Skip to main content

Main menu

  • Home
  • Current Issue
  • Archive
  • Info for
    • Authors
    • Editorial Policies
    • Subscribers
    • Advertisers
    • Editorial Board
    • Special Issues 2025
  • Journal Metrics
  • Other Publications
    • In Vivo
    • Cancer Genomics & Proteomics
    • Cancer Diagnosis & Prognosis
  • More
    • IIAR
    • Conferences
    • 2008 Nobel Laureates
  • About Us
    • General Policy
    • Contact
  • Other Publications
    • Anticancer Research
    • In Vivo
    • Cancer Genomics & Proteomics

User menu

  • Register
  • Subscribe
  • My alerts
  • Log in
  • My Cart

Search

  • Advanced search
Anticancer Research
  • Other Publications
    • Anticancer Research
    • In Vivo
    • Cancer Genomics & Proteomics
  • Register
  • Subscribe
  • My alerts
  • Log in
  • My Cart
Anticancer Research

Advanced Search

  • Home
  • Current Issue
  • Archive
  • Info for
    • Authors
    • Editorial Policies
    • Subscribers
    • Advertisers
    • Editorial Board
    • Special Issues 2025
  • Journal Metrics
  • Other Publications
    • In Vivo
    • Cancer Genomics & Proteomics
    • Cancer Diagnosis & Prognosis
  • More
    • IIAR
    • Conferences
    • 2008 Nobel Laureates
  • About Us
    • General Policy
    • Contact
  • Visit us on Facebook
  • Follow us on Linkedin
Research ArticleClinical Studies

Pancreaticoduodenectomy at a Non-high-volume Center and Efforts to Perform Safe Surgery

TAISHI YAMANE, DAISUKE IZUMI, SHOTARO KINOSHITA, CHIKA SHIRAKAMI, KEISUKE MORITA, SATOSHI IKESHIMA, KEI HORINO, SHINYA SHIMADA and HIDEO BABA
Anticancer Research October 2021, 41 (10) 5223-5229; DOI: https://doi.org/10.21873/anticanres.15341
TAISHI YAMANE
1Department of Surgery, Japan Community and Health Organization Kumamoto General Hospital, Yatsusiro, Japan;
2Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
DAISUKE IZUMI
1Department of Surgery, Japan Community and Health Organization Kumamoto General Hospital, Yatsusiro, Japan;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
SHOTARO KINOSHITA
1Department of Surgery, Japan Community and Health Organization Kumamoto General Hospital, Yatsusiro, Japan;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
CHIKA SHIRAKAMI
1Department of Surgery, Japan Community and Health Organization Kumamoto General Hospital, Yatsusiro, Japan;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
KEISUKE MORITA
1Department of Surgery, Japan Community and Health Organization Kumamoto General Hospital, Yatsusiro, Japan;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
SATOSHI IKESHIMA
1Department of Surgery, Japan Community and Health Organization Kumamoto General Hospital, Yatsusiro, Japan;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
KEI HORINO
1Department of Surgery, Japan Community and Health Organization Kumamoto General Hospital, Yatsusiro, Japan;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
SHINYA SHIMADA
1Department of Surgery, Japan Community and Health Organization Kumamoto General Hospital, Yatsusiro, Japan;
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
HIDEO BABA
2Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: hdobaba@kumamoto-u.ac.jp
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Aim: The aim of the current study was to investigate whether the artery-first approach (AFA) improved surgical outcomes of pancreaticoduodenectomy (PD) at our non-high-volume center. Patients and Methods: We retrospectively reviewed data on 121 consecutive patients who underwent PD between January 2009 and December 2018. The perioperative data of 49 patients who underwent conventional PD (conventional group) and 72 patients who underwent PD via artery-first approach were analyzed and compared to assess the effectiveness of the AFA. Results: Although no significant difference was observed between the two groups overall, in those with pancreatic cancer, the duration of surgery, intraoperative blood loss and transfusion rate in the AFA group (n=33) were significantly lower than those for the conventional group (n=11) (p=0.011, p=0.021 and p=0.038 respectively). Conclusion: AFA can be used to reduce the operative time, intraoperative blood loss, and transfusion rate in patients with pancreatic cancer.

Key Words:
  • Pancreaticoduodenectomy
  • non-high volume center
  • artery-first approach

Pancreaticoduodenectomy (PD) is one of the most challenging and complex procedures among abdominal surgeries. It is commonly performed not only for malignant tumors of the pancreatic head, ampulla, and distal bile duct but also for benign tumors and peripancreatic trauma (1-5). This procedure is associated with a high rate of major complications, including postoperative pancreatic fistula (POPF), bleeding, intra-abdominal collection, and delayed gastric emptying (DGE), resulting in significant postoperative morbidity in 22-60% patients (6-9). A previous study evaluating the retrospective data on 8,575 PDs performed in 1,167 hospitals showed a 30-day mortality rate of 1.2% and an in-hospital mortality rate of 2.8%, which were much higher than those of reported for general abdominal surgeries (10).

