review of literature on clinical pancreatology - The Pancreapedia

cancer [468].To evaluate pancreatic surgery as a model for high-acuity surgery in elderly patients forimmediate and long-term outcomes, predictors <strong>of</strong> adverse outcomes, and hospital costs.Four hundred twelve consecutive patients who underwent pancreatic resection from 2001,through 2008 for benign and malignant periampullary conditions. Clinical outcomes werecompared for elderly (> 75 years) and nonelderly patient cohorts. Quality assessmentanalyses were performed to show the differential impact <strong>of</strong> complications and resourceutilization between the groups. The elderly cohort constituted one-fifth <strong>of</strong> all patients.Benchmark standards <strong>of</strong> quality were achieved in this group, including low operative mortality(1 %). Despite higher patient acuity, clinical outcomes were comparable to those <strong>of</strong>nonelderly patients at a marginal cost increase (median, USD 2202 per case). Cost modelinganalysis showed further that minor and moderate complications were more frequent but nomore debilitating for elderly patients. Major complications, however, were far morethreatening to older patients. In these cases, duration <strong>of</strong> hospital stay doubled, and invasiveinterventions were more commonly deployed. It was concluded that quality standards forpancreatic resection in the elderly can – and should – mirror those for younger patients. Agerelatedcare, including geriatric consultation, supplemental enteral nutrition, and earlyrehabilitation placement planning, can be designed to mitigate the impact <strong>of</strong> complications inthe elderly and guarantee quality [469].Surgical techniquesPancreatojejunostomyTo evaluate the impact <strong>of</strong> the length <strong>of</strong> the isolated jejunal loop and the type <strong>of</strong>pancreaticojejunostomy on pancreatic leakage after pancreaticoduodenectomy 132consecutive patients who underwent a pancreaticoduodenectomy were studied according tothe length <strong>of</strong> the isolated jejunal loop (short loop, 20-25 cm vs long loop, 40-50 cm) and thetype <strong>of</strong> pancreaticojejunostomy (invagination vs duct to mucosa). The use <strong>of</strong> the longisolated jejunal loop was associated with a significantly lower pancreatic leakage ratecompared with the use <strong>of</strong> a short isolated jejunal loop (4.3 % vs 14.2 %). In addition, the use<strong>of</strong> duct-to-mucosa technique was associated with significantly lower incidence <strong>of</strong>postoperative pancreatic fistula compared with the invagination technique (4.2 % vs 14.5 %).Finally, patients with a short isolated jejunal loop compared with patients with a long loop hadincreased morbidity (50.7 % vs 27.5 %) and prolonged hospital stay (16 + 2 days vs 10 +/- 2days). Overall mortality rate was 1.5 percent. It was concluded that the use <strong>of</strong> a long isolatedjejunal loop and a duct-to-mucosa pancreaticojejunostomy is associated with decreasedpancreatic leakage rate after pancreaticoduodenectomy [470].Pancreatic fistula is one <strong>of</strong> the most common complications after pancreaticoduodenectomy.It was now tested the hypothesis that a duct to mucosa pancreaticojejunostomy wouldreduce the pancreatic fistula rate. Between 2006 and 2008, 197 patients at two institutionsunderwent pancreaticoduodenectomy by a total <strong>of</strong> 8 experienced pancreatic surgeons aspart <strong>of</strong> this prospective randomized trial. All patients were stratified by pancreatic texture andrandomized to either an invagination or a duct to mucosa pancreaticojejunal anastomosis.Recorded variables included pancreatic duct diameter, operative time, blood loss,complications, and pathology. Primary end point was fistula rate, as defined by theInternational Study Group on Pancreatic Fistula. Rate <strong>of</strong> pancreatic fistula rate for the entirecohort was 18 percent. There were 23 fistulas (24 %) in the duct to mucosa cohort and 12fistulas (12 %) in the invagination cohort, which was a statistically significant difference. Thegreatest risk factor for a fistula was pancreas texture: pancreatic fistulas developed in only 8patients (8 %) with hard glands, and in 27 patients (27 %) with a s<strong>of</strong>t gland. There were two