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PAPER

Critical Analysisof a Large Series of PancreaticogastrostomyAfter Pancreaticoduodenectomy

Gerard V. Aranha, MD, FRCSC; Joshua M. Aaron, BS; Margo Shoup, MD

Hypothesis: Pancreaticogastrostomy is a safe opera-tion for a variety of periampullary conditions.

Design: Retrospective review of a prospectively col-lected database.

Setting:An academic tertiary care university hospitaland a Veterans Affairs hospital.

Patients:A total of 235 consecutive patients who un-derwent pancreaticogastrostomy.

Main Outcome Measures: Indications for surgery,preoperative risk factors, intraoperative and postopera-tive variables, and factors that affect postoperativecomplications.

Results: The most common initial symptoms were jaun-dice (73.2%), weight loss (23.8%), and abdominal pain(17.0%). The 4 most commonindications for surgery werepancreatic adenocarcinoma (41.3%), ampullary carci-

noma (17.0%), duodenal carcinoma (7.2%), and chronicpancreatitis (7.2%). The median operating time was 6.5hours. Median blood loss was 900 mL. The median in-traoperative blood transfusion was0 U. The median post-operative length of stay was 9 days. Postoperative mor-tality was 0.9%. The most common complications werepancreatic fistulae (13.6%), 1 of which was thought tocause 1 of 2 mortalities in this series. Pancreatic fistulae

developing after pancreaticogastrostomy were signifi-cantly related to a low preoperative alkaline phospha-tase level and surgery for nonpancreatic pathologic find-ings. The presence of a fistula significantly increased thepostoperative length of hospital stay.

Conclusions: Pancreaticogastrostomy is a safe opera-tion associated with low mortality and morbidity ratesand a pancreatic fistula rate of 13.6%. It should be con-sidered as a suitable alternative for management of thepancreatic remnant after pancreaticoduodenectomy.

Arch Surg. 2006;141:574-580

MANAGEMENT OF THE

pancreatic remnant af-ter pancreaticoduode-nectomy continues tobe a source of contro-

versy. This controversy is fueled by thefactthat leakage from the pancreaticoentericanastomosis is responsible for a large per-centage of themorbidity andmortality thatfollows pancreaticoduodenectomy. Tredeand Schwall1 from theMannheim Clinic inMannheim, Germany, published data on233 patients who had pancreaticojejunal

anastomosis and reported 25 pancreaticleaks, for an incidence of 11%, and 20% oftheleaksleddirectlyto postoperativedeaths.TheLahey Clinic2 andthe Mayo Clinic3 re-ported similar findings, with 34 pancreaticleaksin 403pancreaticoduodenectomies,foran incidence of 8%, of which 26% was re-lated directly to postoperative deaths.

Because leakage from the pancreatico-enteric anastomosis has been the leadingcause of morbidity andmortality after pan-

creaticoduodenectomy, various tech-niques for managing the pancreatic rem-nant have been studied, including simpleligation of the pancreatic duct,4,5 occlu-sion of the pancreatic duct using a syn-thetic rubber injectionor fibrin glue,6,7 op-timization of the blood supply of the edgeof the pancreatic remnant and meticu-lous placement of sutures using magnifi-cation,8 the application of fibrin gluesealant aroundthe pancreaticojejunalanas-tomosis,9 various modifications of pan-creaticojejunostomy (either end-to-endor

end-to-side anastomosis),10-15

isolatedRoux-en-Y pancreaticojejunostomy,16,17

and pancreaticogastrostomy.18-32

The purpose of this study is to analyzeour experience with 235 pancreaticogas-trostomies after pancreaticoduodenec-tomy studied in a retrospective mannerfrom a prospectively collected database todetermine whether pancreaticogastros-tomy is a safe and effective method formanaging the pancreatic remnant.

Author Affiliations:Division ofSurgical Oncology, Departmentof Surgery, Loyola University,Stritch School of Medicine,Maywood, Ill (Drs Aranha andShoup and Mr Aaron), andSurgical Service, Hines VAHospital, Hines, Ill(Dr Aranha).

