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Reconstruction of a remnant pancreas with duct-to-duct anastomosis after middle pancreatectomy – A case report
Abstracts / Pancreatology 13 (2013) S1–S80
patients with disturbance of the drainage of the pancreatic juice to the duodenum, the anastomosis between the remnant pancreas and the jejunum may be useful to prevent POPF. Keywords: Postoperative pancreatic fistula, Distal pancreatectomy
[P-156]. A prospective randomized comparison between pylorus-preserving and subtotal stomach-preserving pancreatoduodenectomy on postoperative delayed gastric emptying occurrence and long-term nutritional status in patients with periampullary lesions Ippei Matsumoto, Makoto Shinzeki, Sadaki Asari, Tadahiro Goto, Masaki Tanaka, Hironori Yamashita, Jun Ishida, Taku Matsumoto, Taro Okazaki, Kaori Kuramitsu, Motofumi Tanaka, Atsushi Takebe, Masahiro Kido, Tetsuo Ajiki, Takumi Fukumoto, Yonson Ku Division of Hepato-biliary-pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Background/aim: Pylorus-preserving pancreatoduodenectomy (PPPD) has recently been accepted as a standard surgical procedure for periampullary lesions. However, PPPD has been associated with a higher incidence of delayed gastric emptying (DGE). There are few retrospective studies on comparison of DGE between PPPD and subtotal stomach-preserving pancreatoduodenectomy (SSPPD). One RCT report revealed that resection of the pyloric ring reduced the incidence of DGE. However, the differences of long-term results have not studied. We prospectively investigated whether SSPPD could be substituted for PPPD by comparing the levels of postoperative DGE and long-term nutritional status. Methods: One hundred patients with periampullary lesions excluded pancreatic cancer were randomized to receive either PPPD (n¼50) or SSPPD (n¼50). All patients were followed up 3 years after surgery or their recurrence to evaluate the nutritional status for the study. Results: The incidence of DGE was 20 % in PPPD and 12 % in SSPPD (P¼0.414). DEG assessed by the International Study Group of Pancreatic Surgery was classified into grade A (n¼0), B (n¼3), C (n¼7) in PPPD and A (n¼1), B (n¼3), C (n¼2) in SSPPD. There was no significant differences between the two procedures on postoperative serum albumin levels, serum total cholesterol levels, body mass index, and diabetic status during 3 years follow-up period. Conclusions: This study suggested that SSPPD, which is not technically more complicated than PPPD, could be performed with a good outcome in terms of perioperative and long-term nutritional aspects as well as more widely performed PPPD. Keywords: Subtotal stomach-preserving pancreatoduodenectomy, Pylorus-preserving pancreatoduodenectomy, Delayed gastric emptying, Nutritional status
[P-157]. Reconstruction of a remnant pancreas with duct-to-duct anastomosis after middle pancreatectomy – A case report Masayuki Ishii 1, Yasutoshi Kimura 1, Masafumi Imamura 1, Daisuke Kyuno 1, Tomomi Ueki 1, Motonobu Uchiyama 1, Toru Mizuguchi 1, Mitsuhiro Mukaiya 2, Koichi Hirata *1 1 Department of General Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan 2 Department of Surgery, Hakodate Kyokai Hospital, Hakodate, Japan
Background/aim: Reconstruction of a remnant pancreas with a pancreaticoenterostomy has generally been performed after middle pancreatectomy. Pancreaticoenterostomy has a risk of pancreatic fistula at the proximal and distal pancreatic stumps, and it requires surgical manipulation of the digestive tract. We introduced a more physiological reconstructive procedure with pancreatic duct-to-duct anastomosis followed by middle pancreatectomy.
