Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes
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摘要
Background: Blumgart's pancreaticojejunostomy(PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes. Methods: We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula(CR-POPF) and analysis of its risk factors. Results: The CR-POPF rate was 12.3%. Fistula risk score(FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay. Conclusion: Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.
Background: Blumgart's pancreaticojejunostomy(PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes. Methods: We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula(CR-POPF) and analysis of its risk factors. Results: The CR-POPF rate was 12.3%. Fistula risk score(FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay. Conclusion: Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.
Background: Blumgart's pancreaticojejunostomy(PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes. Methods: We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula(CR-POPF) and analysis of its risk factors. Results: The CR-POPF rate was 12.3%. Fistula risk score(FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay. Conclusion: Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.
引文
[1]Jagad RB,Koshariya M,Kawamoto J,Papastratis P,Kefalourous H,Patris V,et al.Pancreatic neuroendocrine tumors:our approach.Hepatogastroenterology 2008;55:275-281.
[2]Yeo CJ,Cameron JL,Sohn TA,Lillemoe KD,Pitt HA,Talamini MA,et al.Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s:pathology,complications,and outcomes.Ann Surg 1997;226:248-260.
[3]Lupascu C,Andronic D,Ursulescu C,Vasiluta C,Vlad N.Technical tailoring of pancreaticoduodenectomy in patients with hepatic artery anatomic variants.Hepatobiliary Pancreat Dis Int 2011;10:638-643.
[4]Georgescu S,Ursulescu C,Grigorean VT,Lupascu C.Hind right approach pancreaticoduodenectomy:from skill to indications.Gastroenterol Res Pract2014;2014:210835.
[5]Mishra PK,Saluja SS,Gupta M,Rajalingam R,Pattnaik P.Blumgart’s technique of pancreaticojejunostomy:an appraisal.Dig Surg 2011;28:281-287.
[6]Cameron JL,Pitt HA,Yeo CJ,Lillemoe KD,Kaufman HS,Coleman J.One hundred and forty-five consecutive pancreaticoduodenectomies without mortality.Ann Surg 1993;217:430-438.
[7]Grobmyer SR,Kooby D,Blumgart LH,Hochwald SN.Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications.J Am Coll Surg 2010;210:54-59.
[8]Aranha GV,Hodul PJ,Creech S,Jacobs W.Zero mortality after 152 consecutive pancreaticoduodenectomies with pancreaticogastrostomy.J Am Coll Surg2003;197:223-232.
[9]Machado NO.Pancreatic fistula after pancreatectomy:definitions,risk factors,preventive measures,and management-review.Int J Surg Oncol2012;2012:602478.
[10]Shrikhande SV,Sivasanker M,Vollmer CM,Friess H,Besselink MG,Fingerhut A,et al.Pancreatic anastomosis after pancreatoduodenectomy:a position statement by the International Study Group of Pancreatic Surgery(ISGPS).Surgery2017;161:1221-1234.
[11]Blumgart L,Fong Y.Surgery of the liver and biliary tract.3rd ed.New York:Saunders Co Ltd.;2001.p.2000.
[12]Hirche Z,Linden BV,Xiong L,Klippel S,Willis S.Safety of Blumgart s anastomosis during Traverso operation is independent of diagnosis and risk factors for pancreaticojejunal anastomotic failure.Global J Gastroenterol Hepatol2015;3:50-58.
[13]Wang SE,Chen SC,Shyr BU,Shyr YM.Comparison of modified Blumgart pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy.HPB(Oxford)2016;18:229-235.
[14]Kleespies A,Rentsch M,Seeliger H,Albertsmeier M,Jauch KW,Bruns CJ.Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection.Br J Surg 2009;96:741-750.
[15]Fujii T,Sugimoto H,Yamada S,Kanda M,Suenaga M,Takami H,et al.Modified Blumgart anastomosis for pancreaticojejunostomy:technical improvement in matched historical control study.J Gastrointest Surg 2014;18:1108-1115.