(REPRINTED) ARCH SURG/VOL 141, JUNE 2006 WWW.ARCHSURG.COM574

2006 American Medical Association. All rights reserved.

wnloaded From: http://archsurg.jamanetwork.com/ by a World Health Organization User on 02/14/2014

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METHODS

PATIENT DATA

We conducted a retrospective review of a prospective data-base of 235 patients who underwent pancreaticogastrostomyafter pancreaticoduodenectomy at Loyola University MedicalCenter and Hines VA Hospital between June 1, 1990, and July31, 2005. All the patients who underwent pancreaticogastros-

tomy after pancreaticoduodenectomy were operated on by thesame surgeon (G.V.A.), with no patients having pancreatico-duodenectomyreconstructedwith pancreaticojejunostomy dur-ing this period.

Clinical and pathologic data were obtained from the sur-gery database, medical records, and interviews. Data obtainedfor each patient included demographics; preoperative labora-tory values; clinical symptoms and signs; procedures, includ-ing computed tomography (CT), endoscopy, and the place-ment of stents; and intraoperative data, such as the use ofprophylactic antibiotic agents, blood loss, operating time, andunits of blood transfused. Postoperative data, including patho-logic findings, mortality, morbidity, and the use of octreotide,were also analyzed. Analyses were performed using statisticalsoftware (SPSS for Windows; SPSS Inc, Chicago, Ill). The 2

or Fisher exact test was used when appropriate. Statistical sig-nificance was set atP=.05.

SURGICAL TECHNIQUE

All the patients underwent classic pancreaticoduodenectomywith distal gastrectomy. The pancreatic remnant was mobi-lized for 4 cm. Single layers of sutures of 3-0 silk were takenfrom the posterosuperior gastric wall, at least 5 cm from thecut edge of the stomach, to the anterior wall of the body of thepancreas. A gastrotomy was made, and thensutures were placedfrom the posteroinferior gastric wall to the posterior body of

the pancreas. Sutures entered the pancreas at least 2 cm fromthe cut edge and exited 1 cm from the cut edge, and when thesutureswere tied, at least 1 to 2 cm of the pancreas was invagi-nated into the stomach without a stent. The Figuredemon-strates the completed hepaticojejunostomy, gastrojejunos-tomy, and pancreaticogastrostomy.33 Two drains were placed:1 to drain the hepaticojejunostomy on the right side and 1 todrain the pancreaticogastrostomy on the left side. All the pa-tients received prophylactic antibiotics before surgery. Early inthe series, most patients received octreotide, but in the last 123

patients,octreotide wasnot used. Patients began receiving eryth-romycin lactobionate, 250 mg intravenously every 6 hours, onday 4. The nasogastric tube was removed on day 5, and meto-clopramide hydrochloride was added intravenously every 8hours. Proton pump inhibitors were used postoperatively toprevent stress and marginal ulceration.

The patients are given a liquid diet on day 6 and, if tolerated,advanced to a postgastrectomy diet on day 7. After 2 solidmeals,drainage from theleft drain wasmeasured foramylase content. Ifthe amylase level was less than 125U/L, the drainwasremoved ifthe volume was200 mL/d or less. If the volume was greater than200 mL/d, andthe amylase level wasnormal, thepatient wassenthome with thedrainuntil thedrainage decreased to lessthan 200mL/d, and then the drain was removed. If the fluid was amylaserich,thepatientwasfed,andifthevolumedidnotchange,thepa-

tient was senthome on an oral diet. If the fluid was amylase richandthe volume increasedafteran oraldiet, then a drain studywasperformedbyinjecting dye into the drain.In 6 (19%)of 32patientswith a pancreaticleak, thedrain haderodedinto thepancreatico-gastrostomyanastomosisandhadtobepulledback.Thedrainplacedalong the biliary anastomosis was removed on day 5 if there wasno bile in the drain. This was done irrespective of the volume ofdrainage.Apancreaticfistula wasdefined asamylase-richfluid fromthe pancreatic drainwith 3 times the serum amylase level on thefirst day after the patient eats a soliddiet. Delayedgastricempty-ingwas definedas a need fornasogastricsuction formore than 10days after pancreaticoduodenectomy.