Multiple retrospective studies using data from the United States have demonstrated better surgical outcomes of major pancreatic resections at high-volume centers than at non-high-volume centers (11-13). Volume may be a surrogate marker for high-quality care systems, surgical training, and experience. However, more recent analyses of the volume– outcome relationship have demonstrated that in addition to hospital volume, the characteristics of surgeons and system resources affect these qualities (14). Several studies have reported that the outcomes of hepatic and pancreatic resections at low-volume centers are comparable to those at high-volume centers (15, 16). We hypothesized that use of an appropriate surgical technique by well-experienced surgeons leads to sufficient outcomes after PD both in non-high-volume and high-volume centers.

In the artery-first approach (AFA), a prompt dissection is made between the pancreas and the superior mesenteric artery (SMA) ahead of the point of no return, such as pancreatic transection or bile duct division (17, 18). The AFA is recommended for the early determination of resectability in cases of borderline resectable cancer (19), ensuring SMA margin in advanced pancreatic cancer (20), reduction of intraoperative blood loss due to early ligation of the inferior pancreaticoduodenal artery (IPDA) (21), and identification and safeguarding of a replaced right hepatic artery (22). Inoue et al. reported that the blood loss, operative time, and POPF and DGE rates were significantly lower in the AFA-PD group (n=82) than in the conventional PD group (n=80) (17).

In this retrospective study, we have reported on the efforts taken at a non-high-volume center for performing PD safely and improving surgical outcomes using the AFA.

Patients and Methods

Patients. Between January 2009 and December 2018, 121 consecutive patients who underwent PD at Japan Community and Health Organization Kumamoto General Hospital were included in this study. Two expert hepatopancreatobiliary surgeons performed PD as an operator or a lead assistant. In total, 49 patients underwent conventional PD (control group) between January 2009 and January 2013 and 72 patients underwent PD via the AFA between February 2013 and December 2018. Written informed consent was obtained from all patients, and this study was approved by the Ethical Committee (Registry Number 1291).

Surgical technique. After making a reverse T abdominal incision, the peritoneal cavity was explored to confirm the tumor stage and operability. Following a wide Kocher maneuver, the para-aortic lymph nodes were explored and resected if necessary. The gastrocolic ligament and great omentum were dissected until the pancreatic head was well exposed. In the case of carcinoma of the pancreatic head, we chose the mesenteric approach to ensure a forefront margin. The superior mesenteric vein was taped and its branches dissected, including Henle`s gastrocolic trunk, inferior mesenteric vein and middle colic vein when there was no tumor invasion. After the SMA was recognized by palpation and its surrounding tissues were dissected, the procedure was switched to the left side. With the transverse colon retracted cranially, the proximal jejunum and mesojejunum corresponding to the sacrificed jejunum arteries were divided and dissected toward the left aspect of the SMA. The ligament of Treitz and the left side of the SMA were dissected. After completion of the left-side approach, the procedure was switched to dissection of the right side of the SMA. The superior mesenteric vein was retracted to the right and the plexus of the SMA was retracted to the left side. By retracting the smooth muscle actin plexus, the SMA was then easily rotated around the pinpoint to facilitate exposure of its branches. Then, the common trunk of the IPDA and jejunal artery was ligated (Figure 1A), and the first and second nerve plexus of the pancreatic head were dissected (Figure 1B). When the tumor was found to have invaded the right side of the smooth muscle actin plexus, the right hemicircumferential SMA plexus was chosen. The stomach was resected from the subtotal stomach-preserving PD line. After the hepatoduodenal ligament was dissected, the pancreas was transected. Then only the portal vein (PV) was connected to the specimen. When there was no tumor invasion, the branches of the PV to the pancreatic head were resected, otherwise the PV was resected and anastomosed.

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

The strategy of artery first approach and polyglycolic acid felt pasting method. A: The superior mesenteric vein was retracted to the right side and the superior mesenteric artery (SMA) was retracted to the left side. The common trunk of the inferior pancreaticoduodenal artery and jujenal artery (arrowhead) was ligated. B: The superior mesenteric vein was retracted to the right side and the SMA was retracted to the left side. The first and second nerve plexus of the pancreatic head (arrowhead) were dissected. C: The cut end of the pancreatic remnant was pasted with polyglycolic acid felt (arrowheads) using a fibrin sealant. PV: Portal vein.

Reconstruction was performed using a modified Child’s procedure, and end-to-side pancreaticojejunostomy (PJ) anastomosis was performed with a two-layer anastomosis technique. The cut end of the pancreatic remnant was joined together with polyglycolic acid (PGA) felts using a fibrin sealant (Figure 1C). We had introduced the PGA felt technique in January 2012. A pancreatic and biliary duct tube was placed as an external drainage stent. The gastrojejunal anastomosis was placed in an ante-colic position and the gastric remnant was fixed to the transverse mesocolon. The stump of the gastroduodenal artery (GDA) was covered by the round ligament of the liver (Figure 2A and B). Drains were routinely placed close to the PJ and biliary–jejunal anastomosis.

