Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial.
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OBJECTIVE: To evaluate the endpoints of complications (specifically pancreatic fistula and total complications) and death in patients undergoing pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Four randomized, placebo-controlled, multicenter trials from Europe have evaluated prophylactic octreotide (the long-acting synthetic analog of native somatostatin) in patients undergoing pancreatic resection. Each trial reported significant decreases in overall complication rates, and two of the four reported significantly lowered rates of pancreatic fistula in patients receiving prophylactic octreotide. However, none of these four trials studied only pancreaticoduodenal resections, and all trials had high pancreatic fistula rates (>19%) in the placebo group. A fifth randomized trial from the United States evaluated the use of prophylactic octreotide in patients undergoing pancreaticoduodenectomy and found no benefit to the use of octreotide. Prophylactic use of octreotide adds more than $75 to the daily hospital charge in the United States. In calendar year 1996, 288 patients received octreotide on the surgical service at the authors' institution, for total billed charges of $74,652. METHODS: Between February 1998 and February 2000, 383 patients were recruited into this study on the basis of preoperative anticipation of pancreaticoduodenal resection. Patients who gave consent were randomized to saline control versus octreotide 250 microg subcutaneously every 8 hours for 7 days, to start 1 to 2 hours before surgery. The primary postoperative endpoints were pancreatic fistula, total complications, death, and length of hospital stay. RESULTS: Two hundred eleven patients underwent pancreaticoduodenectomy with pancreatic-enteric anastomosis, received appropriate saline/octreotide doses, and were available for endpoint analysis. The two groups were comparable with respect to demographics (54% male, median age 66 years), type of pancreaticoduodenal resection (60% pylorus-preserving), type of pancreatic-enteric anastomosis (87% end-to-side pancreaticojejunostomy), and pathologic diagnosis. The pancreatic fistula rates were 9% in the control group and 11% in the octreotide group. The overall complication rates were 34% in the control group and 40% in the octreotide group; the in-hospital death rates were 0% versus 1%, respectively. The median postoperative length of hospital stay was 9 days in both groups. CONCLUSIONS: These data demonstrate that the prophylactic use of perioperative octreotide does not reduce the incidence of pancreatic fistula or total complications after pancreaticoduodenectomy. Prophylactic octreotide use in this setting should be eliminated, at a considerable cost savings. (+info)
Radical distal pancreatectomy with en bloc resection of the celiac artery, plexus, and ganglions for advanced cancer of the pancreatic body: a preliminary report on perfect pain relief.
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OBJECTIVE: The purpose of this study was to report the effect of radical distal pancreatectomy with en bloc resection of the celiac artery, plexus, and ganglions for locally advanced cancer of the pancreatic body on intractable abdominal and/or back pain and to explore the histopathologic mechanism of this pain. PATIENTS: Five patients with pancreatic body cancer involving the celiac and/or common hepatic artery underwent this radical surgery intended to cure the cancer. DESIGN: A retrospective analysis was performed. MAIN OUTCOME MEASURES: Surgical magnitude, postoperative pain control, postoperative outcome, and histopathologic findings were studied. RESULTS: Arterial reconstruction, gastrointestinal reconstruction, and blood transfusions were unnecessary. The organ deficit was limited to the distal pancreas, spleen and left adrenal gland. There was no postoperative mortality. Postoperative complications occurred in four patients, who were successfully managed with medical treatment. This led to prolonged hospital stays. The intractable preoperative abdominal and/or back pain was completely relieved immediately after surgery in all patients. Perfect pain control has been maintained from surgery to the last follow-up. Histopathologic examination of the surgical specimens revealed cancer invasion of the celiac plexus in all patients. CONCLUSIONS: This operation offers not only disease radicality but also perfect pain relief. The survival benefit has not yet been fully defined. (+info)
Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial.