A B C

1cm

Figure.Construction of the pancreaticogastrostomy. A, Sutures are placed from the posterosuperior gastric wall to the anterior pancreas body. B, A gastrotomy is

made, and sutures are placed from the posteroinferior gastric wall to the posterior pancreas body. C, Completed hepaticojejunostomy, gastrojejunostomy, andpancreaticogastrostomy. Reprinted with permission from Excerpta Medica, Inc, from Aranha GV. A Technique for Pancreaticogastrostomy.Am J Surg.1998;175:328-329. Copyright 1998.




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RESULTS

Patient characteristics and preoperative risk factors arelisted inTable 1. There were 145 men and 90 women(median age, 68 years; range, 21-90 years. The most com-mon initial symptoms included jaundice (73.2%), weightloss (23.8%), and abdominal pain(17.0%). Median weightloss was 6.75 kg (range, 1.80-24.75 kg). Patientswho wereconsidered malnourished (ie, albumin level 2.5 g/dL)were given parenteral or enteral nutrition for 10 to 14

days before surgery. This occurred in fewer than 10 pa-tients. Preoperative risk factors included hypertension,diabetes mellitus, previous cancer, chronic obstructivepulmonary disease or asthma, atrial fibrillation, coro-nary artery disease, peripheral vascular disease, peptic ul-cer,hypothyroidism, and pancreatitis.Indicationsfor pan-creaticoduodenectomy based on pathologic findings aregiven inTable 2. The 4 most common indications forpancreaticoduodenectomy were pancreatic adenocarci-noma (41.3%), ampullary carcinoma (17.0%), duode-nal carcinoma (7.2%), and chronic pancreatitis (7.2%).All the patients underwent preoperative CT, and 142(60.4%) had biliary stents placed via endoscopic retro-grade cholangiopancreatography or percutaneous trans-

hepatic cholangiography.The median operating time was 6.5 hours (range, 3.4-13.0 hours). Median blood loss was 900 mL (range, 200-7500 mL), and the median intraoperative transfusion was0 U (range, 0-7 U). Octreotide was used after surgery in112 patients and was not used in 123 patients. The me-dian postoperative hospital stay was 9 days (range, 5-83days). Thirty-day and in-hospital mortality occurred in2 patients (0.9%) (Table 3). One patient died of acuterespiratory distress syndrome on the 45th postoperativeday. The second patient died at an outside institution of

a massive upper gastrointestinal hemorrhage. Aside fromthe 2 deaths, 191 patients underwent pancreaticoduo-denectomy without mortality.

A pancreatic fistula occurred in 32 patients (13.6%)

and was the most common morbidity. Most of the 32 fis-tulae closed with maintenance of drains and continuedoral intake. In 11 (34.4%) of these 32 patients, paren-teral nutrition was necessary for fistula closure. Only 1patient had to return to surgery for closure of the fis-tula. An intra-abdominal abscess occurred in 14 pa-tients (6.0%) and wound infections in 13 (5.5%). All thepatients with intra-abdominal abscess were treated witheither intraoperatively placed drains or new percutane-ous drains by means of interventional radiology.

Hemorrhage occurred in 4 patients (1.7%). Two of thepatients had hemorrhage from the gastrojejunal anasto-mosis that wascontrolled with endoscopic means, andtheother 2 had pseudoaneurysms. One pseudoaneurysm was

controlled at our institution (Loyola University MedicalCenter) with interventional radiology using coil emboli-zation. The other patient died at an outside institution ofmassive upper gastrointestinal bleeding and is presumedto have had a pseudoaneurysm. Bile leaks occurred in 2patients (0.9%) and weretreated withpercutaneous trans-hepatic stenting of the anastomosis, with resolution of theproblem. Contained leaks from the gastrojejunostomy oc-curred in 3 patients(1.3%), andnone required surgery. De-layed gastric emptying occurredin 14 patients(6.0%), andall resolved with conservative measures.

