The role of pancreatogastrostomy following pancreatoduodenectomy for trauma

The records of all patients undergoing pancreatogastrostomy after pancreatoduodenal resection at the University of Kansas Medical Center were reviewed. Five patients with a mean age of 26 years (range, 20-32 years) and severe penetrating (n = 3) or blunt (n = 2) traumatic injuries have required pancreatoduodenectomy followed by pancreatogastrostomy (n = 4) or pancreatogastrostomy alone (n = 1) since 1975. Their mean Trauma Score was 12 (range, 9-16). All five patients had soft, previously normal pancreatic glands without induration or ductal dilatation. The mean duration of surgery was 6 hours (range, 5-7 hours), mean blood loss was 7200 mL (range, 1,000-17,500 mL), mean transfusion requirements were 14 units of blood (range, 2-32 units), and mean hospital stay was 37 days (range, 11-90 days). Two patients developed right upper quadrant abscesses that required a second procedure. There were no pancreatic anastomotic leaks, fistulas, or other complications related to the pancreatogastrostomy. At last examination, all five patients were alive and well and had not developed endocrine or exocrine pancreatic insufficiency after a mean follow-up of 4 years (range, 1-9 months). Pancreatogastrostomy following pancreatoduodenectomy for trauma has not been previously reported. Our experience demonstrates that pancreatogastrostomy is a safe and expeditious method for handling the pancreatic remnant following pancreatoduodenectomy. Furthermore, the results of this study suggest that pancreatogastrostomy has several advantages over pancreatojejunostomy for restoring pancreato-intestinal continuity in trauma patients.     

Pancreatico-jejunal anastomosis with invagination on isolated loop after cephalic pancreatoduodenectomy

The most frequent and most dangerous complication of the duodenopancreatectomy is pancreatic fistula due to dehiscence of the pancreatic anastomosis. A technique that uses a separate Roux en Y loop for pancreatic anastomosis, to reduce the fatal risks of the pancreatic fistula, has been initially reported more than 50 years ago. With the development of the pancreaticogastrostomy, it seems interesting to present a procedure using an isolated loop for the pancreas; this technique is derived from those previously published, allowing a good intussuception of the pancreas in the intestinal loop. This method has been performed in 35 duodenopancreatectomy (malignant pancreatic disease: 32 patients, benign pancreatic disease: 3 patients). The mean age of the patients was 64 years (range 34-74). There were four operative deaths unrelated to the pancreaticojejunal anastomosis and two pancreatic fistulas with spontaneous healing. The pancreatico-jejunostomy using a separate Roux en Y loop represented in this short experience a safe procedure to prevent pancreatic fistula.     

Bioavailability and phase II study of oral UFT plus leucovorin in patients with relapsed or refractory colorectal cancer

A summary of 733 reported cases of pancreatogastrostomy (PG) as a reconstructive procedure following pancreatoduodenectomy and the traumatically severed pancreas indicates an aggregate leakage rate of 4% over a 52-year period. Although mortality rates have declined over this period, the reported high correlation of leak with mortality seems to indicate the greater safety of PG over other methods for treating the residual pancreatic duct. The lower rate of complications related to pancreatocutaneous fistula from PG should correlate with shorter and less expensive hospital stays for patients treated with this technique. Several questions regarding technique must await further investigation.     

Gas in the temporomandibular joint: computed tomography findings. Report of 3 cases

BACKGROUND: The advantages of pancreatogastrostomy over pancreatojejunostomy after pancreaticoduodenectomy are still debated. This study analyses the results of pancreatogastrostomy to identify factors that could influence immediate outcome. METHODS: During a 10-year period, 160 consecutive patients underwent a pancreatogastrostomy. There were 109 men (68 per cent) and 51 women (32 per cent) with a mean(s.d.) age of 59(10) (range 22-82) years; 27 patients were older than 70 years. The following parameters were assessed: mortality rate, morbidity, reasons for reoperation, length of hospital stay, duration of nasogastric tube and drainage. RESULTS: Hospital mortality rate was 3 per cent; overall morbidity rate was 30 per cent. The reoperation rate was 12 per cent, mainly because of bleeding at the pancreatic margin. Delayed gastric emptying occurred in 36 patients. The overall rate of pancreatic fistula was 2.5 per cent. Age, sex, indications for pancreatoduodenectomy, and the texture of the pancreatic remnant did not influence the occurrence of pancreatic fistula or delayed gastric emptying. CONCLUSION: This study confirmed that pancreatogastrostomy is a safe procedure with low mortality and morbidity rates.     

Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study

BACKGROUND/AIMS: To clarify whether the pancreatic duct remains patent during long-term follow-up of patients after pancreaticogastrostomy. In a previous study of pancreaticogastrostomy with post-operative follow up for 3 years after surgery, we found that the orifice of the pancreatic duct was difficult to detect in some patients because of swelling of the gastric mucosa. Previous studies have not examined pancreatic duct patency during long-term follow-up. METHODOLOGY: Between July 1985 and August 1989, 20 patients underwent a pylorus-preserving pancreaticoduodenectomy with reconstruction by pancreaticogastrostomy. Five of these patients were followed up post-operatively for more than 9 years to determine the patency of the pancreatic duct. All pancreatic anastomoses were performed by the telescopic method. RESULTS: All 5 patients were female, with a mean age of 65.4 years (range: 54-75). Median post-operative follow-up was 10.8 years (range: 9-12). The indications for surgery were carcinoma of the ampulla of Vater in 4 patients and chronic pancreatitis in 1 patient. Pancreatic duct patency was confirmed in 4 patients by gastroscopy and pancreatography. However, the anastomotic orifice could not be detected in the remaining patient because of complete coverage by the gastric mucosa. In this patient, pancreatic exocrine and endocrine function deteriorated with dilation of the distal pancreatic duct. The patient underwent a second operation involving dissociation of the pancreatico-gastric anastomosis and resection of about 1 cm of the fibrous, proximal portion of the pancreas. Reconstruction was performed with a Roux-en-Y pancreaticojejunostomy and a mucosa-to-mucosa anastomosis. CONCLUSIONS: Although pancreaticogastrostomy has been applied as a safe and straightforward method for reconstruction after pancreaticoduodenectomy, anastomotic stenosis is a potential late complication of this approach.     

A modified technique for the reconstruction of the alimentary tract after pancreatoduodenectomy

The high death rate for those patients undergoing pancreatoduodenectomy, which is a result of leakage of biliary and pancreatic anastomoses in most instances, justifies the study of this technique for rebuilding the alimentary tract. The use of two separate intestinal loops for the biliary and pancreatic anastomoses is the basis of this method. This technique reduces the morbidity and the death rates which are the result of leakage in either anastomosis because it separates biliary and pancreatic fistulas.     

Effectiveness of ammonium solution in relieving type I mosquito bite symptoms: a double-blind, placebo-controlled study

Management of the pancreatic remnant following pancreaticojejunostomy remains a technical challenge particularly when the pancreas is soft. A simple technique that consolidates the pancreas in preparation for pancreaticojejunostomy is described. Application of this technique in patients for whom a difficult anastomosis was anticipated has yielded good results.     

Coronary artery bypass grafting performed by the simple and convenient graft supporter

We have experienced a simple, safe and convenient technique for supporting the arterial or saphenous vein graft in the coronary artery bypass grafting. This graft supporter is made of cotton cloth with a 50 percent polyester mix. The supporter is twenty centimeters long and two centimeters wide. This supporter provides the complete fixation of the graft without the holding by the co-operater. Therefore the supporter allows very easy, safe and accurate graft anastomosis with the native coronary artery or the ascendinbg aorta. No complication was encountered in association with this procedure in 127 operations.     

