الفهرس 
Introduction & Aim of the workOnly 14 pages are availabe for public view
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Abstract
Pancreatic cancer is the seventh highest cause of death from cancer worldwide. Despite the recent advances in therapeutic interventions, the 5-year relative survival rate remains approximately 6%. At initial presentation, approximately 50%-55% of the patients are found to have metastatic disease, 20%-25% have locally advanced disease and only 20% have resectable disease. Surgery provides the only curative option with long term survivors. patients who undergo potentially curative resections, the 5-year survival remains at 20%.
Pancreaticoduodenectomy, is a complex operation that is commonly performed for patients with pancreatic ductal adenocarcinoma and other malignant or benign lesions in the head of the pancreas. It can be done with low morbidity and mortality rates, particularly when performed at high-volume hospitals and by high-volume surgeons.
Patient survival associated with malignancy in the region of the pancreatic head remains poor compared with other abdominal malignancies despite improvements in surgical technique and perioperative and in-hospital mortality. Factors influencing longterm patient survival include tumour type, tumour staging (tumour-node-metastasis [TNM] status), resectability, co-morbidity and patient age.
Several methods and techniques of pancreatic anastomosis have been proposed after PD to reduce the rate of POPF including the usage of an external or an internal pancreatic stent, isolated loop pancreaticojejunostomy (IPJ), pancreaticogastrostomy, binding PJ, or an administration of postoperative somatostatin. The safe pancreatic reconstruction after PD continues to be a challenge at the high-volume centers. The variety of reconstruction is a reflection of the lack of the ideal one.
More than 80 different methods of pancreaticoenteric reconstruction have been proposed, illustrating the complexity of surgical techniques as well as the absence of the gold standard. Many factors associated with an increased incidence of its complication have been identified. Among them, a small pancreatic ductal size with a soft pancreas creates one of the technical hurdles to the completion of the anastomosis and is known to be a risk factor for major leakage
Although various surgical procedures have been devised to improve the outcome of pancreatoduodenectomy, pancreaticojejunostomy is the most popular digestive tract reconstruction, and duct-to-mucosa and invagination anastomosis are two major techniques for pancreaticojejunostomy.
This prospective randomized controlled study had been conducted in surgery department, El Minia University and El Maadi military hospital including 80 patients in 2 groups indicated for pancreaticoduodenectomy (PD) (40 patients with duct to mucosa pancreaticojejunostomy ( group 1) and 40 patients with invagination pancreaticojejunostomy (group 2)) in the period between January 2018 and January 2021after approval from the institutional review board and obtaining informed consent from all patients including approval of protocol of treatment.
Consecutive patients treated by PD (Standard) at our centers were randomized into 2 group comparing duct to mucosa and invagination pancreaticojejunostomy, using the closed envelope method. The envelopes were drawn and opened by a nurse in the operating room after pancreatic resection.
The primary outcome measure will be the rate of postoperative pancreatic fistula (POPF); secondary outcomes include; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions.
The intraoperative data in both groups were comparable regarding; tumor size, liver status, pancreatic duct diameter, consistency of pancreas, the median intraoperative blood loss and blood transfusion to find that all data revealed that there is no statistically significant difference between both groups, but there is significant difference (P value less than or equal 0.05) in mean operative time as the mean total operative time was 5.20 hours in group 1 vs. 4.84 hours in group 2 (P=0.003). The mean operative time for the pancreatic anastomosis was 39.13 min in group 1 vs. 24.30 min in group 2 with significant statistical difference (P=0.001). The median hospital stays, the median time to resume oral intake and drain removal had no significance between two groups.
There is no significant difference as regards POPF in both groups. The severity of POPF was noticed more in duct to mucosa PJ with no significant differences.
When we take a look on pancreatic functions which are either exocrine or endocrine; it was revealed that to show that the median one-year postoperative albumin level was significantly more in group 1 than in group 2 (3.58 gm% vs 3.71 gm% respectively), so, there is no significant difference between those two groups. Also, 45% of patients presented with postoperative steatorrhea after one year in group 1 versus 40% of patients in group 2 presented with postoperative steatorrhea
Post operative pancreatitis in our study occur in 16 (15%) of all patients with 12 (30%) in group 1 and 4 (10%) in group 2 with no statistical difference(P=0.076).
While reporting diabetes mellitus incidence preoperatively and one year postoperatively, there is statistical difference in group 1 only.
The development of postoperative complications found to be a risk factor with the patients’ survival after pancreaticoduodenectomy.
When deciding which sort of PJ anastomosis to conduct, surgeon competence, judgment, and comfort level are all aspects to consider. No one PJ-building technique can be utilized universally to all patients, and the ideal strategy for lowering POPF is to adjust PJ creation to the patient and gland type. A soft pancreatic texture and a small duct diameter have been found to enhance the chance of difficulties during pancreatic restoration.