Table 1. Characteristics and Preoperative Risk Factorsof 235 Patients*

Characteristic No.(%)

Age, median (range), y 68 (21-90)

Sex

Male 145 (61.7)

Female 90 (38.3)

Jaundice 172 (73.2)

Weight loss 56 (23.8)Epigastric or back pain 40 (17.0)

Itching 15 (6.4)

Hypertension 98 (41.7)

Coronary artery disease 40 (17.0)

Diabetes mellitus 38 (16.2)

Previous cancer 28 (11.9)

COPD or asthma 21 (8.9)

Atrial fibrillation 19 (8.1)

Hypothyroid 17 (7.2)

GERD 15 (6.4)

Peripheral vascular disease 12 (5.1)

Peptic ulcer disease 10 (4.3)

Abbreviations: COPD, chronic obstructive pulmonary disease;GERD, gastroesophageal reflux disease.*Data are given as number (percentage) of patients except where

indicated otherwise.

Table 2. Indications for Pancreaticoduodenectomy

Pathologic Finding Patients, No. (%)

Adenocarcinoma 97 (41.3)

Ampullary carcinoma 40 (17.0)

Duodenal carcinoma 17 (7.2)

Chronic pancreatitis 17 (7.2)

Common bile duct cancer 14 (6.0)

Mucinous cystadenoma 10 (4.3)

Neuroendocrine 9 (3.8)Intraductal papillary mucinous neoplasm 7 (3.0)

Serous cystadenoma 6 (2.6)

Cystic adenocarcinoma 2 (0.9)

Other 16 (6.8)

Table 3. Postoperative Complications

Complication Patients, No. (%)

Mortality 2 (0.9)

Pancreatic leak 32 (13.6)

Intra-abdominal abscess 14 (6)

Delayed gastric emptying 14 (6)

Wound infection 13 (5.5)

Cardiac complications 8 (3.4)Small intestinal obstruction 5 (2.1)

Pulmonary complications 5 (2.1)

Hemorrhage 4 (1.7)

Gastric leak 3 (1.3)

Bile leak 2 (0.9)

Reexploration 3 (1.3)

Miscellaneous 18 (7.7)




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A second operation was required in 3 patients (1.3%).In the first patient, the surgery was for peritonitis. At ex-ploration, it was found that the pancreatic remnant hadseparated completely from the stomach. In this case, thepancreatic duct was simply oversewn and the gas-trotomy closed. This patient survived. The second pa-tient had a drain included in the closure of the fascia, andwhen the pancreatic drain was removed, it was severed.This patient was taken back to the operating room, and

the drain remnant was found in the wound just after theanterior fascia was opened; therefore, reentry into the ab-domen was not necessary. The third patient who had asecond surgery was the one who had surgical closure ofa persistent pancreatic fistula 3 months after surgery. Ofthe 112 patients receiving octreotide, 12 (10.7%) devel-oped a fistula, and thiswas not significant compared withthe11 (8.9%) of 123 patients who developeda fistulawith-out octreotide administration.

Table 4 lists certain preoperative, intraoperative, andpostoperative variablesin relation to fistulaformation. Age,duration of surgery,use of octreotide, intraoperative bloodtransfusion, intraoperative blood loss, preoperative bili-ary stenting, preoperative endoscopic retrograde cholan-

giopancreatography or percutaneous transhepatic cholan-giography, and a preoperative albumin level of 3 g/dL hadno effect on fistula formation. However, patients with el-evatedalkaline phosphatase levelshada significantlylowerincidence of postoperative pancreatic fistula than thosewhose alkaline phosphatase level was not elevated. Also,patients who had pancreatic adenocarcinoma and pancre-atic pathologic abnormalities had a much lower incidenceof pancreatic fistula than those who had other types ofpathologic abnormality.Finally, a pancreaticfistula wasas-sociated with a doubling in the median length of hospitalstay.