S69
Methods: The reconstructive procedures included pancreatic duct-toduct anastomosis and parenchymal sutures with absorbable monofilament interrupted stitches for non-fibrous and soft pancreas. Interrupted stitches were placed on the up and down sides of the pancreatic duct. Three interrupted stitches were placed each dorsal and ventral side of the pancreatic duct. A pancreatic tube was inserted for decompression at the anastomotic site. These procedures was indicated if, 1) tension-free connection of both cut ends; 2) absence of differences in the diameters between the main pancreatic ducts in both cut ends; and 3) absence of marked differences in the position of the main pancreatic duct in the pancreatic section between both cut ends. Results: The subject comprised a patient with a non-malignant insulinoma located in the pancreatic body, with diameters of 10 mm. The operative time was 352 minutes, and the intraoperative blood loss was 40 mL. Although an ISGPF grade B-pancreatic fistula was observed, it resolved with conservative therapy. The pancreatic duct at the anastomosis site was patent, and no atrophic changes developed in the remnant pancreas in the patient for 9 months. Although pancreatic dust-to-duct anastomosis after middle pancreatectomy is not a common surgical procedure, it has the important benefit of restoration of the normal ductal anatomy while avoiding the additional intestinal resection and reconstruction. Conclusion: Reconstruction of remnant pancreas with pancreatic ductto-duct anastomosis seemed to be feasible and safe for physiological reconstruction without an involvement of the digestive tract in selected case. Keywords: Duct-to-duct anastomosis, Middle pancreatectomy
[P-158]. Adult pancreatic cavernous hemangioma: A case report Takahiro Shibata, Yoichi Matsuo, Shiro Fujihata, Mamoru Morimoto, Yuji Okada, Masahiro Kimura, Hiromitsu Takeyama Gastroenterologocal Surgery, Nagoya City University, Nagoya City, Japan Introduction: Hemangiomas are common in the liver, but are extremely rare in the pancreas. Moreover, few reports describing pancreatic cavernous hemangioma are shown. We report an adult pancreatic cavernous hemangioma with discussion following review of published cases. Case: A 79-yearold-male was introduced to our hospital to receive detailed examination of pancreas, because he had the abnormality of pancreas pointed by medical examination. Contrast CT image showed an 8-millimeter nodule in the body of pancreas, whose contrast effect was almost as strong as arteries. On endoscopic ultrasonography, a low echoic area about 10-millimeter in diameter with abundant blood flow was detected in the body of pancreas. We suspected a pancreatic tumor with abundant blood flow, such as endocrine tumor and paraganglioma. The results of a tumor marker test were as follows: CEA 2.5 ng/mL and CA19-9 16.8 ng/mL. The results of neuroendocrine hormone test were as follows: insulin 49.1 uIU/mL and gastrin 900 pg/mL. Based on these findings, malignant disease of pancreas could not be ruled out, distal pancreatectomy combined with splenectomy was performed. As a result of histopathological examination of the specimen, final diagnosis in this case was a pancreatic cavernous hemangioma. Conclusion: Pancreatic hemangiomas, are very rare and its preoperative diagnosis is very difficult. We report a case of pancreatic cavernous hemangioma, review the relevant literature and discuss diagnostic methods of this rare tumor. Keywords: Pancreas, Cavernous hemangioma
[P-159]. The outcomes following pancreatoduodenectomy with pancreaticogastric anastomosis Hisashi Ikoma, Tatsuro Nishida, Yusuke Yamamoto, Ryou Morimura, Hirotaka Konishi, Yasutoshi Murayama, Syuhei Komatsu, Atsushi Shiozaki, Yoshiaki Kuriu, Takeshi Kubota, Daisuke Ichikawa, Hitoshi Fujiwara, Kazuma Okamoto, Eigo Otsuji
patients with disturbance of the drainage of the pancreatic juice to the duodenum, the anastomosis between the remnant pancreas and the jejunum may be useful to prevent POPF. Keywords: Postoperative pancreatic fistula, Distal pancreatectomy
[P-156]. A prospective randomized comparison between pylorus-preserving and subtotal stomach-preserving pancreatoduodenectomy on postoperative delayed gastric emptying occurrence and long-term nutritional status in patients with periampullary lesions Ippei Matsumoto, Makoto Shinzeki, Sadaki Asari, Tadahiro Goto, Masaki Tanaka, Hironori Yamashita, Jun Ishida, Taku Matsumoto, Taro Okazaki, Kaori Kuramitsu, Motofumi Tanaka, Atsushi Takebe, Masahiro Kido, Tetsuo Ajiki, Takumi Fukumoto, Yonson Ku Division of Hepato-biliary-pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Background/aim: Pylorus-preserving pancreatoduodenectomy (PPPD) has recently been accepted as a standard surgical procedure for periampullary lesions. However, PPPD has been associated with a higher incidence of delayed gastric emptying (DGE). There are few retrospective studies on comparison of DGE between PPPD and subtotal stomach-preserving pancreatoduodenectomy (SSPPD). One RCT report revealed that resection of the pyloric ring reduced the incidence of DGE. However, the differences of long-term results have not studied. We prospectively investigated whether SSPPD could be substituted for PPPD by comparing the levels of postoperative DGE and long-term nutritional status. Methods: One hundred patients with periampullary lesions excluded pancreatic cancer were randomized to receive either PPPD (n¼50) or SSPPD (n¼50). All patients were followed up 3 years after surgery or their recurrence to evaluate the nutritional status for the study. Results: The incidence of DGE was 20 % in PPPD and 12 % in SSPPD (P¼0.414). DEG assessed by the International Study Group of Pancreatic Surgery was classified into grade A (n¼0), B (n¼3), C (n¼7) in PPPD and A (n¼1), B (n¼3), C (n¼2) in SSPPD. There was no significant differences between the two procedures on postoperative serum albumin levels, serum total cholesterol levels, body mass index, and diabetic status during 3 years follow-up period. Conclusions: This study suggested that SSPPD, which is not technically more complicated than PPPD, could be performed with a good outcome in terms of perioperative and long-term nutritional aspects as well as more widely performed PPPD. Keywords: Subtotal stomach-preserving pancreatoduodenectomy, Pylorus-preserving pancreatoduodenectomy, Delayed gastric emptying, Nutritional status
[P-157]. Reconstruction of a remnant pancreas with duct-to-duct anastomosis after middle pancreatectomy – A case report Masayuki Ishii 1, Yasutoshi Kimura 1, Masafumi Imamura 1, Daisuke Kyuno 1, Tomomi Ueki 1, Motonobu Uchiyama 1, Toru Mizuguchi 1, Mitsuhiro Mukaiya 2, Koichi Hirata *1 1 Department of General Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan 2 Department of Surgery, Hakodate Kyokai Hospital, Hakodate, Japan
Background/aim: Reconstruction of a remnant pancreas with a pancreaticoenterostomy has generally been performed after middle pancreatectomy. Pancreaticoenterostomy has a risk of pancreatic fistula at the proximal and distal pancreatic stumps, and it requires surgical manipulation of the digestive tract. We introduced a more physiological reconstructive procedure with pancreatic duct-to-duct anastomosis followed by middle pancreatectomy.
