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Ligation of left gastric vein may cause delayed gastric emptying after pancreatoduodenectomy: a retrospective study | BMC Gastroenterology


In this study, we retrospectively investigated the running pattern of the LGV and development of DGE after ligation of the LGV in SSPPD.

Patients

A total of 105 adults (> 20 years old) who underwent SSPPD for pancreatic head tumours, periampullary tumours, or for diseases manifesting as a pancreatic mass at Matsuyama Red Cross Hospital between January 2016 and September 2021 were included in this study. Patients scheduled to undergo total pancreatectomy, combined liver resection, and pancreaticogastrostomy and those with a history of gastric surgery or colorectal surgery were excluded. All treatment procedures were performed after informed consent was obtained from the patients. Medical charts were retrospectively reviewed to obtain patient data. This study was approved by the Clinical Study Examination Committee of the Matsuyama Red Cross Hospital (Approval No. 919) and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its subsequent amendments.

Surgical procedures

SSPPD with lymph node resection was performed as a standard procedure for pancreatic head, distal common bile duct, or periampullary tumours. The SSPPD involved a division of the stomach 3 cm proximal to the pyloric ring, followed by resection of the entire duodenum, gallbladder, distal common bile duct, and pancreatic head.

We resected the right gastric artery and vein for routine dissection of #5 lymph node for all surgical procedures in SSPPD [11]. Simultaneously, we performed #12 and #8 lymph node dissections and resection of the gastroduodenal artery. The inferior pancreaticoduodenal artery was resected routinely. The lymph nodes of the right semicircle of the superior mesenteric artery were dissected (#14 lymph node dissection) for pancreatic carcinomas.

Reconstruction was performed using the modified Child method. Either Roux-en-Y or Billroth II reconstruction was performed using the modified Child method. Pancreaticojejunostomy was performed using the modified Blumgart anastomosis [12] or Kakita method [13]. There were no restrictions on the hepaticojejunostomy technique used. Alimentary tract reconstruction as side-to-side gastroenterostomy was performed by using an automatic stapling device or hand-sewn anastomosis. Braun anastomosis was performed in all patients with Billroth II reconstruction.

Antecolic alimentary tract reconstruction was performed in all cases. During antecolic reconstruction, the anastomosis was positioned anterior to the transverse colon. The number, types, and locations of the intra-abdominal drainage tubes were determined according to the surgeon’s preference.

Postoperative management

The patients were administered epidural anaesthesia for 3 days, as appropriate. Early mobilisation was encouraged. The nasogastric tube (NGT) was routinely removed on the morning of postoperative day (POD) 1 if the drainage volume was < 200 mL. If a patient vomited persistently or the drainage volume was > 200 mL, an NGT was maintained. Conventionally, a solid diet was initiated on POD 3. However, this schedule was changed according to clinical observations, such as abdominal swelling, little peristaltic sounds, or vomiting. Drainage fluid biochemistry was measured for the presence of postoperative bile leakage or POPF by countering bilirubin and amylase on PODs 1, 3, 5, and 7. Drains were removed if there were no signs of postoperative biliary leakage, POPF, or chylorrhea. Postoperatively, a proton pump inhibitor was administered orally from POD 1 to prevent gastrointestinal ulceration. Octreotide administration was determined according to the attending surgeon’s preferences (from POD 0 to the day of drainage tubes removing). Pancreatic enzyme supplementation, mosapride citrate hydrate, or Japanese herbal medicine daikenchuto was administered according to the patient’s condition.

Postoperative complication definition

DGE

DGE was defined and graded according to the International Study Group of Pancreatic Surgery consensus definition published in 2007 as follows: Grade A, NGT insertion after POD 3 or the inability to tolerate intake of solid diet by POD 7; Grade B, NGT required for 8–14 days postoperatively, NGT reinsertion after POD 7, or the inability to tolerate solid diet by POD 14; and Grade C, NGT required for > 14 days postoperatively, NGT reinsertion after POD 14, or the inability to tolerate solid diet by POD 21 [4].

POPF

According to the 2016 update of the International Study Group for Pancreatic Fistula definition and grading of POPF, POPF is defined as a drain output amylase level > 3 times the upper limit of the institutional normal serum amylase activity. Grade A POPF is defined and termed as a “biochemical leak”, because it has no clinical importance and is no longer referred to as a true pancreatic fistula. Grade B requires a change in postoperative management; drains are either left in place for > 3 weeks or repositioned through endoscopic or percutaneous procedures. Grade C refers to POPFs that require reoperation or lead to single or multiple organ failure and/or mortality attributable to pancreatic fistula [14].

Other complications

Postoperative intra-abdominal infection was defined as the verification of a positive bacterial culture from intra-abdominal drainage tubes after surgery. Sepsis was defined as the detection of bacteria and/or fungi in blood cultures.

Running pattern of LGV classification

Running pattern of LGV was detected by using computed tomography performed before and after surgery and intraoperative findings from operation records. We performed computed tomography on seven days from surgery routinely. Then, we have investigated that the LGV was preserved or not in postoperative computed tomography. Moreover, we have added presence of LGV ligation in operation record. We investigated the anatomy of the LGV and classified it into four types according to the running pattern of the LGV, ventral or distal route of the common hepatic artery (CHA) and splenic artery (SpA) arcade, and joining point to the veins of the portal vein (PV) or splenic vein (SpV). Previous reports have identified three positions for LGV confluence into major veins: the PV, SpV, and junction of the PV and SpV [15, 16]. However, Kawasaki et al. described a relationship between the LGV and arteries around the pancreas [17]. In this study, we classified the running pattern of the LGV to simplify the classification from a surgical and procedural viewpoint.

Type 1 LGV runs dorsal to the CHA or SpA (mostly dorsal to the CHA) and join the PV. Type 2 LGV runs dorsal to the CHA or SpA (mostly dorsal to the SpA) and joins the SpV. Type 3 LGV runs ventral to the CHA or SpA (mostly ventral of CHA) and joins the PV. Finally, type 4 LGV runs ventral to the CHA or SpA (mostly ventral to the SpA) and joins the SpV (Fig. 1). LGV ligation data were collected from operation records.

Fig. 1

Four running patterns of the left gastric vein. Yellow and green arrowheads point to the left gastric veins. The running patterns indicated by the yellow arrowheads were more frequently ligated than the patterns indicated with green arrowheads. LGV, left gastric vein; CHA, common hepatic artery; SpA, splenic artery; DGA, duodenal gastric artery; PHA, proper hepatic artery; PV, portal vein; SpV, splenic vein; SMV, superior mesenteric vein

We found two cases which LGV flows into the left branch of the portal vein. They were excluded in this study.

Statistical analyses

All values are expressed as mean and standard deviation. Categorical variables were compared using χ2 tests. Statistical significance was set at p < 0.05. A logistic regression analysis was used for the multivariate analysis of categorical variables according to risk factors of DGE. All statistical analyses were performed using the JMP 16 software (SAS Institute Japan, Tokyo, Japan).



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