Technik und Risiko von Pankreasanastomosen

Zusammenfassung

Pankreasresektionen sind auch heutzutage noch mit einer signifikanten Morbidität belastet. Die Mehrzahl der chirurgischen Komplikationen sind auf Probleme im Bereich der enteropankreatischen Anastomose zurückzuführen. Durch technische Modifikationen dieser Anastomose wurde daher immer wieder versucht, die lokale Komplikationsrate zu senken.. Vor- und Nachteile der einzelnen Techniken sowie das derzeitige Risiko und die Prognose von Anastomosenkomplikationen werden analysiert. Prospektiv-randomisierte Studien, die sich mit dieser Problematik beschäftigen sind extrem selten. Es gibt dementsprechend auch weiterhin keinen Goldstandard, was die Herstellung einer enteropankreatischen Anastomose angeht.

Abstract

Resection of the pancreas is still an operative procedure with a significant morbidity. Most of the surgical complications are caused by problems of the enteropancreatic anastomosis. The surgical technique of this anastomosis has been repeatedly modified, in order to reduce the risk of local complications. Pro and cons of the individual techniques as well as the risk and the prognosis of anastomotic failure are discussed. Prospective randomized studies, dealing with this problem are exceedingly rare. Thus, up to now, no gold standard exists in respect to the enteropancreatic anastomosis.