Figure 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2.

The strategy used to prevent postoperative bleeding. A: Stump of the gastroduodenal artery (arrowhead) and round ligament. B: The stump of the gastroduodenal artery was covered by round ligament (arrowhead). C: Remnant round ligament was placed between superior mesenteric artery and pancreaticojejunostomy anastomosis. D: Drain was placed on the dorsal side of pancreaticojejunostomy anastomosis.

Data recording. The intraoperative variables included operative time, blood loss, blood transfusion (with vs. without), texture of the pancreas, and pancreatic duct size (≤3 vs. >3 mm). The texture of the pancreas was classified as soft or hard based on the judgement of the operating surgeon, and the pancreatic duct size was measured at the cut surface of the remnant pancreas.

Postoperative variables included measurement of the amylase concentration in serum and drainage fluid on postoperative days 1, 3, 5, and 7. POPF was defined and graded according to the criteria proposed by the International Study Group on Pancreatic Fistula (23). POPF was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase concentration. The severity of POPF was categorized into three grades according to its clinical impact: A, no clinical impact; B, minor adjustment of the clinical pathway; and C, major change in clinical management. Computed tomography was performed on postoperative day 7, and the peripancreatic drains were removed when there were no abnormal findings. The pancreatic duct tube was removed at our outpatient clinic approximately 4 weeks after surgery.

Statistical analysis. All statistical analyses were performed using R (3.3.3, R Development Core Team, https://cran.r-project.org/) and GraphPad Prism V5.0 (GraphPad Software, San Diego, California, USA). The Mann-Whitney U-test, Wilcoxon’s signed-rank test, and Fisher’s exact test were used to analyze clinicopathological data. Associations between morbidity and clinicopathological factors were evaluated using univariate and multivariate logistic regression analyses with odds ratios (ORs). Logistic regression was performed using the “stats” package in R. ORs were calculated using the “vcd” package in R.

Results

Clinicopathological characteristics and intraoperative factors are shown in Table I. There were 67 men (55.4%) and 54 women (44.6%) with a median age of 72 years (range=34-88 years). The pathological diagnoses were pancreatic (n=44) or bile duct cancer (n=34) in the majority of cases. For patients with jaundice, preoperative biliary drainage was performed endoscopically. The median operative time was 383 min (range=245-625 min). The median blood loss was 579 g (range=143-2,675 g).

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table I.

Clinical, epidemiological, and surgical factors of patients undergoing pancreaticoduodenectomy (n=121).

The incidence of postoperative complications is shown in Table II. The overall complication rate (Clavien-Dindo classification ≥II) was 21.5%. The overall POPF and POPF rates were 39.7% and 11.5%, respectively. Postoperative bleeding occurred in one (0.8%) patient and was treated with interventional radiology. One patient (0.8%) underwent reoperation due to leakage of the gastrojejunal anastomosis. No perioperative deaths were reported during the study period.

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table II.

Short-term outcomes after pancreaticoduodenectomy (n=121).

Table III shows the comparison of perioperative characteristics between patients who underwent conventional PD (n=49) and those who underwent conventional PD via the AFA (n=72). No significant difference was observed between the groups in terms of operative time, blood loss, transfusion rates, POPF, and DGE. In pancreatic cancer, plexus dissection around the SMA is technically challenging, and the AFA may reduce the difficulty of the operative procedure (17). Therefore, perioperative characteristics were further compared between patients with pancreatic cancer in the conventional group (n=11) and those in the AFA group (n=33) (Table IV). The operative time, blood loss, and transfusion rate were significantly lower in patients with pancreatic cancer in the AFA group than in those in the conventional group (p=0.011, p=0.021, and p=0.038, respectively). No significant differences were observed between the groups in terms of postoperative complications.

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table III.

Comparison of perioperative factors between patients undergoing pancreaticoduodenectomy by conventional and artery-first approach (AFA) (n=121).

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table IV.

Comparison of perioperative factors in patients with pancreatic cancer between those undergoing pancreaticoduodenectomy by conventional and those treated using an artery-first approach (AFA).

Discussion

PD is a complex procedure with high complication rates (24). Although morbidity and mortality have significantly improved in the past decade due to improvements in intensive care management, surgical techniques and devices, the rates of postoperative complications are high (25).

In this study, the overall complication rate was 21.5%, comparable to that reported in previous studies (22-60%) (6-9). Japanese retrospective data on 8,575 PDs showed that the rate of grade B and C POPF was 13.2% (10), similar to that reported in our study (11.5%). At our Institution, the mortality rate was 0%, which was lower than that reported in a Japanese study (2.8%) (10). Taken together, the postoperative outcomes of PDs performed at our Institute are considered acceptable compared to those reported in previous studies.