Open distal anastomosis or aortic balloon occlusion technique during complete aortic arch replacement

The technique of open distal anastomosis or application of aortic balloon occlusion catheter designed to occlude the descending thoracic aorta have been used in 33 and 19 patients, respectively, to control bleeding during the procedure of distal anastomosis for complete aortic arch replacement with a prosthetic graft. These two techniques allowed us a simple approach to the lesion and the avoidance of clamp injury to the fragile aortic tissue. Open distal anastomosis was applied for 91% patients of operated aortic dissection and all emergent cases, it's duration ranged from 10 to 110 minutes with an average of 58 minutes under 18.2 degrees C of lowest esophageal temperature. On the other hand, aortic occlusion balloon was inserted for mainly true aortic aneurysm patients without an emergency, and helped to maintain the perfusion pressure on a lower part of body around 50 mmHg by the 1550 ml/min in an average of perfusion flow femoral artery under 21.2 degrees C of temperature. The difference of postoperative renal and liver function evaluated by serum enzyme levels of total bilirubin, GOT, GPT, LDH, creatinine and BUN did not reach to statistical significance between the patients using open distal anastomosis and balloon occlusion, however, the incidence of postoperative complication including either renal, liver dysfunction, abdominal problem or paraplegia was significantly higher in the patient group with open distal technique. Either open distal anastomosis or aortic balloon occlusion technique would be appropriately selected according to the patient's characteristics or the condition of aortic disease to be operated.     

Cancer risk of the stomach resected for ulcer. The role of duodenogastric reflux (author's transl)

The purpose of this study was to find whether the reflux of bile and pancreatic juices following stomach resection (duodenogastric reflux) enhances the incidence of carcinomas near the gastroenteric anastomosis. 72 male Wistar rats were subjected to stomach resection. The gastroenteric anastomosis (GE) was performed either as short loop anastomosis (Billroth II; n = 39), thus providing a continuous duodenogastric reflux, or as Y-shaped GE (according to Roux; n = 33). By the latter technique, bile and pancreatic juices are derived quantitatively into the jejunum without coming into contact with the remaining part of the stomach. During a period of 33 weeks, operated rats as well as intact animals were given the carcinogen N-methyl-N'-nitro-N-nitrosoguanidine (NG; 120 mg/l) in the drinking water. At autopsy, 33 to 36 weeks after daily oral administration of NG, most of the tumours were found in operated rats undergoing continuous reflux (Billroth II group). In contrast to these findings, the incidence or carcinomas was significantly lower in animals without reflex (Roux group or intact control rats).-The results of our experiments demonstrate that, in rats, the duodenogastric reflux contributes substantially to the development of carcinomas of the resected stomach.     

Wirsung's duct and chronic pancreatitis. Changes in the morphology of the pancreatic ducts after pancreatic duct shunts. 23 cases followed-up

The authors study in chronic pancreatitis the morphology of Wirsung's duct in 31 patients who had undergone repeated operations, 23 of them were submitted in a first stage to an anastomosis between the pancreatic duct and the digestive tract. The main causes of failure were obstructions of the anastomosis, biliary complications and continuation of the pancreatic disease. The difference in prognosis between pancreatitis with a dilated pancreatic duct, and those with a filiform duct, is perhaps due to lesions of different histological appearance and course. The best results were obtained in patients able to give up alcohol and in whom it was possible to carry out a broader anastomosis on a dilated and unobstructed pancreatic duct.     

Disconnection of the ampulla of Vater: a new technique for reconstruction

We report the case of a 42 year-old patient who had undergone gastric resection and Billroth I reconstruction for a duodenal ulcer 15 years earlier. The patient was admitted to our Department for a high output biliopancreatic fistula which developed after another gastric resection with Billroth II reconstruction which was performed for a peptic stricture of the gastroduodenal anastomosis. At laparotomy, a complete disconnection of the ampulla of Vater was found, with the duodenal stump oversewn 5 cm distally to the papillary area. After plasty of the biliary and pancreatic ducts, a direct anastomosis between the new ampulla and a Roux-en-Y jejunal loop was performed. The post-operative course was uneventful. The details of the surgical technique are reported.     

