Appraisal of two-staged pancreatoduodenectomy : Its technical aspects and outcome

BACKGROUND/AIMS: Leakage from the pancreaticoenteric anastomosis after pancreatoduodenectomy is closely associated with intraabdominal hemorrhage, thus contributing to mortality. Recently, two-staged pancreatoduodenectomy including exteriorization of the pancreatic juice and second-look pancreaticojejunostomy was performed in high-risk patients. METHODOLOGY: The authors reviewed 24 patients who underwent two-staged pancreatoduodenectomy from November 1994 to April 1999. RESULTS: Oral intake could be instituted on the 6th (mean) postoperative day. In 23 of the 24 patients, the pancreatic juice leakage stopped within a mean of 10 days without any complications. In the remaining 1, the leakage lasted over 4 weeks and intraabdominal bleeding from the gastroduodenal artery occurred. The median interval between pancreatoduodenectomy and the second operation was 124 days (range: 93-323 days). In 15 patients, a stent tube was placed at the site of pancreaticojejunostomy: 1 patient developed acute pancreatitis due to dislocation of the stent tube, in 3, pancreatic juice leakage necessitated exteriorization of the juice, and the remaining 11 recovered uneventfully. In the other 9 patients, the pancreatic juice was exteriorized: 1 patient had leakage and the other 8 recovered uneventfully. Overall, there was no mortality. CONCLUSIONS: Our two-staged pancreatoduodenectomy is considered to make pancreatoduodenectomy performable safely without any mortality. This procedure is recommended for selected patients, including those who require concomitant major hepatectomy or resection of other organs or who have liver cirrhosis, and may be indicated for patients who have a soft and fragile pancreas or pancreatic trauma.