In a meta-analysis of AFA versus standard PD evaluating perioperative outcomes and survival, intraoperative blood loss and transfusion rates were significantly lower in the AFA group than in the standard PD group (26). Although the rates of perioperative mortality were comparable between the groups, perioperative morbidity and the incidence of grade B and C POPF were significantly lower in the AFA group (26). In this study, there was no significant difference in the operative time, blood loss, transfusion rates, and postoperative morbidity between groups. However, the operation time, blood loss, and transfusion rates were significantly lower in patients with pancreatic cancer in the AFA group than in those in the conventional group. There was no significant difference in complication rates, including the POPF rate, between groups. In pancreatic cancer, the SMA margin, i.e., the soft tissue directly adjacent to the proximal 3-4 cm of SMA, is the most common cause of R1 resection (positive for cancer cells at the margin), and dissection of the nerve plexuses of the pancreatic head is the most challenging process (27). In the AFA, the plexuses are dissected before transection of the neck of the pancreas, allowing early division of the IPDA and subsequent meticulous dissection along the SMA borders (26). These factors might have resulted in the reduced operation time, blood loss, and transfusion rates in patients with pancreatic cancer in the AFA group in this study.

POPF is the main trigger for other morbidities, such as pseudoaneurysm of the gastroduodenal artery stump, intraabdominal abscess, and sepsis, which are significantly associated with high mortality rates (28). The morbidity rate of POPF is 10-40% after PD (29-31) but there is no consensus regarding the best way to manage pancreaticoenteric anastomosis. PGA is a felt-like absorbable suture-reinforcing material generally used to reinforce sutures of fragile tissues such as the lung, bronchi, liver, and gastrointestinal tract, as well as a wide range of tissue defects (32). Regarding pancreaticojejunostomy using PGA felt, the incidence of POPF formation was lower than in the control group in some retrospective studies (33, 34). Furthermore, we have reported the usefulness of the PGA felt pasting method to reduce POPF in patients with soft pancreas. The overall incidence of POPF in the soft pancreas was significantly lower in the PGA group than in the control group (39.1% vs. 70.0%, p=0.042). We concluded that PGA felt should be used not to tightly seal the PJ anastomosis and block the liquid oozing from the cut end of the pancreas but should be used to reinforce the surface of the pancreatic remnant for tight fixation to the jejunum (35).

In this study, postoperative bleeding occurred in one (0.8%) patient treated with interventional radiology, a rate lower than that reported in a previous study (5.1%) (10). In this study, the stump of the GDA was covered by the round ligament of the liver to prevent erosion hemorrhage (Figure 2B). Furthermore, we placed the remnant round ligament between the SMA and PJ anastomosis to separate the stump of the IPDA from the PJ anastomosis (Figure 2C). The drain was placed on the dorsal side of the PJ anastomosis to absorb pancreatic enzymes when POPF occurred (Figure 2D). A previous study has shown the effectiveness of a falciform ligament wrap in preventing bleeding due to the rupture of the GDA stump after PD (36). Separation of the skeletonized visceral vessels from pancreatic enzymes results in a lower rate of pseudoaneurysm rupture. We believe that this procedure is simple and useful for preventing erosion hemorrhage.

The present study had several limitations. Firstly, this study was a single-institution, retrospective study. Secondly, the observation period was long, which may have resulted in historical bias regarding treatment strategy, perioperative management, and surgical devices that might affect short-term outcomes after surgery. Thus, further multi-institutional prospective investigations with a larger cohort are required to reconfirm the usefulness of the AFA in patients with pancreatic cancer in terms of reducing operative time and blood loss.

In conclusion, the AFA can be used to reduce the operative time, blood loss, and transfusion rate in PD even at non-high-volume centers, and various efforts, such as the induction of the AFA, may lead to comparable outcomes after PD.

Acknowledgements

The Authors thank all the people who contributed to this work.

Footnotes

  • Authors’ Contributions

    T. Yamane wrote the article. D. Izumi and K. Horino planned the study concept and design. S. Kinoshita, C. Shirakami, K. Morita, and S. Ikeshima collected the clinical data. S. Shimada conducted critical revision of the article. H. Baba coordinated the study, oversaw collection and analysis of the results. All Authors discussed the data and commented on the article.

  • Conflicts of Interest

    The Authors declare that they have no conflicts of interest in regard to this study.

  • Received June 16, 2021.
  • Revision received August 15, 2021.
  • Accepted August 24, 2021.
  • Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.

