Training in the Japanese Society of Hepato-Biliary-Pancreatic Surgery board certification system for expert surgeons during 225 consecutive pancreaticoduodenectomies

Daisuke Hashimoto,Takaomi Okawa,Fujio Matsumura 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.2

Backgrounds/Aims: A board certification system has been established by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) for certifying surgeons who can perform high-level hepato-biliary-pancreatic surgeries safely. The aim of this study was to compare operative outcomes after pancreaticoduodenectomy performed by trainees, board-certified instructors, and expert surgeons of JSHBPS to determine the efficacy of education of trainees and operative safety. Methods: From 2009 to 2017, 225 consecutive patients underwent pancreaticoduodenectomy. Operations were performed by trainees, instructors, or JSHBPS experts. Clinical course and postoperative outcomes were retrospectively evaluated. Results: Twenty-two surgeons performed pancreaticoduodenectomy and two became expert surgeons. First, data of all patients who underwent pancreaticoduodenectomy (n=225) were analyzed. Significantly shorter median operating time and less median operative bleeding were documented in the experts’ group (428 min, 576 g, respectively) than in the trainees’ (498.5 min, 818 g, respectively) and instructors’ (557 min, 911 g, respectively) groups. Morbidity did not differ significantly between the three groups. Second, data of patients who underwent simple pancreaticoduodenectomy (n=130) were analyzed. Similarly, operating time was shorter and operative bleeding less in the experts’ group. With increasing their experiences, intraoperative bleeding by 2 surgeons became the expert surgeons decreased. Conclusions: Surgeons judged experts by the JSHBPS board certification system achieve significantly shorter operating time and less operative bleeding during pancreaticoduodenectomy. In addition, PD performed by trainees has an acceptable incidence of postoperative complications. This is the first report which indicated the efficacy of education toward being the JSHPBS board-certified expert surgeon.

Outcomes of pancreaticoduodenectomy in patients with metastatic cancer

Joo Hwa Kwak,Jin Seok Heo,Jin Young Park,Dong Wook Choi,Seong Ho Choi,Hui Song Lee 한국간담췌외과학회 2014 한국간담췌외과학회지 Vol.18 No.4

Backgrounds/Aims: Metastatic cancer of pancreas is rarely resectable. Pancreaticoduodenectomy carries high risks of morbidities and mortalities that it is rarely performed for metastatic cancer. In this study, the clinical features and outcomes of metastatic cancer of pancreas after pancreaticoduodenectomy were reviewed and analyzed. Methods: We retrospectively reviewed patients who underwent pancreaticoduodectomy from January 2000 to December 2012 in Samsung Medical Center. A total of 1045 patients were enrolled in this study. Inclusion criteria were patients who had metachronous lesions with tumors histologically confirmed as metastatic cancer. However, patients with tumors directly invaded pancreas head, bile duct, and duodenum were excluded from this study. Finally, a total of 12 patients who underwent pancreaticoduodenectomy due to metastatic cancer were used in this study. Clinicopathologic features and perioperative data of these 12 patients were retrospectively reviewed. Results: The 12 patients included 6 females and 6 males who had metastatic lesions at pancreas head, duodenum 2nd-3rd portion, and distal common bile duct. The mean age of patients was 62.7 years old at the time of pancreaticoduodenectomy. The interval between the time of the first operation for primary cancer and pancreaticoduodenectomy was 67.7 months. The mean survival time after pancreaticoduodectomy was 38.6 months (range, 12 to 119 months). There was no fatal complication after the surgery. Conclusions: Pancreaticoduodenectomy is becoming a safer procedure with less complication compared to the past. Patients with recurrent metastatic cancer should be considered for metastectomy if tumors are resectable. Pancreaticoduodenectomy should be considered as one main treatment for patients with recurrent metastatic cancer to offer a chance of long-term survival in selected patients.