Reducing early technical complications in gastric bypass surgery

BACKGROUND: The incidence of complications following gastric bypass surgery has decreased markedly over the last 30 years; nevertheless, significant morbidity and mortality is still associated with this procedure. Much of the improved risk of this technique can be attributed to the numerous modifications that have taken place in its evolution. METHODS: We compared our series of 640 primary cases of vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RGB), a form of gastric bypass, with gastric bypass series reported in the literature from 1966 to 1996. Incidences considered were those of subphrenic abscess, gastrointestinal leaks, obstruction of the excluded segment of gastrointestinal tract, splenectomy and death. RESULTS: The overall trend during the last 30 years has been a reduction in the rate of major complications. In our series, we had one major complication, a subphrenic abscess. This compares favorably with the incidence of major complications reported in the literature. CONCLUSIONS: The gastric bypass is a significantly safer operation today than three decades ago. We believe that the relatively low complication rate of VBG-RGB results from: (1) the anatomic location of the gastric pouch; (2) the type of stapling device used in its construction; (3) a pouch outlet restricted by a prosthetic band rather than a narrow anastomosis; and (4) the construction of a retrocolic, retrogastric Roux-en-Y gastrojejunal anastomosis.     

Penetrating ureteral injuries: the impact of associated injuries on management

The ideal management for penetrating ureteral trauma is primary repair, but the effect of other abdominal injuries might preclude this. We attempted to determine what factors could be used to predict a poor outcome of a ureteral anastomosis, so that the initial management can be modified appropriately. The case notes of 41 patients treated for penetrating ureteral trauma were studied retrospectively. Any factors that could influence postoperative complications and outcome were statistically analyzed in order to determine which could be used pre- or intraoperatively to indicate a poor prognosis for the ureteral anastomosis. The presence of shock on admission (P = 0.013), intraoperative bleeding (P = 0.006), colonic injury and specifically injury requiring colectomy (P = 0.006) were associated with a high complication and mortality rate. Patients presenting with penetrating ureteral trauma who are severely shocked and have complicated intraoperative hemostasis and patients who require colectomy should not have a primary ureteral anastomosis, but rather initial ureteral exteriorization or even nephrectomy.     

Acute otitis media in pediatrics

AIM OF THE STUDY: The aim of this retrospective study was to compare pancreatico-jejunostomy vs pancreatico-gastrostomy with regard to safety of pancreatic anastomosis after pancreatico-duodenectomy. PATIENTS AND METHODS: From January 1980 to June 1995, 171 patients underwent pancreatico-duodenectomy, 136 for pancreas, ampulla, distal bile duct or duodenum cancers, and 36 for chronic pancreatitis. Pancreatic anastomosis was realised by pancreatico-jejunostomy in 91 cases and by pancreatico-gastrostomy in 80 cases. There was no significant difference between the two groups (age, gender and primary disease). Comparison between the two groups concerned mainly postoperative mortality and morbidity. RESULTS: The overall postoperative mortality rate was significantly higher in the pancreatico-jejunostomy group (12%) than in the pancreatico-gastrostomy group (3.7%) (P = 0.05); death was directly related to necrosis of the remnant pancreas in four cases among the 14 postoperative deaths. The postoperative morbidity rate was respectively 23% after pancreatico-jejunostomy and 12.5% after pancreatico-gastrostomy; the pancreatic leakage and/or necrosis rate was higher in the pancreatico-jejunostomy group (13%) than in the pancreatico-gastrostomy group (3.75%) (P = 0.029). CONCLUSION: This study seems to demonstrate the superiority of the pancreatico-gastric anastomosis, but these results have to be confirmed or invalidated by a prospective multicentric randomised trial.     

Neoplasms at the site of ureterocolic anastomosis

This paper discusses one of the more uncommon sequelae of ureterocolic anastomosis, namely the formation of tumours at the site of anastomosis. This is a very rare complication and until 1971 the literature recorded only 28 cases of this phenomenon. This present communication adds 2 more cases to the literature--a unilateral tumour and bilateral tumours at the site of anastomosis.     

