A novel technique of managing undilated small pancreatic duct.pptx

A novel technique of managing undilated small pancreatic duct

1. A novel technique of managing undilated small pancreatic duct (SPD) during pancreaticojejunal anastomosis (PJA) in Whipple’s pancreaticoduodenectomy (WPD) for malignancy. A Comparative Retrospective Analysis Dr. Manish Kumar Dr. Suman Mandal, Dr. Tarique Ghazali, Dr. Sanjoy Mandal Department of GI Surgery AMRI Hospitals Kolkata

2. Introduction The pancreaticojejunal anastomosis (PJA) is considered the Achilles heel of WPD. Leak from the PJA is associated with extensive morbidity ranging from 30% to 50% leading to prolonged hospital stay and increased costs. Studies have shown significant association with the size of the pancreatic duct(PD) and pancreatic consistency, with the difficulty of anastomoses and the frequency of PJA leak. In this retrospective comparative study we evaluated a novel technique of managing small PD(SPD) of ≤2mm. No conflict of interest, No financial funding Ann Hepatobiliary Pancreat Surg 2022;26:84-90 J Gastrointest Surg. 2021 Feb;25(2):411-420. doi: 10.1007/s11605-020-04528-3. Epub 2020 Jan 29.

3. Aim Comparative retrospective analysis of clinical outcome of a novel technique of intraoperative on-table sequential dilatation of small pancreatic duct (SPD) during WPD for malignancy

4. Method Study period and population - The study was conducted over two separate time durations, starting from January 2008 to Dec 2017 and Jan 2018 to March 2022.During this period , a total of 138 WPD performed. Patients with chronic pancreatitis(CP)(8), emergency surgery(1), benign tumors (3), HPD (2) & those who underwent dunking (2) were excluded. (Patient number in bracket) After exclusion, total of 122 WPD performed during this period for malignancy Patients with PD size ≤2mm were defined as SPD, while those with >2mm were ‘labeled’ as dilated PD (DPD). In the 1st group (2008-2017) all PJ reconstructions underwent standard Blumgart type PJA (3/0 & 5/0 or 6/0 polypropylene). In the 2nd group (2018-2022) all SPD underwent sequential dilatation with gradually increasing sizes of infant feeding tubes (IFT), each left in position for 10 to 15 minutes, till 10-12Fr IFT could be accommodated

5. Technique of duct-to-mucosa PJA (Blumgart Technique) British Journal of Surgery 2009; 96: 741–750

6. Method Subsequently Blumgart type PJA was done with 6/0 polypropylene for inner duct-to-mucosa & 3/0 polypropylene for outer layer. All anastomoses were stented with IFT and wrapped with omentum PJ leak(PJL) was defined as drain fluid amylase content > 3 times serum value on/after POD3 or evidence of clinical features.(ISGPF). Only Grade B & C leaks were considered. SPD allowing 20G cannula being dilated to 10Fr Transl Gastroenterol Hepatol 2017;2:107

7. Results & Discussion 1st study period(2008-17, n=87), PJL 15(17.2%), Mortality 5(5.8%) 2nd study period(2018-22, n=35), PJL 7(20%), Mortality 1(2.9%) 1st Study period(N=87) P value 2nd Study period (n=35) P value Parameters DPD (n=66) SPD(n=21) DPD (n=20) SPD(n=15) Age (years) 63.4,SD 10.9 58.4,SD 7.6 0.052 58.3,SD 7.6 62.6,SD 7.9 0.118 Bilirubin >3mg/dl 56 (84.9%) 15 (71.4%) 0.166 14 (70%) 8 (53.3%) 0.313 ERCP stenting 47 (71.2%) 9 (42.9%) 0.018 9 (45%) 5 (33.3%) 0.486 PJL (B + C) 6 (9.1%) 9 (42.9%) 0.003 3 (15%) 4 (26.7%) 0.402 PJL grade B 5 (7.5%) 7 (33.3%) 0.017 3 (15%) 3 (20%) 0.702 PJL grade C 1 (1.52%) 2 (9.5%) 0.224 0 (0%) 1 (6.7%) 0.301 Vein resection (VR) 1 (1.5%) 1 (4.8%) 0.506 2 (10%) 2 (13.3%) 0.736 Blood loss (ml) 700,SD 209 698,SD 203 0.96 668,SD 173 634,SD 141 0.545 Operating time (m) 332,SD 35 389,SD 43 0.001 301,SD 39 357,SD 47 0.001 Time to discharge 11.7,SD 2.3 14.5,SD 3.2 0.001 11.1,SD 2.7 13.4,SD 4.2 0.056 Mortality 1 (1.5%) 4 (19.1%) 0.044 0 (0%) 1 (6.7%) 0.301 Table 1. Comparison between DPD and SPD in both study periods