References

  1. ↵
    1. Yeo CJ,
    2. Cameron JL,
    3. Lillemoe KD,
    4. Sitzmann JV,
    5. Hruban RH,
    6. Goodman SN,
    7. Dooley WC,
    8. Coleman J and
    9. Pitt HA
    : Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients. Ann Surg 221(6): 721-31; discussion 731-3, 1995. PMID: 7794076. DOI: 10.1097/00000658-199506000-00011
    OpenUrlCrossRefPubMed
    1. Allema JH,
    2. Reinders ME,
    3. van Gulik TM,
    4. van Leeuwen DJ,
    5. Verbeek PC,
    6. de Wit LT and
    7. Gouma DJ
    : Results of pancreaticoduodenectomy for ampullary carcinoma and analysis of prognostic factors for survival. Surgery 117(3): 247-253, 1995. PMID: 7878528. DOI: 10.1016/s0039-6060(05)80197-7
    OpenUrlCrossRefPubMed
    1. Yoshida T,
    2. Matsumoto T,
    3. Sasaki A,
    4. Morii Y,
    5. Aramaki M and
    6. Kitano S
    : Prognostic factors after pancreatoduodenectomy with extended lymphadenectomy for distal bile duct cancer. Arch Surg 137(1): 69-73, 2002. PMID: 11772220. DOI: 10.1001/archsurg.137.1.69
    OpenUrlCrossRefPubMed
    1. Barens SA,
    2. Lillemoe KD,
    3. Kaufman HS,
    4. Sauter PK,
    5. Yeo CJ,
    6. Talamini MA,
    7. Pitt HA and
    8. Cameron JL
    : Pancreaticoduodenectomy for benign disease. Am J Surg 171(1): 131-4; discussion 134-5, 1996. PMID: 8554127. DOI: 10.1016/s0002-9610(99)80087-7
    OpenUrlCrossRefPubMed
  2. ↵
    1. van der Wilden GM,
    2. Yeh D,
    3. Hwabejire JO,
    4. Klein EN,
    5. Fagenholz PJ,
    6. King DR,
    7. de Moya MA,
    8. Chang Y and
    9. Velmahos GC
    : Trauma Whipple: do or don’t after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB). World J Surg 38(2): 335-340, 2014. PMID: 24121363. DOI: 10.1007/s00268-013-2257-5
    OpenUrlCrossRefPubMed
  3. ↵
    1. Jakhmola CK and
    2. Kumar A
    : Whipple’s pancreaticoduodenectomy: Outcomes at a tertiary care hospital. Med J Armed Forces India 70(4): 321-326, 2014. PMID: 25382904. DOI: 10.1016/j.mjafi.2014.08.011
    OpenUrlCrossRefPubMed
    1. Simons JP,
    2. Shah SA,
    3. Ng SC,
    4. Whalen GF and
    5. Tseng JF
    : National complication rates after pancreatectomy: beyond mere mortality. J Gastrointest Surg 13(10): 1798-1805, 2009. PMID: 19506975. DOI: 10.1007/s11605-009-0936-1
    OpenUrlCrossRefPubMed
    1. Lai EC,
    2. Yang GP and
    3. Tang CN
    : Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy — a comparative study. Int J Surg 10(9): 475-479, 2012. PMID: 22732431. DOI: 10.1016/j.ijsu.2012.06.003
    OpenUrlCrossRefPubMed
  4. ↵
    1. Karim SAM,
    2. Abdulla KS,
    3. Abdulkarim QH and
    4. Rahim FH
    : The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study. Int J Surg 52: 383-387, 2018. PMID: 29438817. DOI: 10.1016/j.ijsu.2018.01.041
    OpenUrlCrossRefPubMed
  5. ↵
    1. Kimura W,
    2. Miyata H,
    3. Gotoh M,
    4. Hirai I,
    5. Kenjo A,
    6. Kitagawa Y,
    7. Shimada M,
    8. Baba H,
    9. Tomita N,
    10. Nakagoe T,
    11. Sugihara K and
    12. Mori M
    : A pancreaticoduodenectomy risk model derived from 8575 cases from a national single-race population (Japanese) using a web-based data entry system: the 30-day and in-hospital mortality rates for pancreaticoduodenectomy. Ann Surg 259(4): 773-780, 2014. PMID: 24253151. DOI: 10.1097/SLA.0000000000000263
    OpenUrlCrossRefPubMed
  6. ↵
    1. Begg CB,
    2. Cramer LD,
    3. Hoskins WJ and
    4. Brennan MF
    : Impact of hospital volume on operative mortality for major cancer surgery. JAMA 280(20): 1747-1751, 1998. PMID: 9842949. DOI: 10.1001/jama.280.20.1747
    OpenUrlCrossRefPubMed
    1. Gordon TA,
    2. Bowman HM,
    3. Bass EB,
    4. Lillemoe KD,
    5. Yeo CJ,
    6. Heitmiller RF,
    7. Choti MA,
    8. Burleyson GP,
    9. Hsieh G and
    10. Cameron JL
    : Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes. J Am Coll Surg 189(1): 46-56, 1999. PMID: 10401740. DOI: 10.1016/s1072-7515(99)00072-1
    OpenUrlCrossRefPubMed
  7. ↵
    1. McPhee JT,
    2. Hill JS,
    3. Whalen GF,
    4. Zayaruzny M,
    5. Litwin DE,
    6. Sullivan ME,
    7. Anderson FA and
    8. Tseng JF
    : Perioperative mortality for pancreatectomy: a national perspective. Ann Surg 246(2): 246-253, 2007. PMID: 17667503. DOI: 10.1097/01.sla.0000259993.17350.3a
    OpenUrlCrossRefPubMed
  8. ↵
    1. Joseph B,
    2. Morton JM,
    3. Hernandez-Boussard T,
    4. Rubinfeld I,
    5. Faraj C and
    6. Velanovich V
    : Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection. J Am Coll Surg 208(4): 520-527, 2009. PMID: 19476785. DOI: 10.1016/j.jamcollsurg.2009.01.019