[16]Hirono S,Kawai M,Okada KI,Miyazawa M,Kitahata Y,Hayami S,et al.Modified Blumgart mattress suture versus conventional interrupted suture in pancreaticojejunostomy during pancreaticoduodenectomy:randomized controlled trial.Ann Surg 2019;269:243-251.
[17]Wang SE,Shyr BU,Chen SC,Shyr YM.Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy:a propensity score-matched study.Surgery 2018;164:1162-1167.
[18]Dindo D,Demartines N,Clavien PA.Classification of surgical complications:a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg 2004;240:205-213.
[19]Wente MN,Bassi C,Dervenis C,Fingerhut A,Gouma DJ,Izbicki JR,et al.Delayed gastric emptying(DGE)after pancreatic surgery:a suggested definition by the International Study Group of Pancreatic Surgery(ISGPS).Surgery2007;142:761-768.
[20]Wente MN,Veit JA,Bassi C,Dervenis C,Fingerhut A,Gouma DJ,et al.Postpancreatectomy hemorrhage(PPH):an International Study Group of Pancreatic Surgery(ISGPS)definition.Surgery 2007;142:20-25.
[21]Bassi C,Dervenis C,Butturini G,Fingerhut A,Yeo C,Izbicki J,et al.Postoperative pancreatic fistula:an international study group(ISGPF)definition.Surgery2005;138:8-13.
[22]Hartwig W,Vollmer CM,Fingerhut A,Yeo CJ,Neoptolemos JP,Adham M,et al.Extended pancreatectomy in pancreatic ductal adenocarcinoma:definition and consensus of the International Study Group for Pancreatic Surgery(ISGPS).Surgery 2014;156:1-14.
[23]Bassi C,Marchegiani G,Dervenis C,Sarr M,Abu Hilal M,Adham M,et al.The2016 update of the International Study Group(ISGPS)definition and grading of postoperative pancreatic fistula:11 years after.Surgery 2017;161:584-591.
[24]Callery MP,Pratt WB,Kent TS,Chaikof EL,Vollmer CM Jr.A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy.J Am Coll Surg 2013;216:1-14.
[25]Venkat R,Puhan MA,Schulick RD,Cameron JL,Eckhauser FE,Choti MA,et al.Predicting the risk of perioperative mortality in patients undergoing pancreaticoduodenectomy:a novel scoring system.Arch Surg 2011;146:1277-1284.
[26]Blamey SL,Fearon KC,Gilmour WH,Osborne DH,Carter DC.Prediction of risk in biliary surgery.Br J Surg 1983;70:535-538.
[27]Müftüoglu MA,Saglam A.A novel reconstructive procedure after pancreaticoduodenectomy:J-pouch dunking pancreaticojejunostomy.Hepatogastroenterology 2003;50:2233-2235.
[28]Peng SY,Wang JW,Li JT,Mou YP,Liu YB,Cai XJ.Binding pancreaticojejunostomy-a safe and reliable anastomosis procedure.HPB(Oxford)2004;6:154-160.
[29]Topal B,Fieuws S,Aerts R,Weerts J,Feryn T,Roeyen G,et al.Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours:a multicentre randomised trial.Lancet Oncol 2013;14:655-662.
[30]Liu FB,Chen JM,Geng W,Xie SX,Zhao YJ,Yu LQ,et al.Pancreaticogastrostomy is associated with significantly less pancreatic fistula than pancreaticojejunostomy reconstruction after pancreaticoduodenectomy:a meta-analysis of seven randomized controlled trials.HPB(Oxford)2015;17:123-130.
[31]Kleespies A,Albertsmeier M,Obeidat F,Seeliger H,Jauch KW,Bruns CJ.The challenge of pancreatic anastomosis.Langenbecks Arch Surg2008;393:459-471.
[32]Daamen LA,Smits FJ,Besselink MG,Busch OR,Borel Rinkes IH,van Santvoort HC,et al.A web-based overview,systematic review and metaanalysis of pancreatic anastomosis techniques following pancreatoduodenectomy.HPB(Oxford)2018;20:777-785.
[33]Xiong JJ,Altaf K,Mukherjee R,Huang W,Hu WM,Li A,et al.Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy.Br J Surg 2012;99:1050-1061.
