Considerations on pancreatic exocrine function after pancreaticoduodenectomy

Abstract

The pancreaticoduodenectomy (PD) procedure may lead to pancreatic exocrine and endocrine insufficiency. There are several types of reconstruction for this kind of operation. Pancreaticogastrostomy (PG) was introduced to reduce the rate of postoperative pancreatic fistula. Although some randomized control trials have shown no differences regarding pancreatic leakage between PG and pancreaticojejunostomy (PJ), recently some reports reveal benefits from the PG over the PJ. Some surgeons concern about the performing of the PG and inactivation of pancreatic enzymes being in contact with the gastric juice, and the detrimental results over the exocrine pancreatic function. The pancreatic exocrine function can be measured with direct and indirect tests. Direct tests have the highest sensitivity and specificity for detection of exocrine insufficiency but require tube placement. Among the tubeless indirect tests, the van de Kamer stool fat analysis remains the standard to diagnose fat malabsorption. The patient compliance and time consuming makes it not so suitable for its clinical use. Fecal immunoreactive elastase test is employed for screening of exocrine insufficiency, is not cumbersome, and has been used to study pancreatic function after resection. We analyze the FE1 levels in our patients after the PD with two types of reconstruction, PG and PJ, and we discuss some considerations about the pancreaticointestinal drainage method after pancreaticoduodenectomy.

Keywords: Fecal elastase; Pancreatic exocrine function; Pancreaticoduodenectomy; Pancreaticogastrostomy; Pancreaticojejunostomy.

Figure 1

Pancreaticogastrostomy. A: A gastrotomy is performed in the posterior wall of the stomach, and a first layer of stitches are applied approximating gastric serosa to the pancreatic stump; B: The pancreas is telescoped into the gastric lumen, and two pancreato-mucosa running sutures complete the second layer of the anastomosis; C: The final step of the anastomosis is concluded applying the last sero-pancreatic outer stitches.

Figure 2

A scanner of the pancreaticogastrostomy in the early postoperative term. In enlarged view. p: Pancreatic stump throw the gastric wall; s: Gastric lumen containing oral contrast media; v: Splenic vein draining to the portal vein on the right side of the patient; j: High density image corresponding to the staplers of the cutting edge of the jejuna limb used in the hepatico-jejunostomy.

Figure 3

Fecal elastase levels in pancreatico-gastrostomy group and pancreatico-jejunostomy group. Means are depicted with horizontal bars.