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10.1245/ASO.2005.04.005
Annals of Surgical Oncology 12:467-472 (2005)
© 2005 Society of Surgical Oncology
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Original Article

Quality of Life and Functional Long-Term Outcome After Partial Pancreatoduodenectomy: Pancreatogastrostomy Versus Pancreatojejunostomy

Ursula Schmidt, MD1, Denis Simunec, MD1, Pompiliu Piso, MD2, Jürgen Klempnauer, MD1 and Hans J. Schlitt, MD2

1 Klinik für Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany
2 Klinik und Poliklinik für Chirurgie, Universität Regensburg, Franz-Josef-Strauss-Allee 11, D-93042 Regensburg, Germany

Correspondence: Address correspondence and reprint requests to: Ursula Schmidt, MD; E-mail: ullaschmidt{at}aol.com


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: To determine the effects of pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) as types of reconstruction after partial pancreatoduodenectomy on postoperative quality of life and long-term gastrointestinal morbidity, the outcomes of 104 patients (PG, n = 63; PJ, n = 41) were evaluated.

Methods: To compare the two groups, the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire (QLQ-PAN 26) standard and an additional self-developed questionnaire were used. The mean time after surgery was 6.4 ± 3.4 years.

Results: In the PG group, there was a significant reduction of gastric acid reflux, gastro-duodenal ulcers, and pain compared with before surgery. However, a significant increase in steatorrhea, intolerance toward larger meals, and aversion against certain foods were observed. In the PJ group, no significant change of preoperative symptoms was present except for jaundice. The incidence of diabetes mellitus and the need for pancreatic enzyme substitution had increased significantly but similarly in both groups. The global quality of life was identical in both groups of patients.

Conclusions: This analysis demonstrates that the global quality of life was not affected by the type of reconstruction after partial pancreatoduodenectomy. Patients who underwent PG had a significant reduction of gastric reflux, pain, and abdominal discomfort compared with before surgery. Patients in both groups showed an impaired exocrine and endocrine pancreatic function of a similar extent.

Key Words: Quality of life • Partial pancreatoduodenectomy • Pancreatojejunostomy • Pancreatogastrostomy • EORTC QLQ-PAN 26


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Partial pancreatoduodenectomies (PPD) have been performed since the beginning of the last century.1,2 These procedures are still very common for various benign and malignant lesions in the pancreatic and periampullary region. Despite recent improvements in operative techniques and perioperative management, this type of surgery is associated with a relatively high rate of postoperative complications. Although perioperative mortality rates after PPD are often <5%, morbidity remains high, with rates of 20% to 40%.3–7 The pancreatic anastomosis seems to be crucial in this complex operation, and leakage frequently increases postoperative morbidity and mortality by inducing severe pancreatitis, bleeding from adjacent large vessels, peritonitis, or sepsis. To reduce the rate of pancreatic leakage after PPD, many modifications in the management of the pancreatic remnant have been developed. One variation is reconstruction of the pancreatic remnant by using pancreatogastrostomy (PG) instead of pancreatojejunostomy (PJ). We have recently shown that PG is a safe alternative to PJ in terms of early postoperative outcome.8 In that analysis, the leakage rate of the pancreatic anastomosis was 2.8% after PG versus 12.6% after PJ, and other surgical complications (bile leakage, hemorrhage, and pancreatitis) were identical in the two groups. In this study, the long-term outcome of PPD according to the type of pancreatoenteral reconstruction (PG vs. PJ) was compared in terms of quality of life and long-term gastrointestinal morbidity by analyzing a subgroup of our previous study population that consisted of patients alive at the time of investigation.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
Between January 1988 and December 2000, 441 patients underwent PPD at our institution. Patients were excluded from the study if a total pancreatectomy, a left pancreatic or segmental resection, or a duodenum-preserving pancreatic head resection had been performed.

At the time of the survey, 133 of these 441 patients were alive. Questionnaires were sent to all 133 patients; 104 patients (78.2%) returned completed forms. The characteristics of the study population are listed in Table 1Go. Among all patients, PPD was performed for malignant diseases in 61 patients (58.7%) and for benign diseases in 43 patients (41.3%; Table 2Go).


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  		TABLE 1. Population characteristics
 

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  		TABLE 2. Indications for partial duodenopancreatectomy
 
Surgical Technique
In the PG group, the pancreatic remnant was anastomosed to the antral posterior wall of the stomach using a single row of inverted interrupted sutures (e.g., 4–0 polydioxanone). Reconstruction by PJ was performed by inserting the pancreas into the antimesenteric side of the jejunum ("dunking" anastomosis), also by using a single row of inverted interrupted sutures.