[34]Dong Z,Xu J,Wang Z,Petrov MS.Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy.Cochrane Database Syst Rev2016(5):CD008914.
[35]Pratt WB,Maithel SK,Vanounou T,Huang ZS,Callery MP,Vollmer CM Jr.Clinical and economic validation of the International Study Group of Pancreatic Fistula(ISGPF)classification scheme.Ann Surg 2007;245:443-451.
[36]Reid-Lombardo KM,Farnell MB,Crippa S,Barnett M,Maupin G,Bassi C,et al.Pancreatic anastomotic leakage after pancreaticoduodenectomy in 1507patients:a report from the Pancreatic Anastomotic Leak Study Group.J Gastrointest Surg 2007;11:1451-1459.
[37]Liang TB,Bai XL,Zheng SS.Pancreatic fistula after pancreaticoduodenectomy:diagnosed according to International Study Group Pancreatic Fistula(ISGPF)definition.Pancreatology 2007;7:325-331.
[38]Fuks D,Piessen G,Huet E,Tavernier M,Zerbib P,Michot F,et al.Life-threatening postoperative pancreatic fistula(grade C)after pancreaticoduodenectomy:incidence,prognosis,and risk factors.Am J Surg 2009;197:702-709.
[39]Yeh TS,Jan YY,Jeng LB,Hwang TL,Wang CS,Chen SC,et al.Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy-multivariate analysis of perioperative risk factors.J Surg Res 1997;67:119-125.
[40]Gouma DJ,van Geenen RC,van Gulik TM,de Haan RJ,de Wit LT,Busch OR,et al.Rates of complications and death after pancreaticoduodenectomy:risk factors and the impact of hospital volume.Ann Surg 20 0 0;232:786-795.
[41]Kollmar O,Moussavian MR,Bolli M,Richter S,Schilling MK.Pancreatojejunal leakage after pancreas head resection:anatomic and surgeon-related factors.J Gastrointest Surg 2007;11:1699-1703.
[42]Yeo CJ,Cameron JL,Maher MM,Sauter PK,Zahurak ML,Talamini MA,et al.Aprospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy.Ann Surg 1995;222:580-592.
[43]Miller BC,Christein JD,Behrman SW,Drebin JA,Pratt WB,Callery MP,et al.Amulti-institutional external validation of the fistula risk score for pancreatoduodenectomy.J Gastrointest Surg 2014;18:172-180.
[2]Yeo CJ,Cameron JL,Sohn TA,Lillemoe KD,Pitt HA,Talamini MA,et al.Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s:pathology,complications,and outcomes.Ann Surg 1997;226:248-260.
[3]Lupascu C,Andronic D,Ursulescu C,Vasiluta C,Vlad N.Technical tailoring of pancreaticoduodenectomy in patients with hepatic artery anatomic variants.Hepatobiliary Pancreat Dis Int 2011;10:638-643.
[4]Georgescu S,Ursulescu C,Grigorean VT,Lupascu C.Hind right approach pancreaticoduodenectomy:from skill to indications.Gastroenterol Res Pract2014;2014:210835.
[5]Mishra PK,Saluja SS,Gupta M,Rajalingam R,Pattnaik P.Blumgart’s technique of pancreaticojejunostomy:an appraisal.Dig Surg 2011;28:281-287.
[6]Cameron JL,Pitt HA,Yeo CJ,Lillemoe KD,Kaufman HS,Coleman J.One hundred and forty-five consecutive pancreaticoduodenectomies without mortality.Ann Surg 1993;217:430-438.
[7]Grobmyer SR,Kooby D,Blumgart LH,Hochwald SN.Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications.J Am Coll Surg 2010;210:54-59.
[8]Aranha GV,Hodul PJ,Creech S,Jacobs W.Zero mortality after 152 consecutive pancreaticoduodenectomies with pancreaticogastrostomy.J Am Coll Surg2003;197:223-232.
[9]Machado NO.Pancreatic fistula after pancreatectomy:definitions,risk factors,preventive measures,and management-review.Int J Surg Oncol2012;2012:602478.
