Complications
The mortality associated with pancreaticoduodenectomy is <5% in high-volume specialist centers. However, morbidity ranges from 30% to 60%. Given that one of the major complications and causes of death after pancreaticoduodenectomy is leakage from the residual pancreatic stump, both pharmacologic and technical attempts have been tried to prevent pancreatic stump-related complications. The only treatments shown to be effective in preventing complications (pancreatic leak and intra-abdominal collections) are somatostatin and its analogs, particularly octreotide.[158][159]
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Pancreatic duct occlusion does not assist in preventing complications associated with pancreatic leak when added to anastomosis, and it is not recommended due to reported increase in pancreatic fistula and pancreatic endocrine and exocrine insufficiency.[158] Although some studies suggest that pancreaticogastrostomy reduces postoperative pancreatic fistula compared with pancreaticojejunostomy,[160][161]
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the evidence is weak, with studies reporting conflicting results and a high risk of bias.[158][162] Dual-loop (Roux-en-Y) reconstruction with isolation of the pancreaticojejunostomy from biliary drainage significantly prolonged operating times, without reducing postoperative complications, and is thus not superior to conventional single-loop reconstruction.[163] There is no evidence that using fibrin glue is effective for preventing pancreatic leak.[158][162][164]
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Early delayed gastric emptying is usually associated with intra-abdominal sepsis; the treatment should be directed toward treating the cause. Prokinetic agents such as erythromycin may help. Evidence suggests that placement of gastroenteric anastomosis either antecolic or retrocolic makes no difference.[165] Furthermore, a Billroth type II reconstruction may reduce early delayed gastric emptying over Roux-en-Y reconstruction.[166]
About 5% of patients develop duodenal obstruction secondary to pancreatic carcinoma. Patients usually present with abdominal pain, vomiting, absolute constipation, and varying degrees of abdominal distention. Treatment of duodenal obstruction can be operatively with a gastrojejunostomy or by endoscopic stenting.[1][41]
Patients present with fever, jaundice, right upper quadrant pain, and, in severe cases, sepsis or mental confusion. Cholangitis has significant potential for mortality and morbidity, with reported mortality rates from 13% to 88%.
Antibiotics are required for the treatment of cholangitis, where the choice of antibiotic treatment depends on the organism found and its antibiotic sensitivity. Many patients respond to antibiotic therapy; patients who do not respond require emergency biliary drainage.
Patients with pancreatic cancer have an increased risk of developing venous thromboembolic disease: incidence rates range from 17% to 57%. Long-term use of low molecular weight heparins is preferred over warfarin in both primary and secondary prevention of venous thromboembolic disease.[157]
If a pancreatic tumor ulcerates into the duodenum and bleeds, therapeutic options include super-selective embolization of bleeding vessels or covered metal stent.
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