Early and late complications of
pylorus-preserving pancreatoduodenectomy in Japan 1998.
Yamaguchi K, Tanaka M, Chijiiwa K, Nagakawa T, Imamura M, Takada
T.
Department of Surgery and Oncology, Kyushu University Graduate
School of Medical Sciences, 3-1-1 Maidashi, Higashi-Ku, Fukuoka
812-8582, Japan.
Early (within 1 month after operation) and late (more than 1
month after surgery) complications after pylorus-preserving pancreatoduodenectomy
(PpPD) were analyzed in 1066 Japanese patients collected from
74 authentic institutions in Japan. As early postoperative complications
after PpPD, delayed gastric emptying was evident in 46% of patients,
pancreatoenterostomy leakage in 16%, intra-abdominal infection
in 14%, cholangitis in 8.9%, hepaticojejunostomy leakage in 4.7%,
intra-abdominal hemorrhage in 3. 5%, upper gastrointestinal hemorrhage
in 3.2%, and duodenojejunostomy leakage in 2.0%. Delayed gastric
emptying resolved 1-24 months after PpPD (mean, 3.1 months). The
direct operative mortality (death within 1 month after the operation)
was 2. 4%. Univariate and multivariate analysis of pancreatoenterostomy
leakage showed that male sex (P = 0.0151) and soft consistency
of the pancreas (P < 0.0001) were independent significant factors.
Univariate analysis of delayed gastric emptying showed that establishment
of gastrostomy (P < 0.0001), length of the preserved duodenum
(P = 0.0406), gastric juice output (P = 0.0001), length of gastric
tube placement (P < 0.0001), and administration of cisapride
(P = 0.0059) were significant variants. As late complications,
stomal ulcer was evident in 3.6% of patients, cholangitis in 6.7%,
and liver abscess in 1.2%. Glucose intolerance appeared in 61
patients, resolved in 15, showed no change in 170, was absent
in 695, and was ameliorated in 17. As a result, the dosage of
hypoglycemic agents or insulin showed no change in 187 patients,
decreased in 16, and increased in 52. Diabetes appeared 0-42 months
after PpPD (mean, 102 months). When present, diabetes deteriorated
0-36 months postoperatively (mean, 6.3 months). Univariate analysis
of the appearance or deterioration of diabetes showed that diabetes
occurred more frequently in the following patients; those with
Billroth I reconstruction compared with those with Billroth II
(P = 0.0041), those with pancreatogastrostomy vs those with pancreatojejunostomy
(P = 0.0229), those with pancreatogastrostomy vs those with end-to-side
pancreatojejunostomy (P = 0.0165), and those with total tube drainage
vs those with pancreatico-whole thickness anastomosis (P = 0.0392);
a high American Society of Anesthesiologist (ASA) score (P = 0.0211)
and pancreatoenterostomy leakage (P = 0.0361) were also significant
factors. Postoperative body weight loss (>3 kg) was evident
in 62% of patients. Body weight loss reached a maximum 4.2 +/-
5.8 months after PpPD (mean, 6.0 kg) and returned to the preoperative
level 4.8 months thereafter. These results suggest that PpPD has
been performed safely in Japan, the operative mortality being
2.4%. However, delayed gastric emptying was evident in 46% of
the patients and pancreatoenterostomy leakage in 16%. Impairment
of glucose tolerance occurred in about 10% of patients more than
1 month after PpPD. Therefore, during the early postoperative
period, patients should be closely monitored for pancreatoenterostomy
leakage and delayed gastric emptying and in the late postoperative
period, glucose tolerance should be carefully followed-up.
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