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OBJECTIVE: To determine whether temporary occlusion of the main pancreatic duct with human fibrin glue decreases the incidence of intra-abdominal complications after pancreatoduodenectomy (PD) or distal pancreatectomy (DP). SUMMARY BACKGROUND DATA: To the authors' knowledge, there are no randomized studies comparing outcomes after pancreatic resection with or without main pancreatic duct occlusion by injection of fibrin glue. Of three nonrandomized studies, two reported no fistulas after intracanal injection and ductal occlusion with fibrin glue after PD with immediate pancreatodigestive anastomosis, while another study reported no protective effect of glue injection. METHODS: This prospective, randomized, single-blinded, multicenter study, conducted between January 1995 and January 1999, included 182 consecutive patients undergoing PD followed by immediate pancreatic anastomosis or DP, whether for benign or malignant tumor or for chronic pancreatitis. One hundred two underwent pancreatic resection followed by ductal occlusion with fibrin glue (made slowly resorbable by the addition of aprotinin); 80 underwent resection without ductal occlusion. The main end point was the number of patients with one or more of the following intra-abdominal complications: pancreatic or other digestive tract fistula, intra-abdominal collections (infected or not), acute pancreatitis, or intra-abdominal or digestive tract hemorrhage. Severity factors included postoperative mortality, repeat operations, and length of hospital stay. RESULTS: The two groups were similar in pre- and intraoperative characteristics except that there were significantly more patients in the ductal occlusion group who were receiving octreotide, who had reinforcement of their anastomosis by fibrin glue, and who had fibrotic pancreatic stumps. However, the rate of patients with one or more intra-abdominal complications, and notably with pancreatic fistula, did not differ significantly between the two groups. There was still no significant difference found after statistical adjustment for these patient characteristic discrepancies, confirming the inefficacy of fibrin glue. The rate of intra-abdominal complications was significantly higher in the presence of a normal, nonfibrotic pancreatic stump and main pancreatic duct diameter less than 3 mm, whereas reinforcement of the anastomosis with fibrin glue or use of octreotide did not influence outcome. In multivariate analysis, however, normal pancreatic parenchyma was the only independent risk factor for intra-abdominal complications. No significant differences were found in the severity of complications between the two groups. CONCLUSIONS: Ductal occlusion by intracanal injection of fibrin glue decreases neither the rate nor the severity of intra-abdominal complications after pancreatic resection. (+info)
Comparison of vasoactive intestinal peptide and secretin in stimulation of pancreatic secretion.
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Pancreatic volume flow as well as bicarbonate and protein secretion have been measured in chronic pancreatic fistula cats and dogs in response to I.V. infusion of VIP and secretin or duodenal perfusion of sodium oleate and HCl solution. 2. VIP and secretin infused I.V. in cats produced superimposable pancreatic dose-response curves for volume flow and bicarbonate secretion, reaching almost identical observed and maximal calculated outputs with both peptides. In dogs, VIP was shown previously to be a much less effective stimulant of pancreatic secretion than secretin and the maximal observed bicarbonate output in response to VIP was only about 17% of that to secretin (Konturek, Thor, Dembinski & Krol, 1975). It is condluded that VIP in cats is a secretin-like full agonist, whereas in dogs it is a partial agonist of pancreatic bicarbonate secretion. 3. In cats, secretin and VIP showed equal efficacy and their combination exhibited an augmentatory action on pancreatic bicarbonate secretion with additive kinetics, whereas in dogs, VIP was found to have a lower efficacy than secretin and to inhibit competitively secretin-induced pancreatic secretion. These results might be explained by the interaction of VIP and secretin, two chemically related peptides, on a common receptor site of the exocrine pancreas. 4. Caerulein, an analogue of CCK-PZ, infused I.V. in cats and dogs caused a negligible pancreatic bicarbonate secretion and a potent dose-dependent protein secretion. The combination of graded doses of VIP or secretin with a background dose of caerulein resulted in significantly higher bicarbonate and protein outputs than those induced by VIP or secretin alone. 5. Duodenal perfusion of sodium oleate soap in cats and dogs produced pancreatic dose-response curves for volume flow and bicarbonate output similar to those evoked by VIP in these species. Pancreatic protein secretion in response to luminal oleate was slightly higher than could be accounted for by the action of VIP alone. This might be attributed to the release by oleate not only of endogenous VIP but also CCK-PZ or to the vago-vagal reflexes from gut to pancreas. The results of our combined study on cats and dogs suggest the possibility that oleate releases VIP from the gut and that this peptide may play a physiological role in the stimulation of pancreatic secretion. (+info)
Pancreaticogastrostomy after pancreatoduodenectomy.