COMMENT

Pancreaticogastrostomy became a reality when Tripodiand Sherwin34 first reported successful transplantationof the pancreas into the stomach in 1934. This findingwas confirmed by Person and Glenn.35 Waug h andClagett36 at the Mayo Clinic were the first to use pancre-aticogastrostomy in the clinical setting in 1946. Furtherimpetus to the success of the operation was provided byMackie et al37 in 1975. Used infrequently initially, pan-creaticogastrostomy has been used much more fre-quently in thepast 20 years.24-32 It is well-known that leak-age from the pancreaticojejunal anastomosis and itsconsequencesare the leading causes of mortality after pan-

creaticoduodenectomy. Datafromthe late1970s and early1980s confirm this. More recently, Yeo et al38 reportedon 650 consecutive pancreaticoduodenectomies per-formed at The Johns Hopkins Hospital. They noted that26 patients (4.0%) required repeated surgery. Of the 26patients, 9 (34.6%) died after the second operation. Inall of these patients, death could be directly related toleakage from the pancreaticojejunal anastomosis. Sev-eral theoretical physiologic and technical advantages toperforming pancreaticogastrostomy have been de-scribed.28 A physiologic advantage is believed to be that

pancreatic enzymes are inactivated by the acidic gastricfluid. In addition, the stomach does not contain entero-kinase, which is required for the conversion of trypsino-gen to trypsin and the subsequent activation of other pro-teolytic enzymes.A lack of enzyme activation may preventautodigestion of the anastomosis. In addition, the alka-line and pancreatic secretions may aid in preventing mar-ginal ulceration. The proximity of thepancreas to the pos-terior wall of the stomach allows for potentially lesstension on the anastomosis. The excellent blood supplyto the stomach wall is favorable to anastomotic healing,

and the thickness of the stomach wall holds sutures well.Nasogastric decompression providesfor continuous emp-tying of the stomach and, therefore, less tension on thepancreaticogastrostomy anastomosis, a benefit not pos-sible with a pancreaticojejunal anastomosis. A review ofthe world literature on pancreaticogastrostomyfrom1946to 1997 by Mason39 seems to confirm the safety of pan-creaticogastrostomy. Of 813 patients who underwent pan-creaticogastrostomy, 32 (4.0%) developed pancreatico-cutaneous fistulae. Of these fistulae, 3 (0.4%)were thoughtto be the primary cause of death. In a meta-analysis of

Table 4. Preoperative, Intraoperative, and PostoperativeVariables in Patients With vs Without a Pancreatic Fistula*

CharacteristicNo Fistula(n = 203)

Fistula(n = 32)

P

Value

Age, y

70 113 (84) 21 (16).29

70 90 (89) 11 (11)

Duration of surgery, h

6.5 110 (89) 13 (11) .156.5 93 (83) 19 (17)

Octreotide therapy

Yes 94 (84) 18 (16).30

No 109 (89) 14 (11)

Intraoperative bloodtransfusion

Yes 65 (81) 15 (19).10

No 138 (89) 17 (11)

Estimated blood loss, mL

1000 128 (90) 15 (10).08

1000 75 (82) 17 (18)

Preoperative stent

Yes 127 (89) 15 (11).09

No 76 (82) 17 (18)

Preoperative ERCP or PTC

Yes 49 (86) 8 (14).92No 154 (87) 24 (13)

Alkaline phosphatase, U/L

110 46 (74) 16 (26).001

110 157 (91) 16 (9)

Albumin, g/dL

3 44 (90) 5 (10).43

3 159 (85) 27 (15)

Pancreatic pathologic findings

Yes 135 (91) 13 (9).005

No 68 (78) 19 (22)

Hospital stay,median (range), d

9 (5-34) 18 (7-83) .001

Abbreviations: ERCP, endoscopic retrograde cholangiopancreatography;PTC, percutaneous transhepatic cholangiography.*Data are given as number (percentage) of patients except where

otherwise indicated.




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105-111.

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8. StrasbergSM, Drebin JA,MokadamNA, et al.Prospectivetrial of a blood supply

based technique of pancreaticojejunostomy: effect on anastomotic failure in the

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rate of pancreatic fistula after pancreaticoduodenectomy? results of a prospec-

tive randomized trial.J Gastrointest Surg. 2004;8:766-774.

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8:733-741.

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jejunostomy following pancreatic resection.Dig Surg. 1997;14:183-186.

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chanical purse-string device.Am J Surg. 1999;177:340-341.