    OpenUrlCrossRefPubMed
  9. ↵
    1. Schwartz GS,
    2. Swan RZ,
    3. Ruangvoravat L and
    4. Attiyeh FF
    : Morbidity and mortality after hepatic and pancreatic resections: results from one surgeon at a low-volume urban hospital over thirty years. Am J Surg 201(4): 438-444, 2011. PMID: 21421096. DOI: 10.1016/j.amjsurg.2010.10.005
    OpenUrlCrossRefPubMed
  10. ↵
    1. Metreveli RE,
    2. Sahm K,
    3. Denstman F,
    4. Abdel-Misih R and
    5. Petrelli NJ
    : Hepatic resection at a major community-based teaching hospital can result in good outcome. Ann Surg Oncol 12(2): 133-137, 2005. PMID: 15827793. DOI: 10.1245/ASO.2005.06.007
    OpenUrlCrossRefPubMed
  11. ↵
    1. Inoue Y,
    2. Saiura A,
    3. Yoshioka R,
    4. Ono Y,
    5. Takahashi M,
    6. Arita J,
    7. Takahashi Y and
    8. Koga R
    : Pancreatoduodenectomy with systematic mesopancreas dissection using a supracolic anterior artery-first approach. Ann Surg 262(6): 1092-1101, 2015. PMID: 25587814. DOI: 10.1097/SLA.0000000000001065
    OpenUrlCrossRefPubMed
  12. ↵
    1. Negoi I,
    2. Hostiuc S,
    3. Runcanu A,
    4. Negoi RI and
    5. Beuran M
    : Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 16(2): 127-138, 2017. PMID: 28381375. DOI: 10.1016/s1499-3872(16)60134-0
    OpenUrlCrossRefPubMed
  13. ↵
    1. Pessaux P,
    2. Varma D and
    3. Arnaud JP
    : Pancreaticoduodenectomy: superior mesenteric artery first approach. J Gastrointest Surg 10(4): 607-611, 2006. PMID: 16627229. DOI: 10.1016/j.gassur.2005.05.001
    OpenUrlCrossRefPubMed
  14. ↵
    1. Hackert T,
    2. Werner J,
    3. Weitz J,
    4. Schmidt J and
    5. Büchler MW
    : Uncinate process first—a novel approach for pancreatic head resection. Langenbecks Arch Surg 395(8): 1161-1164, 2010. PMID: 20582600. DOI: 10.1007/s00423-010-0663-9
    OpenUrlCrossRefPubMed
  15. ↵
    1. Ohigashi H,
    2. Ishikawa O,
    3. Eguchi H,
    4. Yamada T,
    5. Sasaki Y,
    6. Noura S,
    7. Takachi K,
    8. Miyashiro I,
    9. Murata K,
    10. Doki Y and
    11. Imaoka S
    : Early ligation of the inferior pancreaticoduodenal artery to reduce blood loss during pancreaticoduodenectomy. Hepatogastroenterology 51(55): 4-5, 2004. PMID: 15011818.
    OpenUrlPubMed
  16. ↵
    1. Lupaşcu C,
    2. Moldovanu R,
    3. Andronic D,
    4. Ursulescu C,
    5. Vasiluţă C,
    6. Răileanu G,
    7. Fotea V and
    8. Târcoveanu E
    : Posterior approach pancreaticoduodenectomy: best option for hepatic artery anatomical variants. Hepatogastroenterology 58(112): 2112-2114, 2011. PMID: 22234079. DOI: 10.5754/hge09656
    OpenUrlCrossRefPubMed
  17. ↵
    1. Bassi C,
    2. Dervenis C,
    3. Butturini G,
    4. Fingerhut A,
    5. Yeo C,
    6. Izbicki J,
    7. Neoptolemos J,
    8. Sarr M,
    9. Traverso W,
    10. Buchler M and International Study Group on Pancreatic Fistula Definition
    : Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1): 8-13, 2005. PMID: 16003309. DOI: 10.1016/j.surg.2005.05.001
    OpenUrlCrossRefPubMed
  18. ↵
    1. Nussbaum DP,
    2. Penne K,
    3. Stinnett SS,
    4. Speicher PJ,
    5. Cocieru A,
    6. Blazer DG 3rd.,
    7. Zani S,
    8. Clary BM,
    9. Tyler DS and
    10. White RR
    : A standardized care plan is associated with shorter hospital length of stay in patients undergoing pancreaticoduodenectomy. J Surg Res 193(1): 237-245, 2015. PMID: 25062813. DOI: 10.1016/j.jss.2014.06.036
    OpenUrlCrossRefPubMed
  19. ↵
    1. Conzo G,
    2. Gambardella C,
    3. Tartaglia E,
    4. Sciascia V,
    5. Mauriello C,
    6. Napolitano S,
    7. Orditura M,
    8. De Vita F and
    9. Santini L
    : Pancreatic fistula following pancreatoduodenectomy. Evaluation of different surgical approaches in the management of pancreatic stump. Literature review. Int J Surg 21 Suppl 1: S4-S9, 2015. PMID: 26118602. DOI: 10.1016/j.ijsu.2015.04.088
    OpenUrlCrossRefPubMed
  20. ↵
    1. Ironside N,
    2. Barreto SG,
    3. Loveday B,
    4. Shrikhande SV,
    5. Windsor JA and
    6. Pandanaboyana S
    : Meta-analysis of an artery-first approach versus standard pancreatoduodenectomy on perioperative outcomes and survival. Br J Surg 105(6): 628-636, 2018. PMID: 29652079. DOI: 10.1002/bjs.10832
    OpenUrlCrossRefPubMed
  21. ↵
    1. Shah OJ,
    2. Gagloo MA,
    3. Khan IJ,
    4. Ahmad R and
    5. Bano S
    : Pancreaticoduodenectomy: a comparison of superior approach with classical Whipple’s technique. Hepatobiliary Pancreat Dis Int 12(2): 196-203, 2013. PMID: 23558075. DOI: 10.1016/s1499-3872(13)60031-4
    OpenUrlCrossRefPubMed
  22. ↵
    1. Richter A,