수술 전 고빌리루빈혈증 환자에서 췌십이지장 절제술의 안정성

김태윤,김성용,백무준,이문수,조무식,김창호 순천향의학연구소 2004 Journal of Soonchunhyang Medical Science Vol.10 No.1

Backgrounds: Pancreaticoduodenectomy is accompanied by a considerable risk of postoperative complication and potential death. Pancreaticoduodenectomy in patient with obstructive jaundice carry on increased risk of postoperative complication. Preoperative biliary drainage has been developed to reduce this morbidity and mortality but the benefit of preoperative biliary drainage is still questioned for several reasons. This study evaluated postoperative outcomes following pancreaticoduodenectomy in relation to patients with hyperbilirubinemia. Methods: Ninety two patients who underwent pancreaticoduodenectomy between 1992 and 2001 were divided into two groups. Group A included 11 cases in patient with preoperative hyperbilirubinemia (serum bilirubin > 10 mg/dl), and the other 81 cases (serum bilirubin < 10 mg/dl) were Group B. In group A, 6 patients underwent preoperative biliary drainage. In group B, 31 patients underwent preoperative biliary drainage. Postoperative morbidity and mortality were anlaysed comparing with two groups by chi-squared test retrospectively. Results: In group A, whose average value of serum bilirubin was 15.2 mg/dl (range 10.2-20.3 mg/dl), wound complications were seen in 9.0%, hemorrhage in 18.1%, delayed gastric empting in 18.1%, anastomosis leakage in 18.1%, abscess in absent, and mortality in 9%. In group B, whose average value of serum bilirubin was 2.3 mg/dl (range 0.8-7.3 mg/dl), wound complications were seen in 14.8%, hemorrhage in 8.6%, delayed gastric empting in 9.8%, anastomosis leakage in 22.1%, abscess in 4.9%, and mortality in 4.9%. There was no significant difference in morbidity and mortality between two groups. Conclusion: Preoperative hyperbilirubinemia did not influence the incidence of postoperative outcomes following pancreaticoduodenectomy. It can be performed safely in patient with hyperbilirubinemia.

Impact of conversion at time of minimally invasive pancreaticoduodenectomy on perioperative and long-term outcomes: Review of the National Cancer Database

Jennifer Palacio,Daisy Sanchez,Shenae Samuels,Bar Y. Ainuz,Raelynn M. Vigue,Waleem E. Hernandez,Christopher J. Gannon,Omar H. Llaguna 한국간담췌외과학회 2023 Annals of hepato-biliary-pancreatic surgery Vol.27 No.3

Backgrounds/Aims: Current literature presents limited data regarding outcomes following conversion at the time of minimally invasive pancreaticoduodenectomy (MI-PD). Methods: The National Cancer Database was queried for patients who underwent pancreaticoduodenectomy. Patients were stratified into three groups: MI-PD, converted to open pancreaticoduodenectomy (CO-PD), and open pancreaticoduodenectomy (O-PD). Multivariable modeling was applied to compare outcomes of MI-PD and CO-PD to those of O-PD. Results: Of 17,570 patients identified, 12.5%, 4.2%, and 83.4% underwent MI-PD, CO-PD, and O-PD, respectively. Robotic pancreaticoduodenectomy (R-PD) resulted in a higher lymph node yield (n = 23.2 ± 12.2) even when requiring conversion (n = 22.4 ± 13.2, p < 0.001). Margin positivity was higher in the CO-PD group (26.6%) than in the MI-PD group (21.3%) and the O-PD (22.6%) group (p = 0.017). Length of stay was shorter in the MI-PD group (laparoscopic pancreaticoduodenectomy 10.4 ± 8.6, R-PD 10.6 ± 8.8) and the robotic converted to open group (10.7 ± 6.4) than in the laparoscopic converted to open group (11.2 ± 9) and the O-PD group (11.5 ± 8.9) (p < 0.001). After adjusting for patient and tumor characteristics, both MI-PD (odds ratio = 1.40; p < 0.001) and CO-PD (odds ratio = 1.24; p = 0.020) were significantly associated with an increased likelihood of long-term survival. Conclusions: CO-PD does not negatively impact perioperative or oncologic outcomes.

