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Background/purpose: It is important to predict the development of clinically relevant pancreatic fistula (grade B/C) in the early period after pancreaticoduodenectomy (PD). This study has been carried out as a project study of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHPBS) to evaluate the predictive factors associated with clinically relevant pancreatic fistula (grade B/C)., Method: The data of 1,239 patients from 11 medical institutions who had undergone PD between July 2005 and June 2009 were retrospectively analyzed to review patient characteristics and perioperative and postoperative parameters., Results: A drain amylase level >4,000 IU/L on postoperative day (POD) 1 was proposed as the cut-off level to predict clinical relevant pancreatic fistula by the receiver operating characteristic (ROC) curve. The sensitivity, specificity, and accuracy of this cut-off level were 62.2, 89.0, and 84.8%, respectively. A multivariate logistic regression analysis revealed that male [odds ratio (OR) 1.7, P = 0.039], intraoperative bleeding >1,000 ml (OR 2.5, P = 0.001), soft pancreas (OR 2.7, P = 0.001), and drain amylase level on POD 1 >4,000 IU/L (OR 8.6, P < 0.001) were the significant predictive factors for clinical pancreatic fistula., Conclusion: The four predictive risk factors identified here can provide useful information useful for tailoring postoperative management of clinically relevant pancreatic fistula (grade B/C).

The ideal surgical procedure for treating pancreatic cancer achieves radical excision in a minimally invasive manner and allows rapid transition to adjuvant chemotherapy. If the afferent artery to the pancreatic head is not ligated until the latter half of the surgery, congestion of the pancreaticoduodenal vein may occur, leading to phleborrhagia and increased intraoperative hemorrhage. Ligation of the afferent artery, i.e., the inferior pancreaticoduodenal artery (IPDA), in the first half of the surgery may prevent the occurrence of hemorrhage due to congestion. Early ligation of the IPDA is also useful in ensuring the success of radical dissection of the plexus around the superior mesenteric artery or the no. 14 lymph node. We have been performing pancreaticoduodenectomies with antecedent IPDA ligation since 2005 and have found that the percentage of R0 versus R1 and R2 has increased compared with that when standard pancreaticoduodenectomies were performed. Preemptive ligation of the IPDA early in pancreaticoduodenectomy for invasive pancreatic cancer is a useful method for reducing blood loss and achieving R0 resection in a thorough yet efficient manner.

Background: Robotic surgery is the most advanced development in minimally invasive surgery. However, the number of reports on robot-assisted endoscopic gastrointestinal surgery is still very small. In this article, we describe total laparoscopic pancreaticoduodenectomy (PD) undertaken using the da Vinci Surgical System® (Intutive Surgical)., Methods: Three patients underwent robotic PD between November 2009 and February 2010. Following resection of the pancreatic head, duodenum, and the distal stomach, intracorporeal anastomosis was accomplished by Child's method of reconstruction, which includes a two-layered end-to-side pancreaticojejunostomy, an end-to-side choledochojejunostomy, and a side-to-side gastrojejunostomy., Results: The time required for surgery was 703 ± 141 min, and blood loss was 118 ± 72 mL. The average hospital stay period was 26 ± 12 days. As a postoperative complication, pancreatic juice leak occurred in one case, but it was managed with conservative treatment. Of the three patients, one had cancer of the papilla of Vater, one had cancer of the pancreatic head, and one had a solid pseudopapillary neoplasm. In all cases, the surgical margin was negative for tumor., Conclusions: Robot-assisted PD required a long time, but organ removal with less bleeding was able to be safely performed owing to the high degree of freedom associated with the forceps manipulation and the magnified view. Similarly, pancreatojejunostomy could certainly be conducted. No major postoperative complications were found. Accumulation of da Vinci PD experience in the future will lead to safer and faster PD.