    2. Niedergethmann M,
    3. Sturm JW,
    4. Lorenz D,
    5. Post S and
    6. Trede M
    : Long-term results of partial pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head: 25-year experience. World J Surg 27(3): 324-329, 2003. PMID: 12607060. DOI: 10.1007/s00268-002-6659-z
    OpenUrlCrossRefPubMed
  23. ↵
    1. Crist DW,
    2. Sitzmann JV and
    3. Cameron JL
    : Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg 206(3): 358-365, 1987. PMID: 3632096. DOI: 10.1097/00000658-198709000-00014
    OpenUrlCrossRefPubMed
    1. Balcom JH 4th.,
    2. Rattner DW,
    3. Warshaw AL,
    4. Chang Y and
    5. Fernandez-del Castillo C
    : Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 136(4): 391-398, 2001. PMID: 11296108. DOI: 10.1001/archsurg.136.4.391
    OpenUrlCrossRefPubMed
  24. ↵
    1. Winter JM,
    2. Cameron JL,
    3. Campbell KA,
    4. Chang DC,
    5. Riall TS,
    6. Schulick RD,
    7. Choti MA,
    8. Coleman J,
    9. Hodgin MB,
    10. Sauter PK,
    11. Sonnenday CJ,
    12. Wolfgang CL,
    13. Marohn MR and
    14. Yeo CJ
    : Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 10(9): 1280-90; discussion 1290, 2006. PMID: 17114014. DOI: 10.1016/j.gassur.2006.07.020
    OpenUrlCrossRefPubMed
  25. ↵
    1. Shibuya K,
    2. Jang JY,
    3. Satoi S,
    4. Sho M,
    5. Yamada S,
    6. Kawai M,
    7. Kim H,
    8. Kim SC,
    9. Heo JS,
    10. Yoon YS,
    11. Park JS,
    12. Hwang HK,
    13. Yoshioka I,
    14. Shimokawa T,
    15. Yamaue H and
    16. Fujii T
    : The efficacy of polyglycolic acid felt reinforcement in preventing postoperative pancreatic fistula after pancreaticojejunostomy in patients with main pancreatic duct less than 3 mm in diameter and soft pancreas undergoing pancreatoduodenectomy (PLANET-PJ trial): study protocol for a multicentre randomized phase III trial in Japan and Korea. Trials 20(1): 490, 2019. PMID: 31399139. DOI: 10.1186/s13063-019-3595-x
    OpenUrlCrossRefPubMed
  26. ↵
    1. Ochiai T,
    2. Sonoyama T,
    3. Soga K,
    4. Inoue K,
    5. Ikoma H,
    6. Shiozaki A,
    7. Kuriu Y,
    8. Kubota T,
    9. Nakanishi M,
    10. Kikuchi S,
    11. Ichikawa D,
    12. Fujiwara H,
    13. Sakakura C,
    14. Okamoto K,
    15. Kokuba Y and
    16. Otsuji E
    : Application of polyethylene glycolic acid felt with fibrin sealant to prevent postoperative pancreatic fistula in pancreatic surgery. J Gastrointest Surg 14(5): 884-890, 2010. PMID: 20177808. DOI: 10.1007/s11605-009-1149-3
    OpenUrlCrossRefPubMed
  27. ↵
    1. Kang JS,
    2. Han Y,
    3. Kim H,
    4. Kwon W,
    5. Kim SW and
    6. Jang JY
    : Prevention of pancreatic fistula using polyethylene glycolic acid mesh reinforcement around pancreatojejunostomy: the propensity score-matched analysis. J Hepatobiliary Pancreat Sci 24(3): 169-175, 2017. PMID: 28054751. DOI: 10.1002/jhbp.428
    OpenUrlCrossRefPubMed
  28. ↵
    1. Kuramoto M,
    2. Ikeshima S,
    3. Shimada S,
    4. Yamamoto K,
    5. Masuda T,
    6. Nakamura K,
    7. Takeguchi T and
    8. Baba H
    : Pancreaticojejunostomy by reinforcing the pancreas without covering the anastomotic line reduces pancreatic fistula. Int J Surg 11(9): 909-913, 2013. PMID: 23872031. DOI: 10.1016/j.ijsu.2013.07.007
    OpenUrlCrossRefPubMed
  29. ↵
    1. Müssle B,
    2. Wierick A,
    3. Distler M,
    4. Weitz J and
    5. Welsch T
    : Falciform ligament wrap for prevention of gastroduodenal artery bleed after pancreatoduodenectomy. J Surg Res 207: 215-222, 2017. PMID: 27979479. DOI: 10.1016/j.jss.2016.08.087
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Anticancer Research: 41 (10)
Anticancer Research
Vol. 41, Issue 10
October 2021
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author
  • Back Matter (PDF)
  • Ed Board (PDF)
  • Front Matter (PDF)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Anticancer Research.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Pancreaticoduodenectomy at a Non-high-volume Center and Efforts to Perform Safe Surgery
(Your Name) has sent you a message from Anticancer Research
(Your Name) thought you would like to see the Anticancer Research web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
17 + 1 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
Pancreaticoduodenectomy at a Non-high-volume Center and Efforts to Perform Safe Surgery
TAISHI YAMANE, DAISUKE IZUMI, SHOTARO KINOSHITA, CHIKA SHIRAKAMI, KEISUKE MORITA, SATOSHI IKESHIMA, KEI HORINO, SHINYA SHIMADA, HIDEO BABA
Anticancer Research Oct 2021, 41 (10) 5223-5229; DOI: 10.21873/anticanres.15341