Management and prevention of delayed gastric emptying after pancreaticoduodenectomy

Yong Hoon Kim 한국간담췌외과학회 2012 한국간담췌외과학회지 Vol.16 No.1

Although technical advances have been made in pancreaticoduodenectomy, the incidence of delayed gastric emptying (DGE) is reported as being high. Postoperative DGE is not fatal, but often results in prolonging the length of patients’ stay in hospital, increasing their medical expenses, and further lowering their quality of life. DGE is a complex process caused by disorder and incoordination of various factors in charge of gastric mobility, such as smooth muscle cells (myogenic), enteric neuron (hormonal), and autonomic nervous system (neural). DGE often occurs after operative maneuvers that cause the loss of organs responsible for gastric motility and emptying or kinetic muscular or neuromuscular ischemia. To prevent DGE, it is most important to develop and universalize a standardized surgical technique in a way to reduce factors that are considered to cause DGE after pancreaticoduodenectomy. Moreover, if it is suspected that DGE occurred after pancreaticoduodenectomy, a differential diagnosis from diseases with similar symptoms via an accurate diagnostic approach should be implemented. (Korean J Hepatobiliary Pancreat Surg 2012;16:1-6)

췌십이지장절제술 후 발생한 담즙누출의 치료

김태윤,김성용,백무준,이문수,조무식,김창호 순천향의학연구소 2004 Journal of Soonchunhyang Medical Science Vol.10 No.1

Operative morbidity and mortality of pancreaticoduodenectomy has been decreasing but remains high. Unintended postoperative cutaneous biliary fistula involving the major bile ducts is an uncommon complication of pancreaticoduodenectomy. Prolonged biliary drainage may lead to severe metabolic disturbances, renal failure and cardiovascular collapse, and usually requires operative reintervention. Among 90 patients who underwent pancreaticoduodenectomy from Feb. 1992 to Dec, 2000, 70 patients whose hospital records could be reviewed were included in this study. Cutaneous biliary fistula were observed in 19 cases(27.1%). In the 14 cases, a biliary drain was inserted around the injured duct via the biliocutaneous fistula. In these cases, biliary drainage alone resulted in resolution of the bile leak, because the injury was partial without a stricture. In the 5 cases, biliary stents were placed percutaneously across the injured portion of the bile duct. Pancreaticoduodenectomy is still associated with high mortality and morbidity even though there has been significant progress in the field of pancreatic surgery and postoperative follow-up. In the absence of organic stenosis, percutaneous drainage approach may be useful in patients with postoperative biliocutaneous fistula.

A modified single jejunal loop reconstruction by performing proximal gastrojejunostomy after Whipple’s pancreticoduodenectomy in a low-volume hospital

Ali Naki Yucesoy 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.1

Backgrounds/Aims: It is needed to ensure bowel and biliary tract continuity after pancreaticoduodenectomies. It is possible to find a variety of reconstruction methods in literature. Methods: We realized a modified reconstruction method by performing proximal gastrojejunostomy, on a jejunal loop after Whipple’s pancreticoduodenectomy, with surgical succes in 7 patients with pancreatic head or periampullary carcinomas in a low-volume hospital 2009-2017. Results: A modified jejunal loop reconstruction method, was performed in 7 patients after Whipple’s pancreaticoduodenectomy. We had no perioperative mortality. Pancreatic fistula treated with medical attempts was observed following post-operative pancreatitis in a patient. No marginal ulceration was observed. Delayed gastric emptying was not observed, except for post-operative acute pancreatitis and pancreatic fistula developing in a patient. Conclusions: A modified reconstruction method by performing proximal gastrojejunostomy on a jejunal loop, can be considered as alternative reconstructive surgical procedure after pancreaticoduodenectomy.

