INTRODUCTION :
Pancreaticoduodenectomy (PD) is the procedure of choice for
treatment of peri-ampullary and pancreatic head malignancies and was first
described by Allen Whipple et al in the 1930s. Early enthusiasm
concerning the procedure was followed by scepticism because of the
associated high morbidity and mortality rates. However advances in
operative techniques and perioperative patient care have resulted in lower
hospital mortality and longer Survival, making the procedure relatively
safe in expert hands.
AIM : To analyse the results in terms of morbidity and mortality following isolated loop
pancreaticojejunal anastomosis and to look for difference if any between duct to mucosa
versus dunking type of anastomosis.
To evaluate results in terms of morbidity and mortality from isolated loop pancreaticojejunal
anastomosis and compare with results from anastomosis using single jejunal loop and
pancreaticogastrostomy.
MATERIALS AND METHODS :
All patients attending the outpatient department of Surgical Gastroenterology with operable
growth in the periampullary region or head of pancreas were included in the study group. The
data of one hundred and thirty eight patients were collected prospectively. Details tabulated
included demographic characters, preoperative variables , performance status , diagnosis
,type of anastomosis , postoperative morbidity and mortality .Postoperative morbity noted
included delayed gastric emptying , anastomotic leak , hemorrhagic complications ,wound
infection , intraabdominal collection , pneumonitis and urinary tract infection .All patients in
the study underwent a standard whipple’s pancreaticoduodenectomy.
RESULTS :
Of the male and 38% were female patients. The minimum age was 30 and maximum one
hundred and thirty eight patients included in the study 62% were age was 72 with a mean age
of 51.7. The distribution of disease were as follows: periampullary 102[79.68%], pancreatic
15[11.7%], distal CBD 6[6%] and duodenal growth 5[4.6%].Among the complications
delayed gastric emptying occurred in 57[44.53%], haemorrhage in 7[5.4%], pancreatic leak
in 30.46%( grade A-20 [15.6%], grade B-12 [9.3%], and grade C-7[5.4%]), intraabdominal
collection in 15%, wound infection in 22%, pneumonitis in 7%, urinary tract infection in 6%
of patients. The incidence of delayed gastric emptying in the PG group was 38.46% , the
incidence in the PJ group was 40.98% and in the isolated loop pancreaticojejunostomy group
was 44.73%.The incidence of haemorrhage was 7.6% in the PG group, 6.5% in the PJ group
and nil in the isolated PJ group . The incidence of pancreatic anastomotic leak between the
three groups was 33% in the PG , 29.5% in the PJ group and 15.78% in isolated PJ group.
The incidence of intra abdominal collection in the PG group was 7[17.9%], in the PJ group it
was 7 [ 11.4%] and in the isolated PJ group was 5 [13.15%]. The incidence of wound
infection was 20.8% in the PG and 26.9% in the PJ group and 22% in isolated PJ group. The
incidence of pneumonitis in the PG group was 2 [5.1%] compared to 4[6.5%] in the PJ group
and 3[7.8%] in Isolated PJ group. The incidence of urinary tract infection in the PG group
was 1[2.5%] and in the PJ group it was 2[3.2%].and 1 [2.6%] in isolated PJ group. The
mean duration of nasogastric tube removal was 7.5 days in the PG group and 7.8 days in the
PJ group and 7.0 in Isolated PJ group. The mean days of urinary catheter removal was 6.3
days in the PG and 6.7 in the PJ group and 8.0 in isolated PJ group. The mean days of
drainage tube removal was 9.3 days in the PG and 9.9 days in the PJ group and 11 in the
isolated loop PJ group. The mean postoperative hospital stay was 12.6 days in the PG group
and 13.1 days in the PJ group and 11.2 in isolated PJ group. The mortality in the patients who
underwent pancreaticogastrostomy was 5.1% ,in the pancreaticojejunostomy group was 4.9
%and 7.8 %in isolated loop PJ .The overall mortality rate was 5.79%.
DISCUSSION : Among the 138 patients 57 patients developed DGE, 21 patients developed
DGE and pancreatic leak and 15 patients developed other complications along with DGE and
pancreatic leak accounting for a morbidity of 39.28%. 38 % of patients in the PG group and
40.98 % in the PJ and 44.73% group developed DGE. The increase in DGE with isolated
loop was statistically significant (P value=0.052, 0.045).Pancreatic leak occurred in 39
patients with grade A leak in 20(14%), grade B leak in 12(8.6%) and grade C leak in 7(5%)
patients. All patients with pancreatic leak were managed by non-operative means. There was
no statistically significant difference in the incidence of anastomotic leaks among three types
of anastomosis , though isolated loop pancreaticojejunostomy tended to have more type A
leaks .No hemorrhagic complications were seen with isolated loop pancreaticojejunostomy.
There was no significant difference in incidence of other major morbidities. The mortality rate
in our study was5.7 % (5.1% in PG group and 4.9% in PJ grou,7.8% in isolated loop PJ
group) which was not statistically not significant (P value=1.07,1.12) between the three
groups.
CONCLUSION : In comparison to pancreatico gastrostomy or single loop pancreatico
jejunostomy, Isolated loop pancreatico jejunal anastomoses might lead to lower incidence of
higher grade of pancreatic leak .Both dunking and duct to mucosa type anastomoses seem to
have similar incidence of leaks , in all three type of anastomosis .There is no significant
difference in mortality rate between the three types of pancreaticoenteric anastomosis
However, incidence of higher grade leak and anastomotic leak related mortality is lower
with isolated loop anastomosis .Incidence of delayed gastric emptying seems to be higher
and hemorrhagic complications rarer with isolated loop pancreaticojejunal anastomosis
compared to other types of pancreaticoenteric anastomosis