Vesicorectostomy revisited

Between 1948 and 1959 vesicorectostomy, a permanent anastomosis between the bladder and rectum, was constructed in 7 male patients. Scattered reports of this procedure exist but none since 1959 and long-term followup has never been reported. we present long-term followup, including renal function, excretory urography and voiding cystorectography, and review the quality of life in the 7 patients. The most frequent complication was stenosis of the anastomosis. None of the patients in this series with normal preoperative upper tracts showed radiographic or chemical deterioration postoperatively. Since this procedure maintains urinary continence, does not disturb the normal physiology of the ureterovesical junction and minimizes urinary reabsorption its use should be considered in certain patients as an alternative method of urinary diversion.     

Five-year audit of the acute complications of diverticular disease

BACKGROUND: The objective of this study was to audit the presentation and outcome for patients admitted with an acute complication of diverticular disease. METHODS: This study was a retrospective review of 418 admissions with an acute complication of diverticular disease over a 5-year interval. RESULTS: Of the 418 admissions, 15 patients were eventually found to have an alternative diagnosis. Some 403 patients were studied further. The overall mortality rate in this group was 5.7 per cent. A total of 113 patients (28.0 per cent) required an operation and in this group the mortality rate was 17.7 per cent. All deaths occurred in patients who had surgery for septic complications or bowel obstruction. Of the patients who had surgery, 90.2 per cent had a resection of the involved colon. One-third of these had a primary anastomosis; the remainder underwent Hartmann's procedure. Some 83 patients had a stoma fashioned and of these 72 went on to have the stoma closed. The median age of those who died after operation was 80 years. An American Society of Anesthesiologists (ASA) score of 3 or more, concurrent medical disease and shock on admission were all associated with a high mortality rate (P < 0.001). Some 30 per cent of patients were readmitted during this study with a further complication of diverticular disease. CONCLUSION: The mortality rate after surgery for acute diverticular disease remains excessive and a high-risk group can be identified before operation. A policy of resection and anastomosis appears justified for selected patients. Adopting a practice of interval elective sigmoid colectomy after admission with acute diverticulitis might prevent readmission with further complications.     

Ultrasonographic findings of diseases in peripheral lung fields using transtracheobronchial endoscopic ultrasonography (TUS)

Cystic neoplasms of the pancreas constitute about 9% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. The case of a 70 years-old woman with microcystic cystadenoma is reported. CT-scan of the abdomen diagnosed a 5 cm multilocular septated cyst, with calcifications in the context, localized in the head-uncinate process of the pancreas. The mass was well separated by a sharp cleavage plane with portal vein and superior mesenteric vessels. An ERCP showed cephalic symmetrical stenosis (diameter 3 mm) of the main pancreatic duct (MPD), mildly dilated in the remaining tract (diameter 6 mm). An intraoperative biopsy of the cystic wall was performed. Therefore, it was decided to proceed with a duodenum-preserving resection of the head of the pancreas (DPPHR), including the stenosis tract of the MPD in the surgical specimen. The reconstructive procedure consisted, by i.v. jejunal loop transposition, in a side-to-side pancreatico-jejunostomy, including in the anastomosis both corpocaudal stump and the resection cavity of the pancreatic head, and an end-to-side Roux-en-Y jejuno-jejunostomy. With respect to long-lasting pain relief and preservation of the endocrine and exocrine functions of the pancreas, DPPHR is a highly effective surgical procedure with a low early and late morbidity and mortality due to limited surgical resection. This technique, introduced into surgical practice by Beger, is indicated in patients with chronic pancreatitis with an inflammatory mass in the head of the pancreas. The authors conclude that this procedure can be performed also in case of pancreatic benign tumors, as microcystic cystadenoma. Advantages of this technique makes DPPHR an attractive alternative to Pylorus-Preserving-Pancreatico-Duodenectomy (PPPD).     

Colo-anal sleeve anastomosis in the treatment of diffuse cavernous haemangioma involving the rectum

An operative technique, involving a colo-anal sleeve anastomosis, is described for the treatment of cavernous haemangioma of the rectum. All the patients with this condition treated since 1930 at St Mark's Hospital are reviewed, and the presentation and results of treatment in the last 5 patients who have had a resection and colo-anal sleeve anastomosis are discussed.