In the PJ group, the bile duct was inserted into the same retrocolic Rouxen-Y loop a few centimeters distal to the pancreatic anastomosis. In all patients with a primary malignant tumor of the pancreas or duodenum, a systematic lymphadenectomy was also performed. Each of the eight different surgeons involved performed both types of reconstruction in roughly equal proportions. The decision was solely at the discretion of the surgeon. The influence of surgical expertise on functional outcome was deemed insignificant because surgical complications—except the leakage rate of the pancreatic anastomosis (i.e., bile leakage, hemorrhage, and pancreatitis)—were identical in the two groups.8

Questionnaire
For assessment of the quality of life, the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-PAN 26; EORTC Study Group on Quality of Life, Brussels, Belgium) was used. In addition, another self-developed questionnaire was used to determine gastrointestinal complications in more detail. Both questionnaires, which were mailed a mean of 6.4 years after surgery, were self-assessed by the patients. The EORTC questionnaire comprises 29 items relating to physical and gastrointestinal symptoms, physical status, and social, emotional, cognitive, and sexual functioning. Each item was assessed as a score ranging from 1 to 4. The score was calculated as a percentile, and 100% was the highest possible score. Higher scores indicate more pronounced symptoms or a higher functional status. The questionnaire has been previously validated for pancreatic diseases. Four questions concerning endocrine and exocrine pancreatic function were added.

Statistical Analysis
The results of the questionnaire scales were expressed as means ± SD. The postoperative changes in overall, physical, and psychosocial scores were evaluated. Differences between the preoperative and current status in both groups were estimated with the Mann-Whitney U-test and McNemar test. Probability values of <.05 were considered statistically significant, and those <.01 were considered highly significant.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Endocrine Pancreatic Function
In the PG group, eight patients (12.7%) had diabetes mellitus diagnosed before surgery. These eight patients were excluded from the total so that only the new onset of diabetes mellitus after surgery was calculated. In 13 (23.6%) of 55 patients, surgery led to a new onset of diabetes (P < 0.01). As demonstrated in Fig. 1Go, of these 13 patients, 3 were treated by diet only, 3 were treated by oral medication, and 7 needed insulin for treatment. In the PJ group, four patients (9.8%) had diabetes diagnosed before surgery and were also excluded from the total analysis. Twelve (32.4%) of 37 patients newly acquired diabetes after surgery (P < .01). In this group, two patients were treated by diet, four by oral medication, and six by insulin. Comparison of both groups before and after surgery revealed no statistically significant difference, but patients after PJ tended to have slightly worse endocrine pancreatic function.


Figure 1
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  		FIG. 1. Comparison of preoperative versus postoperative treatment for diabetes mellitus in patients with pancreatogastrostomy (PG) and pancreatojejunostomy (PJ).

 
Exocrine Pancreatic Function
In the PG group, seven patients (11.1%) required a pancreatic enzyme substitution before surgery and were also excluded from the calculation of new-onset exocrine pancreatic insufficiency. Thirty-nine patients (69.6%) from a total of 56 patients required de novo oral medication after surgery to compensate for their disturbed exocrine pancreatic function (P < .01). Twenty patients were receiving a daily dosage ≤ 75,000 IU of pancreatic enzyme, and 17 patients required ≥ 75,000 IU; two patients did not communicate the exact dose. In the PJ group, four patients (9.8%) were treated before surgery with exogenous enzyme substitution and were excluded from the analysis. Twenty-two (59.5%) of 37 patients required postoperative de novo enzyme substitution (P < .01). Sixteen patients were receiving a daily dose ≤ 75,000 IU, and four patients received dosages ≥ 75,000 IU. Two patients did not state the exact doses of their medications. Again, no significant differences were found between the two groups (Fig. 2Go), but patients after PG had slightly worse exocrine pancreatic function.


Figure 2
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  		FIG. 2. Comparison of preoperative versus postoperative pancreatic enzyme substitution in patients with pancreatogastrostomy (PG) and pancreatojejunostomy (PJ).

 
Physical and Gastrointestinal Symptoms (EORTC)
Comparison of the preoperative symptoms in the PG and PJ groups revealed no statistically significant difference. The postoperative state was also not significantly different between groups. However, there was a significant difference if the preoperative and postoperative status was compared within the same group (Table 3Go). Those physical and gastrointestinal symptoms that did not significantly change after surgery were meteorism, discomfort in certain body positions, alterations in taste, indigestion, fear about low weight, weakness in arms and legs, dry mouth, itching, frequent bowel movements, and urgent bowel movements.


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  		TABLE 3. Mean symptom score and number of patients with severe or moderate gastrointestinal symptoms on the EORTC Quality-of-Life Questionnaire in the PG (n = 63) versus PJ (n = 41) group
 
The overall physical and gastrointestinal symptom score was 28.31 ± 36 for PG before surgery and 26.33 ± 33 after surgery. In the PJ group, the score was 25.55 ± 37 before surgery and 27.86 ± 36 after surgery. When both patient groups were reviewed as a whole (Table 3Go, far right column), food aversion and intolerance toward large meals constituted the most frequent long-term symptoms after pancreatoduodenectomy, whereas jaundice or gastric or duodenal ulcers were the least prevalent.