[10]Shrikhande SV,Sivasanker M,Vollmer CM,Friess H,Besselink MG,Fingerhut A,et al.Pancreatic anastomosis after pancreatoduodenectomy:a position statement by the International Study Group of Pancreatic Surgery(ISGPS).Surgery2017;161:1221-1234.
[11]Blumgart L,Fong Y.Surgery of the liver and biliary tract.3rd ed.New York:Saunders Co Ltd.;2001.p.2000.
[12]Hirche Z,Linden BV,Xiong L,Klippel S,Willis S.Safety of Blumgart s anastomosis during Traverso operation is independent of diagnosis and risk factors for pancreaticojejunal anastomotic failure.Global J Gastroenterol Hepatol2015;3:50-58.
[13]Wang SE,Chen SC,Shyr BU,Shyr YM.Comparison of modified Blumgart pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy.HPB(Oxford)2016;18:229-235.
[14]Kleespies A,Rentsch M,Seeliger H,Albertsmeier M,Jauch KW,Bruns CJ.Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection.Br J Surg 2009;96:741-750.
[15]Fujii T,Sugimoto H,Yamada S,Kanda M,Suenaga M,Takami H,et al.Modified Blumgart anastomosis for pancreaticojejunostomy:technical improvement in matched historical control study.J Gastrointest Surg 2014;18:1108-1115.
[16]Hirono S,Kawai M,Okada KI,Miyazawa M,Kitahata Y,Hayami S,et al.Modified Blumgart mattress suture versus conventional interrupted suture in pancreaticojejunostomy during pancreaticoduodenectomy:randomized controlled trial.Ann Surg 2019;269:243-251.
[17]Wang SE,Shyr BU,Chen SC,Shyr YM.Comparison between robotic and open pancreaticoduodenectomy with modified Blumgart pancreaticojejunostomy:a propensity score-matched study.Surgery 2018;164:1162-1167.
[18]Dindo D,Demartines N,Clavien PA.Classification of surgical complications:a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg 2004;240:205-213.
[19]Wente MN,Bassi C,Dervenis C,Fingerhut A,Gouma DJ,Izbicki JR,et al.Delayed gastric emptying(DGE)after pancreatic surgery:a suggested definition by the International Study Group of Pancreatic Surgery(ISGPS).Surgery2007;142:761-768.
[20]Wente MN,Veit JA,Bassi C,Dervenis C,Fingerhut A,Gouma DJ,et al.Postpancreatectomy hemorrhage(PPH):an International Study Group of Pancreatic Surgery(ISGPS)definition.Surgery 2007;142:20-25.
[21]Bassi C,Dervenis C,Butturini G,Fingerhut A,Yeo C,Izbicki J,et al.Postoperative pancreatic fistula:an international study group(ISGPF)definition.Surgery2005;138:8-13.
[22]Hartwig W,Vollmer CM,Fingerhut A,Yeo CJ,Neoptolemos JP,Adham M,et al.Extended pancreatectomy in pancreatic ductal adenocarcinoma:definition and consensus of the International Study Group for Pancreatic Surgery(ISGPS).Surgery 2014;156:1-14.
[23]Bassi C,Marchegiani G,Dervenis C,Sarr M,Abu Hilal M,Adham M,et al.The2016 update of the International Study Group(ISGPS)definition and grading of postoperative pancreatic fistula:11 years after.Surgery 2017;161:584-591.
[24]Callery MP,Pratt WB,Kent TS,Chaikof EL,Vollmer CM Jr.A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy.J Am Coll Surg 2013;216:1-14.
[25]Venkat R,Puhan MA,Schulick RD,Cameron JL,Eckhauser FE,Choti MA,et al.Predicting the risk of perioperative mortality in patients undergoing pancreaticoduodenectomy:a novel scoring system.Arch Surg 2011;146:1277-1284.
[26]Blamey SL,Fearon KC,Gilmour WH,Osborne DH,Carter DC.Prediction of risk in biliary surgery.Br J Surg 1983;70:535-538.
