Objective The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula. Summary Background Data Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications. Methods Between May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rich fluid on or after postoperative day 10. Results The pancreaticogastrostomy (n = 73) and pancreaticojejunostomy (n = 72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (17/145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatic fistula was associated with a significant prolongation of postoperative hospital stay (36 ± 5 vs. 15 ± 1 days) (p < 0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p < 0.05). A multivariate logistic regression analysis revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the resected specimen. Conclusions Pancreatic fistula is a common complication after pancreaticoduodenectomy, with an incidence most strongly associated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than pancreaticojejunostomy or is associated with a lower incidence of pancreatic fistula.

A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy

OBJECTIVE: A prospective randomized multicenter study was performed to
 assess whether the results of pylorus-preserving pancreaticoduodenectomy
 (PPPD) equal those of the standard Whipple (SW) operation, especially with
 respect to duration of surgery, blood loss, hospital stay, delayed gastric
 emptying (DGE), and survival. SUMMARY BACKGROUND DATA: PPPD has been
 associated with a higher incidence of delayed gastric emptying, resulting
 in a prolonged period of postoperative nasogastric suctioning. Another
 criticism of the pylorus-preserving pancreaticoduodenectomy for patients
 with a malignancy is the radicalness of the resection. On the other hand,
 PPPD might be associated with a shorter operation time and less blood
 loss. METHODS: A prospective randomized multicenter study was performed in
 a nonselected series of 170 consecutive patients. All patients with
 suspicion of pancreatic or periampullary tumor were included and
 randomized for a SW or a PPPD resection. Data concerning patients'
 demographics, intraoperative and histologic findings, as well as
 postoperative mortality, morbidity, and follow-up up to 115 months after
 discharge, were analyzed. RESULTS: There were no significant differences
 noted in age, sex distribution, tumor localization, and staging. There
 were no differences in median blood loss and duration of operation between
 the 2 techniques. DGE was observed equally in the 2 groups. There was only
 a marginal difference in postoperative weight loss in favor of the
 standard Whipple procedure. Overall operative mortality was 5.3%. Tumor
 positive resection margins were found for 12 patients of the SW group and
 19 patients of the PPPD group (P < 0.23). Long-term follow-up showed no
 significant statistical differences in survival between the 2 groups (P <
 0.90). CONCLUSIONS: The SW and PPPD operations were associated with
 comparable operation time, blood loss, hospital stay, mortality,
 morbidity, and incidence of DGE. The overall long-term and disease-free
 survival was comparable in both groups. Both surgical procedures are
 equally effective for the treatment of pancreatic and periampullary
 carcinoma.

https://repub.eur.nl/pub/10365/15492552.pdf

Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors.

Surgical therapy for chronic pancreatitis is reserved for patients with complications of the disease, intractable abdominal pain, or suspected underlying carcinoma. 1 The choice of operation for chronic pancreatitis is predicated on the two anatomical variants of the disease, which are distinguished by the size of the main pancreatic duct. 2 Large duct disease (>6 mm in diameter) accounts for approximately 40% of cases and is thought to develop from increased pressure in the pancreatic ductal system. 3 In this circumstance, the longitudinal pancreaticojejunostomy (or modified Puestow procedure) has been the treatment of choice, benefiting close to 80% of patients. 4,5 Patients with small duct disease (<6 mm in diameter) generally are thought not to be candidates for that operation and require pancreatic resection. Because of the historical ineffectiveness of distal resections 6,7 and the complications associated with total pancreatectomy, 1 resections targeting the head of the pancreas are the primary operations for patients with chronic pancreatitis of the small duct form that is refractory to medical treatment. Three main operations are available to these patients today: the Whipple-type pancreaticoduodenectomy (with antrectomy), 8 the pylorus-preserving pancreaticoduodenectomy (PPPD), 9 and the Beger duodenum-preserving pancreatic head resection. 10

Regarding pancreaticoduodenectomy for chronic pancreatitis, controversy exists with respect to the choice of operation and the expected rate of successful outcomes. The PPPD was first described by Watson in 1944 11 and reintroduced by Traverso and Longmire in 1978 9 to improve on the nutritional deficiencies associated with the classic Whipple. Large published series, however, report successful weight maintenance or gain in more than 80% of patients after either operation. 12,13 Relief of pain after pancreaticoduodenectomy is another focus of debate. Information from the literature is commonly based on anecdotal experience of a single approach, often with small cohorts or inadequate follow-up information. 12–17 There are few studies comparing alternative surgical treatments. 1 Evaluation of published reports is further complicated by a lack of standard measurements to assess success. 1,18 Successful pain relief after pancreaticoduodenectomy by either technique is reported over the wide range of 60% to 100% of patients.

In this study, we reviewed our experience with pancreaticoduodenectomy in the treatment of chronic pancreatitis for the past 7 years. During this time, we performed an almost equal number of Whipple and PPPD operations. Our goals were twofold. First, we wished to ascertain the advantages or disadvantages of one operation over the other, both in the short term and the long term. Secondly, and perhaps more important, we performed an outcome analysis of these patients in the hopes of providing prospective selection criteria that will improve the likelihood of successful surgical results.

Outcome of Pancreaticoduodenectomy With Pylorus Preservation or With Antrectomy in the Treatment of Chronic Pancreatitis

Objective:To determine in a prospective randomized controlled trial (RCT) whether pylorus-resecting pancreatoduodenectomy (PrPD) with preservation of nearly the entire stomach reduces the incidence of delayed gastric emptying (DGE) compared with pylorus-preserving pancreatoduodenectomy (PpPD).Backgr

Pylorus ring resection reduces delayed gastric emptying in patients undergoing pancreatoduodenectomy: a prospective, randomized, controlled trial of pylorus-resecting versus pylorus-preserving pancreatoduodenectomy.

Randomized prospective trial of pylorus-preserving vs. Classic duodenopancreatectomy (Whipple procedure): initial clinical results.

Since 1978, 252 patients from different centers in the world have undergone pylorus-preserving pancreatoduodenectomy Fifty-five per cent of the patients had malignant tumors in the region of the head of the pancreas The overall operative mortality rate was 28% Anastomotic leakage and fistulae occurred in 19% of the patients Pancreatic, biliary, and enteric fistulae represented 11%, 4%, and 4%, respectively Peptic ulcers were subsequently diagnosed in seven patients (3%), two of whom required vagotomy and antrectomy Delayed recovery of gastric function was the most common complication of this operation, with an overall incidence of 30% Although the cause of this gastric dysfunction is unknown, its transient nature in most patients makes expectant therapy with gastric tube drainage the best remedy when the problem is encountered Pylorus-preserving pancreatoduodenectomy decreased the incidence of postgastric surgery syndromes that are commonly associated with the standard Whipple operation The existing data support the continued use of the operation and the need for future laboratory and clinical investigation of its physiologic impact

Pylorus-preserving pancreatoduodenectomy. A clinical and physiologic appraisal.

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Pylorus-preserving pancreatoduodenectomy. A clinical and physiologic appraisal.