Pylorus Preserving

Pancreaticoduodenectomy
Journal Club
PP Myint
24/01/2020
Hanna et al. J Gastrointest Surg (2015) 19:1542–1552
Pylrous preserving PD (PPPD) vs Pylorus
resecting PD (PRPD)
• PRPD
• Less delayed gastric emptying (DGE)
• Less days with nasogastric tube
• Increased blood loss
• No reported differences in length of hospital stay, incidence of
pancreatic fistula, abscesses, overall morbidity, or postoperative
mortality
• Long-term outcomes?
Clinical question
• Is PRPD a better surgical procedure than PPPD regarding long-term
outcomes?
• How does delayed gastric emptying (DGE) occurring during the early
period after PD affect long-term outcomes?
Setting and Study Design
• Wakayama Medical University Hospital, Wakayama, Japan
• October 2005 – March 2009
• Prospective randomised control trial – PRPD Vs PPRD
• Pancreatic or periampullary tumours
• Follow-up for 24 months after surgery to evaluate recurrence
• clinical, radiologic, and laboratory assessments every 1–3 months
Surgical Procedure
• Right gastric artery and vagal nerve were transected at same levels
during both PPPD and PRPD
• Right gastric artery was dissected by the root, first pyloric branch was
dissected along the lesser curvature of the stomach
• First pyloric branch of the right gastroepiploic artery dissected along
the greater curvature of the stomach
• Pyloric branch of the vagal nerve dissected along with lymph nodes
around the pylorus ring
Surgical Procedure
• PPPD: proximal duodenum divided 3–4 cm distal to pylorus ring
• PRPD: stomach was divided adjacent to the pylorus ring, with more
than 95 % of the stomach being preserved -> pylorus ring resected
• Lymph node dissection:
• Hepatoduodenal ligament
• Circumferentially around the common hepatic artery
• Right half circumference of the superior mesenteric artery
Surgical Procedure
• Pancreaticojejunostomy after both procedures by duct-to-mucosa, end-to-
side pancreaticojejunostomy
• External suture rows as a single suture between the remnant pancreatic
capsule, parenchyma, and jejunal seromuscular area - interrupted suture
with 4-0 Novafil (polybutester)
• Internal suture rows, duct to mucosa between the pancreatic ductal and
jejunal mucosa using eight interrupted sutures with 5-0 PDS-II
• End-to-side hepaticojejunostomy by one layer anastomosis (5-0 PDS-II) 10–
15 cm distal to pancreaticojejunostomy
• Duodenojejunostomy in PPPD or gastrojejunostomy in PRPD by a two-layer
anastomosis (4-0 PDS-II and 3-0 silk) via antecolic route
Post operative management
• Nasogastric tube was inserted prior to surgery and removed from all
patients on postoperative day (POD) 1.
• Oral intake was routinely started on POD 3 or 4
• One drain routinely placed anterior to pancreaticojejunostomy -> If bile
leakage and bacterial contamination were absent, removed on POD 4 in all
patients
• Famotidine for 2 weeks postoperatively and prophylactic antibiotics every
3 h during surgery
• Did not administer prophylactic octreotide or erythromycin postoperatively
• Unless contraindicated, adjuvant Gemcitabine based chemotherapy
• H2-receptor antagonists or proton pump inhibitors given orally for
gastrointestinal symptoms such as heartburn or abdominal discomfort
Follow up
• Nutritional status by body weight change and serum nutritional
parameters was performed before surgery and at 6, 12, 18, and 24
months after surgery
• Albumin, prealbumin, transferrin, retinol-binding protein
• 13C-acetate breath tests at 6, 12, and 24 months after surgery to
compare gastric emptying between PpPD and PrPD: Time to peak
13CO content (T
2 max)
• QOL assessed at 6, 12, and 24 months after surgery using Functional
Assessment of Cancer Therapy-Gastric (FACT-Ga) questionnaire
Late Complications
• Weight loss
• Dumping syndrome
• Peptic ulcer
• Diarrhea
• Diabetes – new or worsening
Statistical Analysis
• Patient characteristics and perioperative and postoperative factors
between the two groups were compared using x2 statistics, Fisher’s
exact test, and the Mann–Whitney U-test
• Statistical significance p < 0.05
• All statistical analyses were performed with SPSS software, version 20
(SPSS, Chicago, IL, USA)
Results
• PPPD: mean F/U – 37.5 months
• PRPD: mean F/U – 41.5 months
• 45/130 patients: died due to recurrence
• PPPD: 19 vs PRPD: 26
• Complete nutritional assessment data available for 52.7% of patients
Take-home points
• PRPD:
• less DGE – 13C-acetate breath test - ?pyloric denervation in PPPD
• Dumping syndrome – ?resection of pyloric ring
• More favorable recovery – body weight change at 18 and 24 months - ?due to
change in intake based on gastric emptying function
• Nutrition biochemical markers similar
• FACT-Ga questionnaires show QOL similar
Take-home points
• DGE does not affect incidence of pancreatic fistula and intra-abdominal
abscess - ?few numbers to compare
• DGE – significantly poorer recovery of body weight, albumin and
prealbumin levels at 24 months
• Early postoperative DGE = longer Tmax in 13C-acetate breath test compared
to those with delayed DGE – ?predictive role
• Weight loss may be affected by malignant disease, administration of a
pancreatic enzyme supplement, or adjuvant chemotherapy -> incidence of
DGE similar in benign and malignant disease
• Neither malignant disease nor postoperative adjuvant chemotherapy
affected the incidence of weight loss at 24 months
Pros
• Prospective RCT with well designed protocol
• Decent numbers
• Standardised surgical techniques
• PRPD more favourable short and long-term outcomes
Cons
• Long-term median follow up < 4 years
• Data reported only up to 2 years after intervention
• ?selection bias when comparing DGE vs without DGE – few numbers
• Complete nutritional assessment data available for half of patients