[27]Müftüoglu MA,Saglam A.A novel reconstructive procedure after pancreaticoduodenectomy:J-pouch dunking pancreaticojejunostomy.Hepatogastroenterology 2003;50:2233-2235.
[28]Peng SY,Wang JW,Li JT,Mou YP,Liu YB,Cai XJ.Binding pancreaticojejunostomy-a safe and reliable anastomosis procedure.HPB(Oxford)2004;6:154-160.
[29]Topal B,Fieuws S,Aerts R,Weerts J,Feryn T,Roeyen G,et al.Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours:a multicentre randomised trial.Lancet Oncol 2013;14:655-662.
[30]Liu FB,Chen JM,Geng W,Xie SX,Zhao YJ,Yu LQ,et al.Pancreaticogastrostomy is associated with significantly less pancreatic fistula than pancreaticojejunostomy reconstruction after pancreaticoduodenectomy:a meta-analysis of seven randomized controlled trials.HPB(Oxford)2015;17:123-130.
[31]Kleespies A,Albertsmeier M,Obeidat F,Seeliger H,Jauch KW,Bruns CJ.The challenge of pancreatic anastomosis.Langenbecks Arch Surg2008;393:459-471.
[32]Daamen LA,Smits FJ,Besselink MG,Busch OR,Borel Rinkes IH,van Santvoort HC,et al.A web-based overview,systematic review and metaanalysis of pancreatic anastomosis techniques following pancreatoduodenectomy.HPB(Oxford)2018;20:777-785.
[33]Xiong JJ,Altaf K,Mukherjee R,Huang W,Hu WM,Li A,et al.Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy.Br J Surg 2012;99:1050-1061.
[34]Dong Z,Xu J,Wang Z,Petrov MS.Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy.Cochrane Database Syst Rev2016(5):CD008914.
[35]Pratt WB,Maithel SK,Vanounou T,Huang ZS,Callery MP,Vollmer CM Jr.Clinical and economic validation of the International Study Group of Pancreatic Fistula(ISGPF)classification scheme.Ann Surg 2007;245:443-451.
[36]Reid-Lombardo KM,Farnell MB,Crippa S,Barnett M,Maupin G,Bassi C,et al.Pancreatic anastomotic leakage after pancreaticoduodenectomy in 1507patients:a report from the Pancreatic Anastomotic Leak Study Group.J Gastrointest Surg 2007;11:1451-1459.
[37]Liang TB,Bai XL,Zheng SS.Pancreatic fistula after pancreaticoduodenectomy:diagnosed according to International Study Group Pancreatic Fistula(ISGPF)definition.Pancreatology 2007;7:325-331.
[38]Fuks D,Piessen G,Huet E,Tavernier M,Zerbib P,Michot F,et al.Life-threatening postoperative pancreatic fistula(grade C)after pancreaticoduodenectomy:incidence,prognosis,and risk factors.Am J Surg 2009;197:702-709.
[39]Yeh TS,Jan YY,Jeng LB,Hwang TL,Wang CS,Chen SC,et al.Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy-multivariate analysis of perioperative risk factors.J Surg Res 1997;67:119-125.
[40]Gouma DJ,van Geenen RC,van Gulik TM,de Haan RJ,de Wit LT,Busch OR,et al.Rates of complications and death after pancreaticoduodenectomy:risk factors and the impact of hospital volume.Ann Surg 20 0 0;232:786-795.
[41]Kollmar O,Moussavian MR,Bolli M,Richter S,Schilling MK.Pancreatojejunal leakage after pancreas head resection:anatomic and surgeon-related factors.J Gastrointest Surg 2007;11:1699-1703.
[42]Yeo CJ,Cameron JL,Maher MM,Sauter PK,Zahurak ML,Talamini MA,et al.Aprospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy.Ann Surg 1995;222:580-592.
[43]Miller BC,Christein JD,Behrman SW,Drebin JA,Pratt WB,Callery MP,et al.Amulti-institutional external validation of the fistula risk score for pancreatoduodenectomy.J Gastrointest Surg 2014;18:172-180.