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Reprints and Permissions
Share
Pancreaticoduodenectomy at a Non-high-volume Center and Efforts to Perform Safe Surgery
TAISHI YAMANE, DAISUKE IZUMI, SHOTARO KINOSHITA, CHIKA SHIRAKAMI, KEISUKE MORITA, SATOSHI IKESHIMA, KEI HORINO, SHINYA SHIMADA, HIDEO BABA
Anticancer Research Oct 2021, 41 (10) 5223-5229; DOI: 10.21873/anticanres.15341
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • Patients and Methods
    • Results
    • Discussion
    • Acknowledgements
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • Tight Anastomosis of the Pancreatojejunostomy During Pancreatoduodenectomy May Cause Late Acute Pancreatitis
  • Clinical Features and Treatment Outcomes of Pseudoaneurysm Following Pancreatic Resection
  • Pancreatectomy With Artery En-bloc Resection for Pancreatic Neck/Body Cancer: A Single-arm Pilot Study
  • Google Scholar

More in this TOC Section

  • Four Different Artificial Intelligence Models Versus Logistic Regression to Enhance the Diagnostic Accuracy of Fecal Immunochemical Test in the Detection of Colorectal Carcinoma in a Screening Setting
  • In-hospital Outcomes Between Total Parenteral Nutrition and Enteral Feeding in Esophageal and Gastric Cancer: A Nationwide Analysis
  • Phase II Study of the Effectiveness of the Germinated Wheat-derived Rigenase Plus Polyhexanide in the Prophylaxis for Hypofractionated Radiation-induced Acute Skin Toxicity in Breast Cancer
Show more Clinical Studies

Similar Articles

Keywords

  • pancreaticoduodenectomy
  • non-high volume center
  • artery-first approach
Anticancer Research

© 2025 Anticancer Research

Powered by HighWire