Surg. 1994 Apr;129(4):405–412. doi: 10.1001/archsurg.1994.01420280081010. [DOI] [PubMed] [Google Scholar]
  28. Wade T. P., Radford D. M., Virgo K. S., Johnson F. E. Complications and outcomes in the treatment of pancreatic adenocarcinoma in the United States veteran. J Am Coll Surg. 1994 Jul;179(1):38–48. [PubMed] [Google Scholar]
  29. Warshaw A. L., Swanson R. S. Pancreatic cancer in 1988. Possibilities and probabilities. Ann Surg. 1988 Nov;208(5):541–553. doi: 10.1097/00000658-198811000-00001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Williams J. A., Cubilla A., Maclean B. J., Fortner J. G. Twenty-two year experience with periampullary carcinoma at Memorial Sloan-Kettering Cancer Center. Am J Surg. 1979 Nov;138(5):662–665. doi: 10.1016/0002-9610(79)90341-6. [DOI] [PubMed] [Google Scholar]
  31. van Heerden J. A., McIlrath D. C., Ilstrup D. M., Weiland L. H. Total pancreatectomy for ductal adenocarcinoma of the pancreas: an update. World J Surg. 1988 Oct;12(5):658–662. doi: 10.1007/BF01655878. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES