We retrospectively analyzed 148 patients who underwent LPD at Li Huili Hospital of Ningbo Medical Center from November 2015 to September 2021. We treated 63 patients (39 males and 24 females, mean age: 69.13 ± 8.96) without wrapping of the GDA (the unwrapped group) and 85 patients (52 men and 33 women, average age: 68.12 ± 10.26) were the wrapping group. We compared baseline preoperative information, intraoperative variables, total hospital stay, and postoperative bleeding treatment.
Preoperative Information Collection
Preoperative information features included gender, age, body mass index, total bilirubin, transaminases, prothrombin time, globulin, and platelets (Table 1). Intraoperative variables included operation time, tumor size, intraoperative bleeding, blood transfusion, and death (Table 2). Postoperative complications included GDA stump bleeding, anastomotic bleeding, pancreatic fistula, bile fistula, arterial stenosis, abdominal infection, delayed gastric emptying (DGE), first water intake, first food intake, time to first passage of flatus, and total hospital stay (Table 3).
Table 1
Basic preoperative information of the patients in both groups
|
Unwrapped group
(n = 63, female = 25, male = 38)
|
Wrapped group
(n = 85, female = 32, male = 53)
|
p value
|
Age (years, mean ± SD)
|
69.13 ± 8.96
|
68.12 ± 10.26
|
0.534
|
BMI (kg/m2, mean ± SD)
|
21.46 ± 4.47
|
22.28 ± 4.07
|
0.80
|
TBil (µmol/L, mean ± SD)
|
80.54 ± 95.95
|
89.23 ± 104.17
|
0.692
|
AST (U/L, mean ± SD)
|
99.81 ± 103.53
|
96.3 ± 96.15
|
0.98
|
ALT (U/L, mean ± SD)
|
145.56 ± 159.79
|
118.58 ± 133.78
|
0.661
|
PT (s, mean ± SD)
|
11.51 ± 1.25
|
11.85 ± 1.61
|
0.316
|
GLB (g/L, mean ± SD)
|
27.75 ± 4.04
|
27.23 ± 6.10
|
0.088
|
PLT (× 109/L, mean ± SD
|
212.94 ± 64.98
|
223.47 ± 79.49
|
0.777
|
BMI: Body Mass Index, TBil: total bilirubin, AST: Aspartate aminotransferase, ALT: Alanine aminotransferase, PT:prothrombin time, GLB: Globulin, PLT:platelet |
Table 2
Intraoperative comparison table of the two groups of patients
|
Unwrapped group
(n = 63, female = 25, male = 38)
|
Wrapped group
(n = 85, female = 32, male = 53)
|
p value
|
Duration of surgery (min, mean ± SD)
|
364.92 ± 87.42
|
339.18 ± 77.05
|
0.086
|
Intraoperative bleeding (ml, mean ± SD)
|
387.62 ± 392.96
|
382.41 ± 438.91
|
0.361
|
Intraoperative blood transfusion (ml, mean ± SD)
|
251.90 ± 411.92
|
205.76 ± 397.25
|
0.42
|
Diagnosis(n, %)
|
|
|
|
Pancreatic cancer
|
21 (24.3%)
|
32.7%
|
0.265
|
IPMN
|
12 (19.0%)
|
9 (10.6%)
|
0.145
|
cholangiocarcinoma
|
7 (11.1%)
|
11 (12.9%)
|
0.736
|
Duodenum tumor
|
13 (20.6%)
|
22 (25.9%)
|
0.458
|
carcinoma of gallbladder
|
3 (4.8%)
|
0 (0%)
|
0.075
|
duodenum neuroendocrine tumors
|
1 (1.6%)
|
0 (0%)
|
0.426
|
Pancreatic neuroendocrine tumors
|
2(3.2%)
|
0 (0.0%)
|
0.18
|
other
|
4 (6.3%)
|
7 (8.2%)
|
0.759
|
Intraoperative death (n, %)
|
0 (0.0%)
|
0 (0.0%)
|
NS
|
IPMN: intraductal papillary mucinous neoplasm ; |
Table 3
Comparison of postoperative complications between the two groups
|
Unwrapped group
(n = 63, female = 25, male = 38)
|
Wrapped group
(n = 85, female = 32, male = 53)
|
p value
|
GDA stump hemorrhage
|
5 (7.9%)
|
0 (0.00%)
|
0.013
|
Anastomotic hemorrhage
|
3 (4.76%)
|
2 (2.35%)
|
0.651
|
Pancreatic fistula
|
21(33.3%)
|
36 (42.4%)
|
0.265
|
A
|
7 (33.3%)
|
12 (33.3%)
|
1
|
B
|
11 (52.4%)
|
22 (61.1)
|
0.52
|
C
|
3 (14.3%)
|
2 (5.6%)
|
0.346
|
Biliary fistula
|
8 (12.7%)
|
10 (11.8%)
|
0.864
|
Artery stenosis
|
1 (1.6%)
|
0 (0.00%)
|
0.426
|
Abdominal infection
|
14 (22.2%)
|
13 (15.3%)
|
0.281
|
DGE
|
6 (9.5%)
|
3(3.5%)
|
0.17
|
Drinking water for the first time (days)
|
3.62 ± 3.49
|
3.76 ± 1.23
|
0.001
|
Meal for the first time (days)
|
5.76 ± 3.57
|
4.96 ± 1.25
|
0.287
|
Time to first passage of flatus (days)
|
3.17 ± 1.76
|
3.66 ± 1.25
|
0.098
|
Postoperative hospital stay (days)
|
30.63 ± 18.79
|
26.89 ± 13.61
|
0.152
|
Death
|
n = 2 (3.2%)
|
n = 1 (1.2%)
|
0.575
|
female = 0
|
female = 1 (3.1%)
|
> 0.99
|
male = 2 ( 5.3%)
|
male = 0 (0.0%)
|
0.172
|
GDA: gastroduodenal artery, DGE: Delayed gastric emptying
Main Surgical Points
The same surgeon performed all operations. Unified laparoscopic resection and anastomosis standard procedures were performed in all 148 patients. The resection scope included the distal stomach (about 60% of the whole stomach), duodenum, head of the pancreas, uncinate process, gallbladder, and common bile duct. The sequence of anastomosis was pancreaticojejunostomy, biliojejunostomy, and gastrointestinal anastomosis. The wrapped group is distinguished from the unwrapped group: The LTH was retained in the unwrapped group. In the wrapped group, the LTH was reserved for 8–12 cm after being freed from the abdominal wall. The anterior side of the LTH was cut open and wrapped 360° around the common hepatic artery and GDA stump and fixed with a 3 − 0 barbed suture (Fig. 1).
Postoperative Treatment
The patients stayed in the intensive care unit for at least 12 hours after surgery. When vital signs were stable, the patients were transferred to the general ward and given somatostatin 4 m L/h (6 mg dissolved in 100 ml saline) by micropump injection for three days (when drainage amylase exceeded 2000 U/L or extended depending on symptoms).
Definition Of Complications
Pancreatic fistula definition: According to the International Study Group of Pancreatic Surgery (ISGPS), postoperative pancreatic fistula is classified into grades A, B, and C [27]. A bile fistula was defined as bile output greater than 100 ml/day [28]. DGE was defined as the nasogastric tube remaining for more than ten days with at least one of the following conditions: (I) repeated vomiting after extraction of the gastric tube; (II) use of gastric motility agents more than ten days after surgery; (III) reinsertion of a nasogastric tube for decompression; (IV) inability to resume feeding [29]. Patients were also diagnosed with DGE when they had nasogastric tube retention for less than ten days by iodine imaging or upper abdominal computed tomography.
Statistical analysis
Continuous data were expressed as the mean ± standard deviation and were compared using the Student’s t-test for normally distributed data. Categorical variables were compared using the chi-square or non-parametric test (as appropriate). Statistical analysis was performed using version SPSS 25.0 (SPSS Inc., Chicago, Illinois, USA). Differences where P < 0.05 were considered statistically significant.