S69
Methods: The reconstructive procedures included pancreatic duct-toduct anastomosis and parenchymal sutures with absorbable monofilament interrupted stitches for non-fibrous and soft pancreas. Interrupted stitches were placed on the up and down sides of the pancreatic duct. Three interrupted stitches were placed each dorsal and ventral side of the pancreatic duct. A pancreatic tube was inserted for decompression at the anastomotic site. These procedures was indicated if, 1) tension-free connection of both cut ends; 2) absence of differences in the diameters between the main pancreatic ducts in both cut ends; and 3) absence of marked differences in the position of the main pancreatic duct in the pancreatic section between both cut ends. Results: The subject comprised a patient with a non-malignant insulinoma located in the pancreatic body, with diameters of 10 mm. The operative time was 352 minutes, and the intraoperative blood loss was 40 mL. Although an ISGPF grade B-pancreatic fistula was observed, it resolved with conservative therapy. The pancreatic duct at the anastomosis site was patent, and no atrophic changes developed in the remnant pancreas in the patient for 9 months. Although pancreatic dust-to-duct anastomosis after middle pancreatectomy is not a common surgical procedure, it has the important benefit of restoration of the normal ductal anatomy while avoiding the additional intestinal resection and reconstruction. Conclusion: Reconstruction of remnant pancreas with pancreatic ductto-duct anastomosis seemed to be feasible and safe for physiological reconstruction without an involvement of the digestive tract in selected case. Keywords: Duct-to-duct anastomosis, Middle pancreatectomy
[P-158]. Adult pancreatic cavernous hemangioma: A case report Takahiro Shibata, Yoichi Matsuo, Shiro Fujihata, Mamoru Morimoto, Yuji Okada, Masahiro Kimura, Hiromitsu Takeyama Gastroenterologocal Surgery, Nagoya City University, Nagoya City, Japan Introduction: Hemangiomas are common in the liver, but are extremely rare in the pancreas. Moreover, few reports describing pancreatic cavernous hemangioma are shown. We report an adult pancreatic cavernous hemangioma with discussion following review of published cases. Case: A 79-yearold-male was introduced to our hospital to receive detailed examination of pancreas, because he had the abnormality of pancreas pointed by medical examination. Contrast CT image showed an 8-millimeter nodule in the body of pancreas, whose contrast effect was almost as strong as arteries. On endoscopic ultrasonography, a low echoic area about 10-millimeter in diameter with abundant blood flow was detected in the body of pancreas. We suspected a pancreatic tumor with abundant blood flow, such as endocrine tumor and paraganglioma. The results of a tumor marker test were as follows: CEA 2.5 ng/mL and CA19-9 16.8 ng/mL. The results of neuroendocrine hormone test were as follows: insulin 49.1 uIU/mL and gastrin 900 pg/mL. Based on these findings, malignant disease of pancreas could not be ruled out, distal pancreatectomy combined with splenectomy was performed. As a result of histopathological examination of the specimen, final diagnosis in this case was a pancreatic cavernous hemangioma. Conclusion: Pancreatic hemangiomas, are very rare and its preoperative diagnosis is very difficult. We report a case of pancreatic cavernous hemangioma, review the relevant literature and discuss diagnostic methods of this rare tumor. Keywords: Pancreas, Cavernous hemangioma
[P-159]. The outcomes following pancreatoduodenectomy with pancreaticogastric anastomosis Hisashi Ikoma, Tatsuro Nishida, Yusuke Yamamoto, Ryou Morimura, Hirotaka Konishi, Yasutoshi Murayama, Syuhei Komatsu, Atsushi Shiozaki, Yoshiaki Kuriu, Takeshi Kubota, Daisuke Ichikawa, Hitoshi Fujiwara, Kazuma Okamoto, Eigo Otsuji