13. Landen S. Consolidation of a friablepancreas forpancreaticojejunal anastomosis.

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year survival with notes on the metabolism. Br J Surg. 1956;44:299-302.

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transection: a complete and efficient operation. Ann Surg. 1972;176:16-18.

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cinomaof theheadof thepancreas orthe papilla of vater. ActaChir Scand. 1958;

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ment of chronic pancreatitis.Am J Surg. 1985;150:608-611.

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DISCUSSION

Michael B. Farnell, MD, Rochester, Minn:Dr Aranha and hiscolleagues have been proponents of the use of pancreaticogas-trostomy for reconstruction following pancreaticoduodenec-tomy for a number of years. Their experience with 235 con-secutivepatientsundergoing pancreaticogastrostomyfor a varietyof indications, to my knowledge, is the largest reported to date.The hypothesis in this retrospective analysis of prospectivelycollected data is that pancreaticogastrostomy is a safe recon-struction for a variety of periampullary conditions.

I believe that Dr Aranha and his colleagues data supporttheir conclusions that pancreaticogastrostomy is a safe alter-native to pancreaticojejunostomy. The morbidity and mortal-ity rates in this series are commendable. Pancreatic leak oc-curred in 13.6% and delayed gastric emptying in only 6.0% ofpatients. The mean length of stay was 9 days, and only 3 pa-tients required reoperation. There were only 2 postoperativedeaths, for a mortality rate of 0.9%. Also, Dr Aranha pointedout in his presentation, pancreatic fistula was correlated withthe consistency of the pancreas and is consistent with large se-ries thatone sees reportedfor pancreaticoduodenectomy. Theseresults are outstanding and are comparable to results obtainedin other high-volume centers employing more conventional re-construction techniques consisting of either invagination or duct-to-mucosa pancreaticojejunostomy.

The theoretic physiologic and technical advantages es-poused by proponents of pancreaticogastrostomy include lackofenzymeactivation andalkalinemilieu in thestomach,whichmayprevent marginal ulceration, the superb bloodsupplyto thestom-ach, which may facilitate healing of the anastomosis, and naso-gastric decompression, which may allow for lack of tension onthe anastomosis, unlike a jejunal limb, which may distend witha pancreaticojejunostomy. The merits of these advantages, I amsure, can be debated by proponents of pancreaticojejunal recon-struction, many of whom report outstanding results comparableto those we have heardfrom Dr Aranha today. Pancreaticrecon-struction has been analyzed in a prospective, randomized fash-




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ionbyYeoetal(Ann Surg. 1995;222:580-592), and in their study,the morbidity and mortality was no different in pancreaticogas-trostomy vs pancreaticojejunostomy.

Dr Aranhas rich experience reported today and the surgi-cal literature support the observation that either of these anas-tomotic techniques are excellent for reconstruction with com-parable safety. In other words, it doesnt matter whether onedoes pancreaticogastrostomy or pancreaticojejunostomy. Whatreally matters is that it is done well.

Heretofore, the durability of pancreatic anastomosis has not

been a high priority, unfortunately, and this is due to the poorprognosis of many patients undergoing the operation. As theindications for pancreaticoduodenectomy have broadened andpancreatic surgeons are operating on more patients with cys-tic neoplasms, the prognosis is improving and patients are liv-ing for a longer period of time.

This leads me to my first question for Dr Aranha and thathas to do with patency of the anastomosis and preservation ofendocrine and exocrine function. The anastomosis with pan-creaticogastrostomy is easily accessible endoscopically, and Iwondered if Dr Aranha has any experience with assessing pat-ency and durability of his anastomosis and preservation of en-docrine and exocrine function?

Second, in my practice I reconstruct using the duct-to-mucosa technique, and should a leak concur, once it is wellcontrolled, I am comfortable feeding the patients and then ul-

timately dismissing them even with the leak persisting. Pre-sumably with a leak following pancreaticogastrostomy, thereis extravasation from the stomach. Are you able to feed thesepatients and are you able to dismiss them from the hospital,ordo you have to wait until it is completely healed?