To apply duodenum-preserving pancreatic head resection (DPPHR) as radical procedure for benign or low-grade malignant tumors, it needs the reconciliation of complete pancreatic head resection and preservation of the bile duct and peripancreatic vessels. Several modifications have been introduced and applied to remove these lesions, however, the techniques have not been made clear in the management of the peripancreatic vessels and the bile duct. The long-term outcomes of the DPPHR have been reported as extremely rare in comparison with pylorus preserving pancreatoduodenectomy (PPPD) in these pancreatic head tumors. The angiograms by multi-detector row CT (MD-CT) can be reconstructed more physiologically than selective angiography. The anterior arcade is predominant in 43% of 64 patients. Therefore, we modified the DPPHR to include a complete resection of the pancreatic head and the preservation of both anterior and posterior arterial arcades. The bile duct is covered by the pancreatic parenchyma in various ways. The techniques of the preservation of the bile duct are also introduced. We performed 21 DPPHRs and 19 PPPDs in the patients with benign or low-grade malignant pancreatic head tumor. There was no significant difference in operative factors. The postoperative death was one patient in PPPD, but none in DPPHR. The postoperative complications of PPPD were more often than that of DPPHR. There is no postoperative recurrence in DPPHR in the follow-up period from 2 to 216 months. Both exocrine and endocrine function and the long-term results following DPPHR were superior to those following PPPD. The DPPHR should be favored over the PPPD in benign or low-grade malignant tumors of the head of the pancreas if there is no compromise with oncologic radicality.

Background/purpose: During a pancreatoduodenectomy (PD) it is important that the anatomy of the arcade of blood vessels in the head of the pancreas is fully understood before the surgery in order to reduce intraoperative bleeding. In most of the patients our group has treated, the inferior pancreaticoduodenal artery (IPDA), one of the efferent arteries of the head of the pancreas, has formed a short common trunk with the first jejunal artery (FJA). Thus, by first locating the origin of the FJA, it was easier to locate the IPDA. There are two ways to locate the IPDA: (1) by measuring the distance between the origin of the superior mesenteric artery (SMA) and that of the FJA; (2) by measuring the distance between the origin of the middle colic artery (MCA) and that of the FJA. Here, we report our measurements of both distances using three-dimensional (3D) models of arteries constructed with multidetector-row computed tomography (MD-CT) images and discuss which is the better measurement to determine the location of the IPDA during PD., Methods: A total of 140 patients underwent 64-MD-CT imaging to acquire early and late arterial phase scans. The distance between the origin of the SMA and that of the FJA and the distance between the origin of the MCA and that of the FJA origin were measured., Results: In patients whose IPDA formed either a common trunk with the FJA or arose directly from the SMA, the IPDA or the common truck was located in parallel with the SMA at a very short distance of approximately 18 mm from the MCA origin towards the center. The distance between the SMA origin and the IPDA was significantly longer (approximately 36 mm). Therefore, locating the MCA origin during PD helped determine the location of the IPDA. However, in patients whose anterior inferior pancreaticoduodenal artery (AIPDA) and posterior inferior pancreaticoduodenal artery (PIPDA) arose separately, the distance between the AIPDA origin and the MCA origin was approximately 18 mm, the distance between the AIPDA origin and the PIPDA origin was approximately 19 mm, and the distance between the PIPDA origin and the SMA origin was 19 mm. Thus, locating the SMA helped determine the location of the IPDA during PD in these patients., Conclusion: Based on our findings that the distance between the IPDA origin and the MCA origin was short, we have shown that it is effective to locate the MCA origin in order to determine the location of the IPDA.

Background: In patients having locally advanced cancer of the stomach with suspected tumor infiltration to the pancreatic head or the duodenum, a concurrent pancreaticoduodenectomy with gastrectomy is occasionally prerequisite to achieve a microscopically tumor-free surgical margin., Materials and Methods: We present the first series of successful totally laparoscopic pancreaticoduodenectomy (TLPD) for advanced gastric cancer with suspected infiltration to the pancreatic head., Results: TLPD was successfully performed without adverse events during surgery and resulted in favorable short-term outcomes of three patients with locally advanced gastric cancer with suspected invasion to the pancreas., Conclusions: Although TLPD for locally advanced gastric cancer is a technically difficult challenging operation that requires careful dissection along the major vessels, intracorporeal tie sutures, and the placement of an external drainage tube into a narrow pancreatic duct, this procedure is technically feasible and safe in the hands of experienced surgeons. Long-term follow-up is mandatory to validate oncological outcome.