8. Categorical variables compared with Pearson’s Chi Square test for Independence of Attributes/ Fisher's Exact Test as appropriate. Continuous variables compared using unpaired t test. DPD group (n=86) p value SPD group (n=36) P value Parameters 1st study(n=66) 2nd study(n=20) 1st study(n=21) 2nd study(n=15) Age 63.4,SD 10.9 58.3,SD 7.6 0.053 58.4,SD 7.6 62.6,SD 7.9 0.121 Bilirubin >3mg/dl 56 (84.9%) 14 (70%) 0.135 15 (71.4%) 8 (53.3%) 0.265 ERCP stenting 47 (71.2%) 9 (45%) 0.031 9 (42.9%) 5 (33.3%) 0.563 PJL(B+C) 6/66 (9.1%) 3/20 (15%) 0.499 9 (42.9%) 4 (26.7%) 0.303 PJL grade B 5 (7.5%) 3 (15%) 0.389 7 (33.3%) 3 (20%) 0.360 PJL grade C 1 (1.52%) 0 (0%) 0.314 2 (9.5%) 1 (6.7%) 0.753 Vein Resection 1 (1.5%) 2 (10%) 0.217 1 (4.8%) 2 (13.3%) 0.388 Blood loss(ml) 700,SD 209 688,SD 173 0.52 698,SD 203 634,SD 141 0.304 Op. time (m) 332,SD 35 301, SD 39 0.001 389,SD 43 357,SD 47 0.046 Mortality 1/66 (1.5%) 0/20 (0%) 0.314 4 (19.1%) 1 (6.7%) 0.248 Discharge (d) 11,SD 2.3 11.1,SD 2.7 0.339 14.5,SD 3.2 13.4,SD 4.2 0.390 Table 2. Comparison between DPDs in both study periods & SPDs in both study periods

9. Discussion 1st group Age distribution & blood loss was same. PJL & mortality was higher in SPD Operating time and time to discharge was higher in SPD compared to DPD and these were statistically significant. 2nd group The SPD underwent sequential dilatation. PJL, mortality, operating time and time to discharge were all on the higher side in the SPD and they were not statistically significant Only the operating time was statistically significant One other study where they concluded that SPD <2mm was associated with poorer outcome. This also included consistency of pancreas as a criteria.

10. Limitations Small number of patients Two different time periods studied PJL in Stent vs non stented patients was not evaluated Pancreas consistency BMI

11. Conclusion SPD is associated with higher PJL, mortality, operating time & time to discharge. Intraoperative on-table sequential dilatation of SPD (though not reaching statistical significance) helps in easier anastomosis decreases postoperative leak & mortality

12. References J Gastrointest Surg. 2021 Feb;25(2):411-420. doi: 10.1007/s11605-020-04528-3. Epub 2020 Jan 29. J Surg Oncol. 2018 Apr;117(5):928-939. doi: 10.1002/jso.24986. Epub 2018 Mar 25 British Journal of Surgery 2009; 96: 741–750 Transl Gastroenterol Hepatol 2017;2:107 Ann Hepatobiliary Pancreat Surg 2022;26:84-90

13. Thank You Dr Kasturi Banerjee , Consultant Anesthetist, Medica Superspecialty Hospital , Kolkata Dr Saurav Mukherjee, Dr Amlan Chatterjee, Dr Saugata Paul, Dr Krishnendu Chandra Consultant Anesthetist, AMRI Hospitals, Kolkata Dr Sanjay Basu, Dr Sujit Chaudhuri, Dr. Gautam Das, Dr Sudipta Ghosh, Dr TNL Majumdar, Consultants Gastroenterologist , AMRI Hospitals , Kolkata Mr Sauvik Dutta, MS in QE, Indian Statistical Institute., Consultant Statistician AMRI Hospitals, Kolkata. Acknowledgements