Hepatic artery pseudoaneurysm after pancreaticoduodenectomy treated with coil embolization in combination with portomesenteric venous stenting

Seung Chul Han,Tae Hwan Kim,Hee Chul Yang,Jae Uk Chong 소화기인터벤션의학회 2020 International journal of gastrointestinal interven Vol.9 No.3

Delayed massive hemorrhage after pancreaticoduodenectomy is known as a fatal complication, frequently caused by gastroduodenal artery stump bleeding or hepatic artery pseudoaneurysm. Transarterial hepatic artery embolization is one of the treatment options in such cases. However, hepatic artery embolization can also result in ischemic complications of the liver, even fatal sometimes. We report a case of a 70-year-old male patient with distal common bile duct cancer who underwent pancreaticoduodenectomy. After three weeks, there was a bloody drain component accompanied with a decreased hemoglobin level. The immediate computed tomography scan and subsequent angiography demonstrated a hepatic artery pseudoaneurysm (1.8 cm in size) with segmental narrowing of the portal vein and superior mesenteric vein. The pseudoaneurysm and common hepatic artery were embolized using microcoils, following percutaneous portomesenteric stenting. There was no such ischemic complication as hepatic infarction after the procedure, and the patient was well tolerable. We suggest that the simultaneous portomesenteric stenting prior to hepatic artery embolization may be helpful to reduce the risk of hepatic infarction/failure in a patient with hepatic artery pseudoaneurysm accompanying portomesenteric vein stenosis after pancreaticoduodenectomy.

Hepatic artery pseudoaneurysm after pancreaticoduodenectomy treated with coil embolization in combination with portomesenteric venous stenting

Seung Chul Han,Tae Hwan Kim,Hee Chul Yang,Jae Uk Chong 소화기인터벤션의학회 2020 Gastrointestinal Intervention Vol.9 No.3

Delayed massive hemorrhage after pancreaticoduodenectomy is known as a fatal complication, frequently caused by gastroduodenal artery stump bleeding or hepatic artery pseudoaneurysm. Transarterial hepatic artery embolization is one of the treatment options in such cases. However, hepatic artery embolization can also result in ischemic complications of the liver, even fatal sometimes. We report a case of a 70-year-old male patient with distal common bile duct cancer who underwent pancreaticoduodenectomy. After three weeks, there was a bloody drain component accompanied with a decreased hemoglobin level. The immediate computed tomography scan and subsequent angiography demonstrated a hepatic artery pseudoaneurysm (1.8 cm in size) with segmental narrowing of the portal vein and superior mesenteric vein. The pseudoaneurysm and common hepatic artery were embolized using microcoils, following percutaneous portomesenteric stenting. There was no such ischemic complication as hepatic infarction after the procedure, and the patient was well tolerable. We suggest that the simultaneous portomesenteric stenting prior to hepatic artery embolization may be helpful to reduce the risk of hepatic infarction/failure in a patient with hepatic artery pseudoaneurysm accompanying portomesenteric vein stenosis after pancreaticoduodenectomy.

A comparative study of postoperative outcomes after stapled versus handsewn gastrojejunal anastomosis for pylorus-resecting pancreaticoduodenectomy

Sook Hyun Lee,Yun Ho Lee,Young Hoe Hur,Hee Joon Kim,Byung Gwan Choi 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.1

Backgrounds/Aims: A stapler is widely used in various surgeries, and there have been recent attempts to use it for performing duodenojejunostomy and gastrojejunostomy during pancreaticoduodenectomy. This study aimed to compare the postoperative results of handsewn gastrojejunostomy (HGJ) and stapled gastrojejunstomy (SGJ) limited to pylorus-resecting pancreaticoduodenectomy (PrPD) performed by a single surgeon. Methods: This retrospective study was conducted between January 2014 and March 2020, and included 131 patients who underwent PrPD performed by a single surgeon. Of the total subjects, 90 were in the HGJ group and 41 in the SGJ group. Results: The mean time of surgery was significantly shorter in the stapled group than in the handsewn group (450.4±75.4 min vs. 397.1±66.5 min, p<0.001). However, there were no significant differences between the groups in the rates of postoperative pancreatic fistula, bile leak, chyle leak, intra-abdominal fluid collection, postoperative bleeding, ileus, Clavien-Dindo, rate of reoperation, and 30-day mortality, including delayed gastric emptying (DGE) (n=11 vs. n=6, p=0.92). Conclusions: Gastrojejunostomy using a stapler in PrPD reduces the reconstruction time without any increase in the rate of complications, including DGE. Therefore, using a stapler for gastrojejunostomy in pancreaticoduodenectomy is feasible and safe.