Schlüsselwörter

Pankreasresektion - enteropankreatische Anastomose - Nahtinsuffizienz

Key words

pancreas resection - enteropancreatic anastomosis - anastomotic failure

Literatur

• 1 Adam U, Makowiec F, Riediger H, Schareck W D, Benz S, Hopt U T. Risk factors for complications after pancreatic head resection.  Am J Surg. 2004;  187 201-208
• 2 Schafer M, Mullhaupt B, Clavien P A. Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis.  Ann Surg. 2002;  236 137-148
• 3 Sosa J A, Bowman H M, Gordon T A. et al . Importance of hospital volume in the overall management of pancreatic cancer.  Ann Surg. 1998;  228 429-438
• 4 Yeo C J, Cameron J L, Sohn T A. et al . Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes.  Ann Surg. 1997;  226 248-257
• 5 Strasberg S M, Drebin J A, Mokadam N A. et al . Prospective trial of a blood supply-based technique of pancreaticojejunostomy: effect on anastomotic failure in the Whipple procedure.  J Am Coll Surg. 2002;  194 746-758
• 6 Adam U, Makowiec F, Riediger H, Benz S, Liebe S, Hopt U T. Pankreasleckage nach Pankreasresektion. Eine Analyse von 345 operierten Patienten.  Chirurg. 2002;  73 466-473
• 7 Z'Graggen K, Uhl W, Friess H, Büchler M. How to do a safe pancreatic anastomosis.  J Hepatobiliary Pancreat Surg. 2002;  9 733-737
• 8 Büchler M W, Friess H, Wagner M, Kulli C, Wagener V, Z'Graggen K. Pancreatic fistula after pancreatic head resection.  Br J Surg. 2000;  87 883-889
• 9 Gouma D J, Geenen R CI van, Gulik T M van. et al . Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume.  Ann Surg. 2000;  232 786-795
• 10 Tsuji M, Kimura H, Konishi K. et al . Management of continuous anastomosis of pancreatic duct and jejunal mucosa after pancreaticoduodenectomy: historical study of 300 patients.  Surgery. 1998;  123 828-834
• 11 Hosotani R, Doi R, Imamura M. Duct-to-mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatoduodenectomy.  Worl J Surg. 2002;  26 99-104
• 12 Ohwada S, Ogawa T, Kawate S. et al . Results of duct-to-mucosa pancreaticojejunostomy for pancreaticoduodenectomy Billroth I type reconstruction in 100 consecutive patients.  J Am Coll Surg. 2001;  193 29-35
• 13 Howard J M. Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection.  J Am Coll Surg. 1997;  184 454-457
• 14 Greene B S, Loubeau J M, Peoples J B, Elliot D W. Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures?.  Am J Surg. 1991;  161 45-50
• 15 Bassi C, Falconi M, Molinari E. et al . Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial.  Surgery. 2003;  134 766-771
• 16 Khan A W, Agarwal A K, Davidson B R. Isolated Roux loop duct-to-mucosa pancreaticojejunostomy avoids pancreatic leaks in pancreaticoduodenectomy.  Dig Surg. 2002;  19 199-204
• 17 Papadimitriou J D, Fotopoulos A C, Smyrniotis B. et al . Subtotal pancreaticoduodenectomy: use of a defunctionalized loop for pancreatic stump drainage.  Arch Surg. 1999;  134 135-139
• 18 Poon R TP, Lo S H, Fong D. et al . Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy.  Am J Surg. 2002;  183 42-52
• 19 Arnaud J P, Tuech J J, Cervi C, Bergamaschi R. Pancreaticogastrostomy compared with pancreaticojejunostomy after pancreaticoduodenectomy.  Eur J Surg. 1999;  165 357-362
• 20 Takano S, Ito Y, Watanabe Y, Yokoayama T, Kubota N, Iwai S. Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy.  Br J Surg. 2000;  87 423-427
• 21 Schlitt H J, Schmidt U, Simunec D. et al . Morbidity and mortality associated with pancreatogastrostomy and pancreatojejunostomy following partial pancreatoduodenectomy.  Br J Surg. 2002;  89 1245-1251
• 22 Yeo C J, Cameron J L, Maher M M. et al . A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy.  Ann Surg. 1995;  222 580-588
• 23 Hyodo M, Nagai H. Pancreatogastrostomy (PG) after pancreatoduodenectomy with or without duct-to-mucosa anastomosis for the small pancreatic duct: short- and long-term results.  Hepato-Gastroenterol. 2000;  47 1138-1141
• 24 Okamoto A, Tsuruta K. Fistulation method: simple and safe pancreaticojejunostomy after pancreatoduodenectomy.  Surgery. 2000;  127 433-438
• 25 Yoshimi F, Ono H, Asato Y. et al . Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy in patients undergoing pancreatoduodenectomy to promote earlier discharge from hospital.  Surg Today. 1996;  26 665-667
• 26 Mok K T, Wong B W, Liu S I. Management of pancreatic remnant with strategies according to the size of pancreatic duct after pancreaticoduodenectomy.  Br J Surg. 1999;  86 1018-1019
• 27 Roder J D, Stein H J, Böttcher K A, Busch R, Heidecke C D, Siewert J R. Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy: a prospective study.  Ann Surg. 1999;  229 41-48
• 28 Imaizumi T, Harada N, Hatori T, Fukuda A, Tkasaki K. Stenting is unnecessary in duct-to-mucosa pancreaticojejunostomy even in the normal pancreas.  Pancreatology. 2002;  2 116-121
• 29 Trede M, Schwall G. The complications of pancreatectomy.  Ann Surg. 1988;  207 39-47
• 30 Keck H, Steffen R, Waluja W, Neuhaus P. Anastomosenprotektion durch ein spezielles Drainageverfahren bei der Kausch-Whipple-Operation.  Chirurg. 1991;  62 561-565
• 31 Fallick J S, Farley D R, Farnell M B, Ilstrup D M, Rowland C M. Venting intraluminal drains in pancreaticoduodenectomy.  J Gastrointest Surg. 1999;  3 156-161
• 32 Riediger H, Makowiec F, Schareck W D, Hopt U T, Adam U. Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications.  J Gastrointest Surg. 2003;  7 758-765
• 33 Conlon K C, Labow D, Leung D. et al . Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection.  Ann Surg. 2001;  234 487-493
• 34 Heslin M J, Harrison L E, Brooks A D. et al . Is intra-abdominal drainage necessary after pancreaticoduodenectomy?.  J Gastrointest Surg. 1998;  2 373-378
• 35 Büchler M, Friess H, Klempa I. et al . Role of octreotide in the prevention of postoperative complications following pancreatic resection.  Am J Surg. 1992;  162 125-130
• 36 Friess H, Beger H G, Sulkowski U. et al . Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis.  Br J Surg. 1995;  82 1270-1273
• 37 Montorsi M, Zago M, Mosca F. et al . Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial.  Surgery. 1995;  117 26-31
• 38 Pederzoli P, Bassi C, Falconi M, Camboni M G. Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Italian Study Group.  Br J Surg. 1994;  81 265-269
• 39 Lowy A M, Lee J E, Pisters P W. et al . Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease.  Ann Surg. 1997;  226 632-641
• 40 Yeo C J, Cameron J L, Lillemoe K D. et al . Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial.  Ann Surg. 2000;  232 419-429
• 41 Waclawiczek H W, Lorenz D. Der Schutz der pancreatico-digestiven Anastomose nach Pancreaskopfresektion durch Pankreasgangocclusion mit Fibrin(-kleber).  Chirurg. 1989;  60 403-409
• 42 Al Sharaf K, Ihse I, Dawiskiba S, Andren-Sandberg A. Characteristics of the gland remnant predict complications after subtotal pancreatectomy.  Dig Surg. 1996;  73 101-108
• 43 Izbicki J R, Bloechle C, Broering D C, Knoefel W T, Kuechler T, Broelsch C E. Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy.  Ann Surg. 1998;  228 771-779
• 44 Hamanaka Y, Nishihara K, Hamasaki T. et al . Pancreatic juice output after pancreaticoduodenectomy in relation to pancreatic consistency, duct size, and leakage.  Surgery. 1996;  119 281-287
• 45 Yeh T S, Yan Y Y, Jeng L B. et al . Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy - multivariate analysis of perioperative risk factors.  J Surg Res. 1997;  67 119-125
• 46 Srivastava S, Sikora S S, Pandey C M, Kumar A, Saxena R, Kapoor V K. Determinants of pancreaticoenteric anastomotic leak following pancreaticoduodenectomy.  ANZ J Surg. 2001;  71 511-515
• 47 Bassi C, Butturini G, Molinari E. et al . Pancreatic fistula rate after pancreatic resection.  Dig Surg. 2004;  21 54-59
• 48 Balcom J H, Rattner D W, Warshaw A L, Chang Y, Fernandez-del-Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization.  Arch Surg. 2001;  136 391-398
• 49 Hopt U T, Makowiec F, Adam U. Nahtinsuffizienzen im biliopankreatischen Bereich.  Chirurg. 2004;  75 1079-1087
• 50 Berge Henegouwen M I, Allema J H, Gulik T M van, Verbeek P C, Obertop H, Gouma D J. Delayed massive haemorrhage after pancreatic and biliary surgery.  Br J Surg. 1995;  82 1527-1531
• 51 Rumstadt B, Schwab M, Korth P, Samman M, Trede M. Hemorrhage after pancreatoduodenectomy.  Ann Surg. 1998;  227 236-241
• 52 Brodsky J T, Turnbull A D. Arterial hemorrhage after pancreatoduodenectomy. The sentinel bleed.  Arch Surg. 1991;  126 1037-1040
• 53 Farley D R, Schwall G, Trede M. Completion pancreatectomy for surgical complications after pancreaticoduodenectomy.  Br J Surg. 1996;  83 176-179
• 54 Gueroult S, Parc Y, Duron F, Paye F, Parc R. Completion pancreatectomy for postoperative peritonitis after pancreaticoduodenectomy: early and late outcome.  Arch Surg. 2004;  139 16-19