Functional Outcome (EORTC)
In terms of functional outcome (measured only after surgery), the mean score was 67.06 ± 37 for PG and 66.89 ± 38 for PJ. The score for physical status was 59.76 ± 41 for PG and 57.37 ± 43 for PJ; for working ability and social activities, it was 77.63 ± 34 for PG and 79.88 ± 34 for PJ; for emotional functioning, it was 55.73 ± 38 for PG and 57.63 ± 40 for PJ; and for cognitive abilities, it was 75.07 ± 33 for PG and 72.68 ± 36 for PJ.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We have shown, by analyzing the short-term complications of 441 patients who underwent PPD at our institution over 13 years, that PG (compared with PJ) is a reliable method of reconstruction after PPD. To assess potential differences in the quality of life and functional long-term outcome depending on the method of enteral reconstruction after PPD, this study was set up to include the 104 patients of the previously described cohort who were alive at the time of investigation. Of the survivors, 63 patients underwent PG and 41 patients underwent PJ for reconstruction.

The instrument used in this study was the EO-RTC Quality-of-Life Questionnaire, which has been shown to have excellent validity.9–12 The parameters studied included endocrine and exocrine pancreatic function, physical and gastrointestinal symptoms, and social, emotional, cognitive, and sexual functioning.

In our study, the postoperative incidence of diabetes mellitus increased significantly but similarly in both groups, although there was a tendency toward a higher rate of de novo diabetes mellitus among patients after PJ compared with PG (32.4% vs. 23.6%, respectively). One explanation might be that patients who received a more extended pancreatic resection also more often received a PJ because of technical aspects.

Various investigations have examined the exocrine pancreatic changes in patients after PG. Although theoretically the reflux of gastric acid may result in early inactivation of pancreatic enzymes and early insufficiency of the pancreatic remnant, Takada et al.13 showed that there was no significant difference in the extent of pancreatic enzyme activation between PG and PJ after pylorus-preserving pancreatoduodenectomies. In contrast, Jang et al.14 demonstrated in 34 patients that although the general nutritional status and quality of life were independent of the type of reconstruction, patients after PG were significantly more often affected by steatorrhea as a sign of exocrine pancreatic insufficiency than were patients after PJ. Likewise, in our study, more patients in the PG group than in the PJ group reported steatorrhea after surgery compared with before surgery. It remains unclear whether the symptom scores for food aversion and the amount of tolerated food are inversely altered because of the presence of pancreatic insufficiency, increased gastric pH, or an increased amount of digestive fluids in the stomach. At the same time, the possible increase of gastric pH might have significantly diminished the incidence of gastric reflux symptoms and upper gastrointestinal tract ulcers after PG as compared with PJ.

The incidence of exocrine and endocrine insufficiency also depends to a certain extent on the underlying diagnosis. For example, patients with chronic pancreatitis are at a higher risk of developing diabetes mellitus, which, in concert with steatorrhea, reflects the natural course of the disease that seems to be accelerated by surgery because of the loss of parenchyma. According to studies by Ammann et al.,15,16 without surgery 75% of patients with alcohol-induced chronic pancreatitis developed diabetes mellitus within a median of 6 years. Other authors17–21 have reported a rate of postoperative new-onset diabetes mellitus between 11% and 60%. The incidence of postoperative exocrine insufficiency22–25 in these patients increases to 60% to 80%.

The overall quality of life, measured in terms of physical and gastrointestinal symptom scores and functional status, did not significantly differ between groups, although in our study patients who received PG had a discrete tendency to do better after surgery (the overall symptom score was 28.31 before compared with 26.33 after surgery), whereas the PJ group experienced a mild deterioration (symptom score 25.55 vs. 27.86). The functional status comprising the physical status, working ability, social activities, and emotional functioning was nearly identical in both groups (67.06 vs. 66.89). Because the change in the quality-of-life score was generally not significant within the PJ group, we did not compare changes in scores between groups. Our results are in accordance with the findings of Ohtsuka et al.,26 who examined the quality of life after pylorus-preserving pancreatoduodenectomy and found overall physical and psychosocial quality-of-life scores of 64.9 and 65.2, respectively.

One concern regarding this study is the very heterogeneous patient group in terms of the underlying diagnoses, although the distribution among the two groups was approximately equal. Patients with malignant diseases received a more extended resection with lymphadenectomy and, in a few cases, with extended local resection (e.g., portal vein resection), which frequently is associated with increased morbidity.27 In addition, a malignant diagnosis negatively affects the overall quality of life because of the prospect of limited survival.28

Huang et al.29 have shown that early complications after PPD, such as pancreatic fistula and delayed gastric emptying, did not influence the long-term quality of life after surgery; however, it could be hypothesized that the effects of late postoperative complications such as deterioration of diabetes mellitus, diarrhea, and gastric ulcers often develop as chronic diseases and are likely to affect the long-term quality of life after PPD.

In this analysis, we demonstrated that the global quality of life was not affected by the type of gastroenteral reconstruction after PPD. Patients who underwent PG had a significant reduction of gastric reflux, pain, and abdominal discomfort compared with before surgery. Patients in both groups showed impaired exocrine and endocrine pancreatic function of a similar extent. This study demonstrates that PG after PPD is associated with a satisfactory overall quality of life.

Received for publication April 5, 2004. Accepted for publication January 19, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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