Anatomy-Specific Pancreatic Stump Management to Reduce the Risk of Pancreatic Fistula After Pancreatic Head Resection.

BACKGROUND: The anatomical status of the pancreatic remnant after a pancreatic head resection varies greatly among patients. The aim of the present study was to improve management of the pancreatic remnant for reducing pancreatic fistula after pancreatic head resection. METHODS: Ninety-five consecutive patients who underwent an end-to-side, duct-to-mucosa pancreaticojejunostomy after pancreatic head resection were included in the study. To approximate the pancreatic stump to the jejunum, the transfixing and interrupted suture techniques were used in 51 and 44 patients, respectively. We modified the interrupted suture technique according to the anatomical status of the pancreatic remnant, i.e., the shape of the pancreatic stump and the location of the pancreatic duct. RESULTS: There was no operative mortality in this study. Overall, 14 patients (15%) developed a clinically relevant pancreatic fistula. Certain anatomical features, including a small pancreatic duct, a soft, nonfibrotic pancreatic gland, and a pancreatic duct adjacent to the posterior cut edge, were significantly associated with pancreatic fistula. The fistula rate in the interrupted suture group was 7%, lower than that (22%) in the transfixing suture group (P = 0.036), and it was not influenced by pancreatic anatomy. Multivariate analysis identified a nonfibrotic pancreas (versus fibrotic pancreas; odds ratio [OR] 12.58, 95% CI 1.2-23.9; P = 0.001), a soft pancreas (versus hard pancreas; OR 4.67, CI 1.2-51.1; P = 0.006), and the transfixing suture technique (versus interrupted suture technique; OR 9.91, CI 1.7-57.5; P = 0.003) as significant predictors of clinically relevant pancreatic fistula. CONCLUSIONS: Pancreatic anastomosis modified according to the pancreatic anatomy is effective in reducing the risk of pancreatic fistula formation with end-to-side, duct-to-mucosa pancreaticojejunostomy after pancreatic head resection

Development of a novel rat model with pancreatic fistula and the prevention of this complication using tissue-engineered myoblast sheets

Background: Pancreatic fistula (PF) is one of the most important complications of pancreatic surgery. The aims of this study were to establish a PF model in rats and to investigate the efficacy of our new method for preventing PF, which utilizes myoblast sheets made using tissue engineering techniques. Methods: To establish a PF model, the rats underwent transection of each of four pancreatic ducts: the gastric, duodenal, common, and splenic ducts, respectively. Their ascitic amylase and lipase levels were then measured. To investigate the efficacy of myoblast sheets at preventing PF, a myoblast sheet was attached to the pancreatic stump in the PF models. The levels of amylase and lipase in both serum and ascites were then measured, and surgical specimens were investigated pathologically. Results: The new PF model established by transecting the splenic duct in rats may prove very useful. There were no significant differences in serum amylase and lipase levels between the myoblast sheet (+) group and the sheet (-) group. However, there were significant differences in ascitic amylase and lipase levels between the two groups (p < 0.05). Among the pathological findings, the number of inflammatory cells in the myoblast sheet group was smaller than that in the control group. In addition, the presence of the myoblast sheets on the surface of the pancreatic stump was confirmed by immunofluorescence staining. Conclusion: Our data demonstrate the efficacy of the new rat model of PF presented herein, and that it might be possible to prevent PF using myoblast sheets