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The aim of this study was to evaluate the place of pancreaticogastrostomy (PG) in reducing pancreatic fistula after pancreatoduodenectomy. From January 1988 to June 1991, 32 consecutive patients (mean age, 57 years) were operated on, 25 for malignant disease (78%). The pancreatic remnant was normal in 17 patients (53%) and sclerotic in the others. There was one operative death (3.1%) unrelated to PG. Post-operative complications occurred in five patients (16%). Only two complications were related to PG: 1 patient had anastomotic intra-gastric bleeding and was reoperated on, 1 patient with a normal pancreatic remnant developed a pancreatic fistula (3.1%) treated conservatively. Reported series of PG, as well as our results, demonstrates that PG is associated with a dramatic decrease of both pancreatic fistula and mortality rates. The risk of anastomotic haemorrhage can be reduced by preventative ligation of submucosal gastric vessels. In conclusion, PG appears as a simple and reliable method of management of the pancreatic remnant after pancreatoduodenectomy. (+info)
Surgical treatment of pancreatic carcinoma.
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OBJECTIVE: To evaluate the surgical treatment of pancreatic carcinoma. METHODS: 101 patients with pancreatic carcinoma admitted from 1995 to 2002 were studied retrospectively. Of 83 patients undergoing surgery, 56 (64.5%) were subjected to tumor resection. Whipple's procedure was performed in 48 patients, extended regional pancreatectomy and autograft intestinal transplantation in 2, combined resection of pancreatic body or tail carcinoma in 6, and 27 patients with unresectable pancreatic carcinoma were given inner drainage. RESULTS: Wound dehiscence and digestive bleeding were found in one patient respectively. Pancreatic fistula was found in one patient undergoing extended regional pancreatectomy and autograft intestinal transplantation. Other patients recovered uneventfully. CONCLUSIONS: Most patients with pancreatic carcinoma could undergo tumor resection. Blood vessel repair or transplantation can be used if the tumor adherent to the superior mesenteric-portal vein. Extended regional pancreatectomy and autograft intestinal transplantation are feasible. Simple inner drainage should be used in the patient whose neoplasm is unresectable. (+info)
Surgical treatment of chronic pancreatitis.
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OBJECTIVE: To summarize the experience in the surgical treatment of chronic pancreatitis. METHODS: 189 patients with pancreatitis admitted from May 1983 to August 1999 to our hospital were reviewed. RESULTS: 136 (72%) patients received surgical treatment including pancreatoduodenectomy (15 patients), distal pancreatectomy (12), internal drainage of pancreatic pseudocyst (28), side-to-side pancreaticojejunostomy (16), relief of biliary stenosis (58), and pancreatic biopsy (7). Pain was relieved in 97.8% of the patients, and the complication rate was 1.5%. CONCLUSIONS: It is crucial to select various surgical strategies at a proper time for chronic pancreatitis patients. Patients with chronic pancreatitis complicated by dilation or obstruction of the pancreatic duct or with biliary pancreatitis should be operated on in early stages, whereas those with other types of chronic pancreatitis should receive the therapy focusing on the alleviation of their symptoms, not on early surgical intervention. The timing and modality of surgery are important in improving the life quality of the patients and changing their natural history of the disease. (+info)
Role of leptin in the control of postprandial pancreatic enzyme secretion.
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Leptin released by adipocytes has been implicated in the control of food intake but recent detection of specific leptin receptors in the pancreas suggests that this peptide may also play some role in the modulation of pancreatic function. This study was undertaken to examine the effect of exogenous leptin on pancreatic enzyme secretion in vitro using isolated pancreatic acini, or in vivo in conscious rats with chronic pancreatic fistulae. Leptin plasma level was measured by radioimmunoassay following leptin administration to the animals. Intraperitoneal (i.p.) administration of leptin (0.1, 1, 5, 10, 20 or 50 microg/kg), failed to affect significantly basal secretion of pancreatic protein, but markedly reduced that stimulated by feeding. The strongest inhibition has been observed at dose of 10 microg/kg of leptin. Under basal conditions plasma leptin level averaged about 0.15 +/- 0.04 ng/ml and was increased by feeding up to 1.8 +/- 0.4 ng/ml. Administration of leptin dose-dependently augmented this plasma leptin level, reaching about 0.65 +/- 0.04 ng/ml at dose of 10 microg/kg of leptin. This dose of leptin completely abolished increase of pancreatic protein output produced by ordinary feeding, sham feeding or by diversion of pancreatic juice to the exterior. Leptin (10(-10)-10(-7) M) also dose-dependently attenuated caerulein-induced amylase release from isolated pancreatic acini, whereas basal enzyme secretion was unaffected. We conclude that leptin could take a part in the inhibition of postprandial pancreatic secretion and this effect could be related, at least in part, to the direct action of this peptide on pancreatic acini. (+info)