Pancreatic Neoplasms; Periampullary Neoplasms
Conditions
Keywords
pancreatic surgery; neoplasms
Brief summary
This prospective observational cohort study aims to improve the postoperative course after minimally invasive pancreaticoduodenectomy (MIP) with stented pancreaticogastrostomy (sPG) for pancreatic head or peri-ampullary neoplasms. Patients are submitted to an enhanced recovery after surgery (ERAS) program with early enteral nutrition (EEN).
Detailed description
Pancreaticoduodenectomy (PD) is the standard of care for patients with malignant or benign disease of the pancreatic head or peri-ampullary region. The postoperative course after PD is strongly dependent of the occurrence of pancreatic fistula (POPF) and/or delayed gastric emptying (DGE). In a recent multicentre randomized controlled trial, the investigators have shown pancreaticogastrostomy (PG; without a stent in the pancreatic duct) to be associated with 8% POPF rate, significantly lower than pancreaticojejunostomy (20%) (1). Since then, PG reconstruction is considered the standard of care in PD, which is also underlined in more recent systematic reviews. In patients without POPF after PD, the length of hospital stay is determined by the occurrence of DGE, which is poorly understood and currently lacks any effective treatment. Patients who developed DGE after PD with PG anastomosis (n=18; 20%) had a significantly (p=0.014) longer (mean + sem) length of hospital stay (LOS) of 26.3 + 1.58 days, as compared to 22.4 + 1.27 days for patients without DGE (n=69). These figures are observed in the investigators' center as part of the multicentre RCT. Enhanced recovery after surgery (ERAS) or fast-track (FT) programs are able to reduce postoperative length of hospital stay (LOS). Indeed recently, ERAS or FT programs have been implemented successfully in PD (2). Patients were discharged 4 days earlier in the ERAS group, without a negative effect on the clinical outcome. Still, many surgeons are reluctant to implement ERAS programs because they fear compromising patient safety. In efforts to improve the outcomes of PD, many surgical techniques have been evaluated to restore the pancreatic digestive continuity after PD. However, the best way to ensure this and whether or not to perform the procedure via standard open or minimally invasive, i.e. 2- or 3-dimensional laparoscopic (3D-LPD) or 3-dimensional robotic surgery (RPD), is still under debate. The investigators have passed the learning curve of 50 3D-LPD and hypothesize the implementation of ERAS and EEN in 3D-LPD can improve short-term outcomes.
Interventions
PROCEDUREERAMIP
3D-LPD with stented umbrella-pancreaticogastrostomy & Roux-en-Y reconstruction of the biliary limb of the hepatico-jejunostomy onto the efferent limb of the gastro-enterostomy (RY-GES)
Sponsors
University Hospital, Gasthuisberg
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to 85 Years
Healthy volunteers
No
Inclusion criteria
* Patients, male or female, who undergo MIP + sPG for a pancreatic or peri-ampullary tumor * Patients with and without pre-operative biliary drainage (for obstructive jaundice) * Patients fit for minimally invasive pancreaticoduodenectomy (MIP) * Informed consent signed
Exclusion criteria
* Pregnancy * MIP for pancreatic trauma * MIP for complications of endoscopic retrograde cholangio-pancreaticography (ERCP) * Reconstruction of the portal vein or superior mesenteric vein * Any arterial reconstruction at the time of surgery
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The incidence of severe complications | From date of pancreaticoduodenectomy until the date of discharge from hospital or date of death from any cause, whichever came first, assessed up to 3 months | Severe complications are classified according to the Clavien-Dindo Classification, i.e. Therapy Oriented Severity Grading Score of postoperative complications (TOSGS grade 3 or more): complication that needs interventional therapy under local or general anaesthesia |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Postoperative in-hospital, 30-day and 90-day mortality | From date of pancreaticoduodenectomy until the date of discharge from hospital or date of death from any cause, whichever came first, assessed up to 3 month | Postoperative mortality rate |
Other
| Measure | Time frame | Description |
|---|---|---|
| Clinical postoperative pancreatic fistula (POPF) rate | From date of pancreaticoduodenectomy until the date of discharge from hospital or date of death from any cause, whichever came first, assessed up to 3 months | The incidence of POPF will be registered and defined according to the ISGPF |
| Postoperative bleeding (PPH) rate | From date of discharge from hospital until date of re-admission to hospital within 2 weeks after discharge, assessed up to 3 months | The incidence of PPH will be registered and defined according to the ISGPF |
| Length of postoperative hospital stay (LOS) | From date of pancreaticoduodenectomy until the date of discharge from hospital or date of death from any cause, whichever came first, assessed up to 3 months. Readmissions within 30days after discharge will be added to the duration of LOS. | Length of hospital stay (days) will be registered starting from the day of surgery until discharge |
| Delayed gastric emptying (DGE) rate | From date of pancreaticoduodenectomy until the date of discharge from hospital or date of death from any cause, whichever came first, assessed up to 3 months | The incidence of DGE will be registered and defined according to the ISGPF |
Countries
Belgium
Outcome results
None listed