Background/purpose: Pancreatoduodenectomy (PD) is one of the most difficult operations in gastrointestinal surgery. Standard PD ligates and cuts superior mesenteric vein (SMV) branches after the removal of the pancreas head, which leads to congestion and bleeding of these veins., Methods: In this study, we modified the standard PD and first ligated the efferent vessels (arteries); namely, the gastroduodenal artery and inferior pancreatoduodenal artery (IPDA), before ligating and cutting the corresponding afferent vessels (veins) of the pancreas head. By doing this, congestion of these veins was relieved and bleeding from the resected surface was substantially prevented. Thirty-six patients (18 underwent standard PD and 18 had modified PD) formed the study population., Results: The amount of bleeding in the modified PD group was significantly lower than that in the standard PD group. (678 +/- 329 g vs 1225 +/- 375 g, respectively; P < 0.05) However, no difference in operation time was found between the two groups., Conclusions: We believe this modified PD procedure is valuable to enable the safe performance of PD.

Background/aims: The aim of this study was to determine whether Billroth I pancreaticogastrostomy (PG-I) or Billroth II pancreaticojejunostomy (PJ-II) after pylorus-preserving pancreatoduodenectomy is associated with better postoperative fat absorption, based on residual pancreatic exocrine function. Several reconstructive operations have been employed after pylorus-preserving pancreatoduodenectomy to maximize postoperative nutrition. However, no single-institution study has been published comparing the reconstructive procedures with respect to digestion and absorption of fat., Methodology: Fat absorption was studied using the 13C-trioctanoin breath test in patients who were grouped according to the degree of fibrosis of the pancreatic remnant, which was determined by histologic examination of the resection specimen. The fibrosis was graded: grade 0, < 10% fibrosis; grade 1, 10-30% fibrosis; and grade 2, > 30% fibrosis. There were 22 patients in the PG-I group and 22 patients in the PJ-II group., Results: There were no significant differences between the PG-I and PJ-II groups in the cumulative excretion of labeled carbon dioxide in the patients with grade 0 pancreatic fibrosis. The cumulative excretion in the PG-I group was better than in the PJ-II group in the patients with grade 1 and grade 2 pancreatic fibrosis., Conclusions: Fat absorption after PG-I is superior to that after PJ-II in patients with disordered exocrine function of the pancreatic remnant. Billroth I pancreaticogastrostomy allows more effective utilization of the exocrine enzymes of the pancreatic remnant due to elimination of the blind loop characteristic of the Billroth II pancreaticojejunostomy.

The aim of this study was to determine if fat absorption is better after pylorus-preserving pancreatoduodenectomy (PPPD) or duodenum-preserving pancreatic head resection (DPPHR) compared with that following pancreatoduodenectomy with gastrectomy (SPD), provided the patients have similar pancreatic exocrine function. Fat absorption was studied using the 13C-trioctanoin breath test in patients who were grouped according to the degree of fibrosis of the pancreatic remnant. The latter was judged by histologically measuring the fibrosis in a transectional wedge of resected pancreas. We evaluated 11 SPD cases, 25 PPPD cases, and 9 DPPHR cases. The 13C excretion rates and cumulative excretion values following DPPHR or PPPD were significantly better than those following SPD. The 13C excretion rates and cumulative values for the patients with > 30% fibrosis of the pancreas were lower than those in patients with < 30% pancreatic fibrosis, regardless of the surgical procedure. The cumulative value in the SPD group, however, was lower than that in the PPPD or DPPHR patients with < 30% pancreatic fibrosis. The results suggested that fat absorption following PPPD or DPPHR is superior to that after SPD in patients with the same fibrotic area of the pancreatic remnant and depends on the degree of fibrosis in the pancreatic remnant.