1. VCU DEATH AND COMPLICATIONS CONFERENCE

2. Introduction  Complication  Pancreaticojejunal anastamotic leak, UTI, sepsis  Procedure  Pylorus preserving pancreaticoduodenectomy  Primary Diagnosis  Pancreatic cancer

3. Clinical History: LH #7273931  77 yo male presenting with anorexia, weakness, painless jaundice and weight loss  PMH  Htn, TIAs, PVD, Hypercholesterolemia, colonic polyps  PSH  Right CEA, iliac stenting, transverse colectomy

4. LH #7273931  Alert, significant jaundice, NAD  RRR, no mrg  Lungs ctab  Abd soft, NT/ND, + BS, no masses  Tbili = 20.7, Ca 19-9 = 1

12. LH #7273931  Given preop bowel prep and oral vitamin K  12/12 underwent pylorus preserving Whipple  No metastatic disease  No vascular invasion, margin on SMV close  Invagination technique used for pancreaticojejunal anastamosis, gland moderately soft  Interrupted choledochojejunal anastamosis  Hand sewn duodenojejunal anastamosis  Feeding tube placed distal

13. Invagination PJ anastamosis

14. LH #7273931  Initial course proceeded well  Flatus by day 5, BM day 7, JPs serous  Urinary retention following foley removal x2 requiring reinsertion  Day 7 diet advanced to full liquids  Preparing for discharge the following day  On afternoon rounds patient noted to be hypotensive to 60 systolic with dark brown drainage from JPs  Transferred to ICU, pressors, recuscitation  CT scan obtained

18. LH #7273931  Pt weaned off pressors within 24 hours, no renal failure  Cultures revealed Enterobacter cloacae in blood and urine  Failed to progress with continued drainage from JPs of 500cc/day  Tube feeds started with return of bowel function  CT on 12/30 revealed undrained collection, contrast extravasation from J tube, percutaneous drain placed, TPN initiated  Pt currently on floor progressing slowly (malnutrition, debilitation)

19. Pancreaticoduodenectomy  Operative mortality <5%  Operative morbidity 20-60%  PJ fistula 10-28.5%  Several techniques utilized for PJ anstamoses with varying published single institution results

20. Duct to mucosa PJ anastamosis

21. Overlapping technique

22. Berger et al. Does Type of Pancreaticojejunostomy after Pancreaticoduodenectomy Decrease Rate of Pancreatic Fistula? A Randomized, Prospective, Dual-Institution Trial, J Am Col Surg. May 2008, 208 (5): pg 738-747  Thomas Jefferson and Indiana University Hospital  Prospective, Randomized  Aug 2006-May 2008

23. Berger et al.

25. Berger et al conclusions  Complications in 53% of patients  33% Clavian grade 1 (minor, not prolonging hospitalization)  No difference in overall complications, mortality, reoperative rate  Overall leak rate 17.8%  Duct to mucosa 23 (24%)  Invagination 12 (12%) p <0.05  Hard glands 8 (8%)  Soft glands 27 (27%)  2 deaths, both with preceding PJ leaks (duct to mucosa)

26. Clavian complication classification system

27. Analysis of Complication Was the complication potentially avoidable? – No- Optimal surgical approach utilized Would avoiding the complication change the outcome for the patient? – Yes- Prolonged hospitalization, PC fistula, debilitation What factors contributed the complication? – Gland density, known operative mobidity, technical error

28. Teaching points  Pancreaticojejunectomy carries a high perioperative morbidity rate despite the technique  Pancreaticojejunal leak is the Achilles heel of the operation, especially in soft glands  Invagination end to side PJ anastamosis is the preferred technique