Last, I was impressed with your low incidence of delayedgastric emptying. In the manuscript, your protocol for post-operative management included both erythromycin on day 4and Reglan [metoclopramide hydrochloride] on day 5 whentheNG [nasogastric] tube wasremoved.To what extentdo youfeelthat this pharmacologic regimen is responsible for your verylow 6.0% incidence of delayed gastric emptying?

Dr Aranha: You asked about whether I have studiedthe pan-creatic duct. We have not as of yet. I am in the process of get-ting IRB [institutional review board] approval to do such a study,

but I do have quality-of-life studies that we presented recentlyin Durban, South Africa, at the International Surgical Society

Week. We studied 88 patients who had a pancreaticogastros-tomy and 44 patients with pancreaticojejunostomy. Patients whohad the pancreaticogastrostomy took pancreatic enzymes fora longer period than those who had the pancreaticojejunos-tomy, suggesting that acid does inactivate amylase, and there-fore, patients with pancreaticogastrostomy have more steator-rhea. Overall, 40% of patients with pancreaticogastrostomyweretaking enzymes for more than 1 year after their Whipple pro-cedure. However, 60% had stopped taking pancreatic en-zymes.

The incidence of diabetes was 9% overall, but it was sig-nificantly lower in those with pancreaticogastrostomy than inthose who have pancreaticojejunostomy. My feeling has al-

ways been that diabetes occurredbecause the duct became ob-structed, but this has not been studied in a prospective fash-ion. There are other reasons for patients getting diabetes. Theamount of pancreas one removes may result in a decrease ofpancreatic polypeptide, and this may make the liver resistantto insulin.

Your second question was, how do we treat leaks? If I have aleakfrom the pancreaticogastrostomy, I willcontinue to feedthepatient. If the amount of fluid from the drain increases, I get adrain study. Of the 23 leaks that we had, 6 patients had the pan-

creatic drain erode into the anastomosis. The drain was pulledback, and the leak was closed. Also, one needs to get a CT scanto make sure that thereis no abscess that has to be drained. If thepatient can eat and the volume does not go up, we send the pa-tient home with the drain until the fistula closes, at which timewe remove the drain. Fewer than 5 patients have had to stay inthe hospital and receive total parenteral nutrition.

Finally, your question about erythromycin and Reglan asprokinetic agents. Erythromycin, as most of youknow,is a mo-tilin agonist. Motilin is concentratedin theduodenum, andthere-fore,lossof motilin is thought to be the reason for delayed gas-tric emptying that occurs more in the pylorus-preserving

Whipple procedure. I think one of the reasons that we do nothave the same incidence of delayed gastric emptying is be-cause we do the classic Whipple.

Lawrence J. Koep, MD, Phoenix, Ariz: The real advantageof this drainage is access to the pancreas. We have continuedto do this despite the Baltimore data, like you in many cases,whether it is papillary disease in the pancreatic duct or whetherit is pancreatitis, where it is essential to be able to get access tothat pancreatic duct as time goes on. The question of whetheryou have been able to access this so far is really critical. Wehave tried to do this. Early on we can do it up to about a year;we can access that pancreatic duct,watching what is goingon.Then after that, we are havinga lot of difficulty finding the pan-creatic duct in the stomach because it seems like they lose it.My question is, is this something we are going to be able to do?Do youthink that we will be able to accessthe anastomosislongterm and know what is happening to the pancreatic duct andto exocrine function?

Dr Aranha: You asked if we have studiedthe patency of thepancreatic duct after a pancreaticogastrostomy. We have notas of yet. We did have 2 patients who had recurring attacks ofpancreatitis. On these patients, we did an upper GI [gastroin-testinal] endoscopy and gave them secretin, and we were ableto identify the duct. I believe that over time, the gastric mu-cosa may grow over the end of the pancreatic duct, but I havenot been able to prove this with endoscopic studies.

Your second question was in regard to patients with intra-ductal papillary mucinous neoplasms. In patients who have a

Whipple procedure for an intraductal papillary mucinous neo-plasm, a pancreaticogastrostomy is suggested in the manage-ment of pancreatic remnant because the remnant can be ob-servedfor changes by an endoscopic ultrasound. In this situation,the Johns Hopkins group also supports pancreaticogastrostomy.



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