Pankreatikoduodenektomi yapılan olgularda dren amilazı değerlerinin pankreas anastomoz kaçağı ile ilişkisi

Amaç: Pankreatikoduodenektomi ameliyatı yapılan olgularda dren amilazının seyrini izlemek ve pankreas anastomozu kaçakları ile olan ilişkisini tanımlamak, bunları tanımlarken anastomoz kaçaklarını gruplandırmaktır. Yöntem ve Gereç: Nisan 1999-Şubat 2006 arasında pankreatikoduodenektomi yapılan ve prospektif olarak kayıtları tutulmakta olan ardışık, toplam 187 hastanın yaş, cinsiyet verileri, semptomlar, ameliyat öncesi yapılan drenaj işlemleri, tümörün yerleşimi, patolojik tanı, ameliyat sırasında yapılan ek cerrahi girişimler, PJ (pankreatikojejunostomi) anastomozunda kullanılan teknik, morbidite, hastane mortalitesi, pankreas kaçağı varlığı, ilk 7 gün bakılan kan ve dren amilazı değerleri, kaçağın sınıflaması, fistül varlığı bilgileri, bu değişkenlerin pankreas anastomoz kaçağı ile ilişkisi ve dren amilazlarının anastomoz kaçağını tespit etmedeki önemini ortaya koymak üzere çalışmaya başlanmıştır. Toplanan veriler 'Retrospektif kohort' şeklinde değerlendirilmiştir. Bulgular: Çalışmada pankreatikoduodenektomi uygulanan 187 olgunun 120'si erkek (%64.2), 67'si kadın (%35.8) idi. Ortalama yaş 57.39±11.421 idi. En sık başvuru semptomları, %64.7 ile sarılık, %29.9 ile karın ağrısı idi. Olgularda morbidite %59.4 oranında izlenirken, mortalite %11.2 oranında izlendi. Çalışmada ortaya konan gruplamaya göre, 187 olgunun %37.4'ünde dren amilazları 200 U/L altında seyrederken, %20.9 olguda biyokimyasal kaçak, %21.4 olguda minör kaçak, %10.7 olguda majör kaçak, %9.6 olguda da pankreatik fistül izlendi. Sonuç: Pankreatikoduodenektomi yapılan olgularda dren amilaz düzeyi, klinik, laboratuar ve radyolojik tetkikler ile birleştirilerek pankreas anastomoz kaçaklarıyla ilgili yeni bir sınıflama tanımlanmıştır.

The relationship between drain amylase values and pancreas anastomotic leaks in pancreaticoduodenectomy cases

Aim:To follow the drain amylase levels, to determine and to classify the relationship between drain amylase levels and pancreaticojejunostomy anastomose leaks in Whipple procedure. Material and Methods: Data from 187 patients on which a pancreaticoduodenectomy was performed were analyzed retrospectively between April 1999 and February 2006. Age, sex, symptoms, preoperative drainage procedures, the location of tumour, pathologic diagnose, additional surgical procedures during the operation, PJ anastomose technic, morbidity, hospital mortality, existence of pancreatic anastomose leak and fistula, the level of pancreatic drain amylase at first 7 days, the relationship of these variables with pancreatic anastomose leaks and the importance in determining anastomotic leaks were all examined. The collected data were evaluated as retropective cohort study. Results:One hundred and twenty of the cases studied were male, and 67 were female. The mean age was 57.39±11.421 years. The most applicable symptoms were jaundice (64,7%) and abdominal pain (29,9%). The morbidity and mortality were 59,4% and 11,2%, respectively. According to the classification done in the study, 37,4 patients had normal drain amylase values, 20,9% had biochemical leak, 21,4% had minor leak, 10,7% had major leak, and 9,6% had pancreatic fistula. Conclusion: A new classification was determined which classified the pancreatic anastomotic leaks together with the levels of drain amylase, clinic, laboratory and radiologic data in the patients on which pancreaticoduodenectomy were performed.

___

  • 1) Yeo YC, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty consecutive pancreaticoduodenectomies in 1990s: pathology, complications and outcomes. Ann Surg. 1997;226:248-60.
  • 2) Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, Obertop H. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg. 2000;232:786-95.
  • 3) Thomas B, Junginger T. Factors influencing morbidity and mortality after pancreaticoduodenectomy: Critical analysis of 221 resections. World J Surg. 1999;23:164-172.
  • 4) Makowiec F, Post S, Saeger HD, Senninger N, Becker H, Betzler M, Buhr HJ, Hopt UT; German Advanced Surgical Treatment Study Group. Current practice patterns in pancreatic surgery: results of a multiinstutional analysis of seven large surgical departments in Germany with 1454 pancreatic head resections, 1999 to 2004 (German Advanced Surgical Treatment Study Group). J Gastrointest Surg 2006;9:1080-6.
  • 5) Bottger TC, Junginger T. Factors influencing morbidity and mortality after pancreaticoduodenectomy: critical analysis of 221 resections.World J Surg. 1999;23:164-71.
  • 6) Grace PA, Pitt HA, Tompkins RK, DenBesten L, Longmire WP Jr. Decreased morbidity and mortality after pancreaticoduodenectomy. Am J Surg 1986;151:141-9.
  • 7) Pellegrini CA, Heck CF, Raper S, Way LW. An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy. Arch Surg. 1989;124:778-81.
  • 8) Pellegrini CA, Heck CF, Raper S, Way LW. An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy. Arch Surg. 1989;124:778-81.
  • 9) van Berge Henegouwen MI, De Wit LT, Van Gulik TM, Obertop H, Gouma DJ. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg. 1997;185:18-24.
  • 10) Yeh TS, Jan YY, Jeng LB, Hwang TL, Wang CS, Chen SC, Chao TC, Chen MF. Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy--multivariate analysis of perioperative risk factors. J Surg Res. 1997;67:119-25.
  • 11) Lowy AM, Lee JE, Pisters PW, Davidson BS, Fenoglio CJ, Stanford P, Jinnah R, Evans DB. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg. 1997;226:632-41.
  • 12) Talamini MA, Moesinger RC, Pitt HA, Sohn TA, Hruban RH, Lillemoe KD, Yeo CJ, Cameron JL. Adenocarcinoma of the ampulla of Vater. A 28-year experience. Ann Surg. 1997;225:590-9.
  • 13) Yang YM, Tian XD, Zhuang Y, Wang WM, Wan YL, Huang YT. Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenterol. 2005;11:2456-61.
  • 14) de Castro SMM, Busch ORC, van Gulik TM, Obertop H, Gouma DJ. Incidence and management of pancreatic leakage after pancreatoduodenectomy. Br J Surg 2005;92:1117-23.
  • 15) Konishi T, Hiraishi M, Kubota K. Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy. Ann Surg 1995;221:165-70.
  • 16) Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak ML, Talamini MA, Lillemoe KD, Pitt HA. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg. 1995;222:580-8.
  • 17) de Castro SM, Busch OR, Gouma DJ. Management of bleeding and leakage after pancreatic surgery. Best Pract Res Clin Gastroenterol. 2004;18:847-64.
  • 18) Buchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z'graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003;138:1310-4.
  • 19) Howard JM. Pancreatico-duodenectomy: Forty-one consecutive Whipple resections without an operative mortality. Ann Surg 1968;168:629-636.
  • 20) Russel GP. Past, present and future of pancreatic surgery. Am J Surg. 2001;182: 547-51.
  • 21) Kausch W. Das carcinom der papilla duodenia und scine radikale entfernung. Beitrage Klin Chir 1912:78:439-486.
  • 22) Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of ampulla of Vater. Ann Surg 1935;102:763-76.
  • 23) Kamal H, Eduvard C, Onye EA, Meyers W. Pylorus preserving pancreaticoduodenectomy. Ann Surg. 1986; 204:655-64.
  • 24) Cameron JL, Henry AP, Charles JY. One hundred and forty five consecutive pancreaticoduodenectomies without mortality. Ann Surg. 1993;217:430-8.
  • 25) Yeo YC, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA. Six hundred fifty consecutive pancreaticoduodenectomies in 1990s: pathology, complications and outcomes. Ann Surg. 1997;226:248-60.
  • 26) Chew DW, Attiyeh FF. Experience with the Whipple procedure (pancreaticoduodenectomy) in a University-affiliated community hospital. Am J Surg. 1997;174:312-15.
  • 27) Bassi C, Butturini G, Molinari E, Mascetta G, Salvia R, Falconi M, Gumbs A, Pederzoli P. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg. 2004;21:54-9.
  • 28) Yoshida T, Matsumoto T, Sasaki A, Morii Y, Aramaki M, Kitano S. Prognostic factors after pancreatoduodenectomy with extended lymphadenectomy for distal bile duct cancer. Arch Surg 2002;137:69-73.
  • 29) Doerr RJ, Yıldız İ, Flint LM. Pancreaticoduodenectomy. University experience and resident education. Arch Surg. 1990;125:463-5.
  • 30) Braasch JW, Rossi RL, Watkins E, Deziel DJ, Winter PF. Pyloric and gastric preserving pancreatic resection. Experience with 87 patients. Ann Surg 1986; 204:411-17.
  • 31) Montorsi M, Zago M, Mosca F. Efficiacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections; a prospective, controlled, randomized clinical trial. Surgery 1995;117:26-31.
  • 32) Büchler M, Friess H, Klempa I. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992:163:125-36.
  • 33) Trede M, Chir B, Schwall G, Saeger HD. Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality. Ann Surg 1990; 211:447-58.
  • 34) Cullen JJ, Sarr MG, Ilstrup DM. Pancreatic anastomotic leak after pancreaticoduodenectomy:incidence, significance, and management. Am J Surg 1994;168:295-8.
  • 35) Balachandran P, Sıkora SS, Rao RVR, Kumar A, Saxena R, Kapoor VK. Haemorrhagic complications of pancreaticoduodenectomy. ANZ J Surg.2004;74:945-50.
  • 36) Shrinkhande SV, Qureshi SS, Rajneesh N, Shukla PJ. Pancreatic anastomoses after pancreaticoduodenectomy: Do we need further studies? World J Surg 2005;29:1642-9.
  • 37) Aramba GV, Hodul P, Golts E, Oh D, Pickleman J, Creech S. A comparison of pancreaticogastrostomy and pancreaticojejunostomy following pancreaticoduodenectomy. J Gastrointest Surg.2003;5:672-81.
  • 38) Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J. One hundred and forty five consecutive pancreaticoduodenectomies without mortality. Ann Surg. 1993;217:430-5.