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Pancreatic leakage after pancreaticoduodenectomy for cancer

Pancreatic leakage after pancreaticoduodenectomy for cancer. Roberto Tersigni Massimo Capaldi. Benevento, 22 giugno 2012. PANCREATICODUODENECTOMY FOR CANCER.

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Pancreatic leakage after pancreaticoduodenectomy for cancer

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  1. Pancreaticleakageafterpancreaticoduodenectomyforcancer Roberto Tersigni Massimo Capaldi Benevento, 22 giugno 2012

  2. PANCREATICODUODENECTOMYFOR CANCER Pancreaticoduodenectomy is the treatment of choice for patients with resectable carcinoma of the pancreatic head and periampullary region • Morbidityis still around 20% to 50% • Mortality is < 5 % in high volume centers • Mortality is 12,5% in Italy

  3. Pancreas Duodenum

  4. IntrapancreaticBiliaryDuct AmpullaofVater

  5. RadicalLimphadenectomy

  6. AnomalousVessels

  7. Arterial and Venousinvolvement

  8. Venousinfiltration > 180 ° Venousinfiltration < 180°

  9. SecondaryPancreatic Head Cancer

  10. IntraOperativeRadioTherapy

  11. TYPE OF COMPLICATION CLINICAL DEFINITION Abdominal complications after duodenopancreatic resection • Pancreatic Fistula • Abdominal collection • Haemorrhage • Delayed gastric empting • Acute pancreatitis • Output rich in amylase, stadiation by ISGPF • Collection of fluid measuring at least 5 cm in diameter • Requirement of > 3 Units of pRBC/ 1000 ml • Nasogastric tube decompression for >10days • At least a 3 fold increase of normal plasma amylase or lipase 48h after the operation

  12. PANCREATIC FISTULA Pancreatic leakage is the most important complication from which 40% of patients death are the result of septic or haemorrhagic complications The incidence of Pancreatic Fistula varies from 10% to 25% without reduction in the past decade Whipple reported 19,5% Fistula rate more than 50 years ago

  13. Main Pancreatic Duct • Pancreatic cut surface Origin and Definitionof Pancreatic Anastomotic Fistula ORIGIN: DEFINITION: (ISGPF) Any measurable volume of fluid after p.o. day 3 with amylase content greater than 3 times the serum amylase activity

  14. Pancreatic anastomotic fistula severity • Transient, asimptomatic fistula with elevated drain amylase without clinical relevance • Symptomatic fistula that require diagnostic evaluation and therapeutic management and prolongation of hospital stay • Fistula with severe clinical impact that require aggressive diagnostic and therapeutic management (percutaneousdrains or re-surgery). Possibility of mortality • A • B • C Grade

  15. C. MAX SCHMIDT HPB SURGERY 2009 MF • PATIENT DEMOGRAPHICS • PATHOLOGY • PANCREATIC TEXTURE • PANCREATIC DUCT SIZEPREANASTOMOTIC or POSTOPERATIVE STENT • TYPE ANASTOMOSIS • SURGEON VOLUME n.s. Classical risk factors associated with pancreatic Fistula in 510 pancreaticoduodenectomies Pancreatic lesionsPeriampullarylesions <0,001 SoftFirmHard <0,001 P-VALUE <3mm3-5 mm > 5 mm <0,001 n.s. <0,001 <0,001

  16. PANCREATICOGASTROSTOMY VS PANCREATICOJEJUNOSTOMY RANDOMIZED CONTROLLED TRIALS COMPARING

  17. Selection of anastomotic techniqueaccording to pancreatic texture andduct size Texture Ductsize Anastomotictechnique • SOFT < 3 mmDuct occlusion – Pancreaticojejunostomy - Pancreaticogastrostomy • FIRM 3 – 5 mm • HARD >5 mm Duct to mucosa Pancreaticojejunostomy Pancreaticogastrostomy

  18. Wirsung’s occlusionwithCianoacrilate (Glubran 2®)

  19. BiliodigestiveAnastomosis

  20. End to Side PJ anastomosis

  21. Ductto Mucosa PJ anastomosis

  22. Double Major PancreaticDuct

  23. Delayed Haemorrhage Emergency resuscitative measures Endoscopy Angiography Failure to control bleed Emergency Re-surgery Worsening clinical signs Re-Surgery Management of Pancreatic Fistula No clinical signs Conservative management Decreasing output Improving condition Increasing output Worsening condition Drains Worsening clinical signs Improving condition

  24. Duodenopancreatectomy Management of Pancreatic Stump Total 150 Classical Whipple 46 Pylorus Preserving 104 Tersigniet al.

  25. Postoperative Course, Complications and Outcome Tersigniet al.

  26. Periampullary and pancreaticneoplasms Tersigniet al.

  27. Grazie per l’attenzione

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