| Objective To discuss the clinical value and safety of a modified pancreatojejunal anastomosis, namely horizontal mattress suture in pancreaticoduodenectomy, and analysis the related risk factors of pancreatic fistula after pancreaticoduodenectomy to propose prevention strategies.Methods In first part, we We retrospectively reviewed 145 consecutive patients undergone pancreaticoduodenectomy (PD) at our hospital from January 2013 to December 2016. We collected clinical data including age, gender, medical history,laboratory findings, pathological diagnosis, texture of pancreas, pancreatic duct diameter, operation time, amount of bleeding, pancreatojejunal anastomotic method,blood transfusion, postoperative complications and postoperative hospitalization time.A group of 33 patients were treated with modified horizontal mattress method, and the other group of 112 patients was treated by traditional method of eight needle thread suture. All cases underwent radical pancreaticoduodenectomy, followed by the principle of no-touch isolation technique and en-bloc resection. Complete resection of section of the pancreas head on the left margin of the mesenteric-portal vein,cholecystectomy, section of biliary duct, section of gastric or preservation of the pylorus, section of the first jejunal loop and adjacent tissues and lymph nodes.Postoperative pathology margins were negative. The modified Child method was used for the reconstruction of digestive tract according to the order of pancreaticoj ejunostomy, choledochojejunostomy, gastrointestinal anastomosis.Pancreatic duct stent, jejunum nutrition tube or enterostomy were routinely placed.Criteria and grading criteria for pancreatic fistula after pancreaticoduodenectomy.Criteria and grading for pancreatic fistula after pancreaticoduodenectomy were according to the International Study Group on Pancreatic Surgery Standard(2005),defined as output containing transient pancreatic amylase on or after the third postoperative day from an operatively positioned drain with a pancreatic amylase level more than three times the upper serum reference value,which was divided into Grade A, B, C according to the severity of the disease and the impact on the patients.The differences between the two groups were compared, including gender,age, medical history, laboratory examination results, history of the general clinical data, intraoperative hemorrhage and blood transfusion volume, operation time, texture of pancreas, pancreatic duct diameter and intraoperative factors of postoperative pancreatic fistula, biliary fistula, chylous fistula, postoperative bleeding, delayed gastric emptying, ascites, abdominal infection, wound infection, in-hospital mortality and other complications.Explore the difference in intraoperative bleeding, blood transfusion, operation time and postoperative complication rate between modified horizontal mattress suture group and eight needle suture group.SPSS22.0 software was used for statistical analyses, measurement data with the mean or median description, grouped data in percentage description; Chi-square test or Fisher's exact test used to compare the measurement data, Comparison of measurement data using rank sum test. P value less than 0.05 were considered statistically significant.In second part, we retrospectively reviewed 145 consecutive patients undergone pancreaticoduodenectomy (PD) at our hospital from January 2013 to December 2016 .The following factors were selected as variables.Including gender, age, with the history of hypertension, diabetes, heart and lung disease, jaundice, pancreatitis,drinking or not, and Lesion location, preoperative bilirubin, albumin, hemoglobin,level of tumor markers and intraoperative variables including the texture of pancreas,pancreatic duct diameter,pancreaticojejunostomy methods, jejunostomy or jejunal tube, combined with hepatic resection or not, combined with vascular resection or not,pylorus preserving or not, operation time ,volume of bleeding and transfusion or not.Univariate analysis was performed by Chi-square test or Fisher's exact test. The risk factors for clinically relevant POPF were evaluated using Logistic regression. P value less than 0.05 were considered statistically significant. Statistically significant variables demonstrated in the univariate analysis were incorporated into a multivariate logistic regression analysis to identify the independent risk factors for pancreatic fistula after pancreaticoduodenectomy.Results In first part, 145 cases were included in this study. The horizontal mattress suture group has 33 patients and eight needle thread suture group has 112 cases. 60 cases of pancreatic head tumor, 5 cases of common bile duct tumor, 24 cases of duodenal tumor, 17 cases of Vater ampulla tumor, 2 cases of pancreatitis, 2 cases of pancreatic cyst,1 cases of eosinophilic enteritis were confirmed by pathology. There were 51 males and 94 females, with an average age of 59.5 years, range from 22 to 81 years. The two groups have no significant difference in gender, age, preoperative bilirubin, albumin, hemoglobin level, texture of pancreas, pancreatic duct diameter,intraoperative blood transfusion and bleeding. There was significant difference between the two groups in the operation time and postoperative hospital stay.Horizontal mattress suture group' s average operation time was 4.5h (3.5h-9h),while eight needle thread suture group' s the average operation time is 6h(4h-12h).The operation time of eight needle thread suture group' s operation time was significantly higher than the horizontal mattress group' s(P=0.015). Horizontal mattress suture group' s average postoperative hospitalization time(14days) was significantly shorter than eight needle thread suture group' s (P=0.017). The horizontal mattress suture group has obvious advantages in shortening the operation time and reducing the time of hospital stay. The two groups have no difference in the biliary fistula, postoperative bleeding, gastric emptying, ascites, abdominal infection,wound infection, hospital mortality and chylous fistula.However, eight needle thread suture group' s pancreatic fistula rate was significantly higher than the horizontal mattress suture group' s(P=0.018).In the second part, univariate analysis showed no significant correlation between postoperative pancreatic fistula (POPF) and the following factors: gender, age, history of hypertension,diabetes,heart and lung disease,jaundice,pancreatitis,drinking,the level of laboratory test results including bilirubin, albumin, hemoglobin, tumor markers, intraoperative factors including enterostomy or intestinal feeding tube,combined hepatectomy or vascular resection, pylorus preserving, volume of bleeding and transfusion.Conversely, a significant correlation was observed between POPF and the following factors: pancreatic texture(soft vs hard: 41.9% vs 14.9%, P = 0.001),pancreatic duct diameter (? 3 mm vs > 3mm: 33.3%% vs 12.5%, P = 0.002),pancreaticojejunal anastomose technique(horizontal mattress suture vs eight needle thread suture: 6.1%% vs 25.0%, P = 0.018), operation time(>6.5h vs <6.5h:31.7%% vs 16.4%, P = 0.040), lesion location (P=0.001).Multivariate logistic regression analysis showed that pancreatic duct diameter < 3 mm, and lesionlocation were independent risk factors for pancreatic fistula after pancreaticoduodenectomy.Conclusion Horizontal mattress suture is a safe and effective pancreatojejunostomy,The horizontal mattress suture group has obvious advantages in shortening the operation time and reducing the time of hospital stay reduce pancreatic fistula related complications.Operation time, pancreaticojejunal anastomose technique and the texture of pancreas is the related risk factors of pancreatic fistula after pancreaticoduodenectomy; Pancreatic duct diameter?3 mm, and tumor location were independent risk factors for pancreatic fistula after pancreaticoduodenectomy.If the texture of pancreas is soft ,or pancreatic duct diameter less than 3mm,or the location of lesions in the duodenum, the horizontal mattress suture for pancreaticojejunostomy can be used to prevent the occurrence of postoperative pancreatic fistula. |
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