الفهرس 
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Abstract
The present randomized comparative study included patients with presumably operable lesions of the peri-ampullary region including lesions of the pancreatic head, the distal common bile duct, ampulla of vater and duodenal lesions within 2 cm from the ampulla detected by MDCT assessed for pancreaticoduodenectomy at the Hepato-biliary-pancreatic surgical unit of the Alexandria Main University Hospital, Alexandria, Egypt from April 2016 through April 2018.
The aim of the present study was to compare the surgical outcomes of the Modified Blumgart’s technique and the Kakita technique of pancreaticojejunostomy following pancreaticoduodenectomy as regards the incidence of post-operative pancreatic fistula and its related morbidity and mortality.
Following preoperative evaluation and preparation for surgery, patients were randomly assigned using the closed envelope technique into either one of two groups: the Modified Blumgart’s Pancreaticojejunostomy group (m-Blumgart group) = 20 patients and the Kakita Pancreaticojejunostomy group (Kakita group) = 20 patients.
No statistically significant difference was found between both study groups as regards age and sex distribution, body mass index, incidence of both associated co-morbidities and previous abdominal surgeries. No statistically significant difference was found between the mean/median laboratory values of measured parameters in both study groups.
No statistically significant difference was found between both study groups as regards the tumor size and location.
Pancreaticoduodenectomy was performed in the present study in 32 patients (80%). Details of operative technique adopted and standardised in present study according to classification system by the ISGPS. In two patients one in either study group had a pancreatic duct diameter of less than 2 millimeters rendering a stented duct-to-mucosa pancreatico-jejunostomy technically impossible. For these two patients an open pancreaticogastrostomy was performed as described by Bassi et al. These two patients were therefore excluded from further analysis and consequently each study group included 15 patients. There was no statistically significant difference between study groups as regards pancreatic texture and type of trans-anastomotic pancreatic duct stent.
Although no statistically significant difference was found between both study groups as regards the total operative time, however, the time required for construction of a Kakita type pancreatico-jejunostomy was statistically significantly longer than that required to construct a modified Blumgart pancreatico-jejunostomy (51.13 ± 13.73 minutes Vs 41.33 ± 9.72 minutes respectively, p= 0.032). No statistically significant difference was found between both study groups as regards the median/mean volume of blood lost intra-operatively (P=0.285).
The overall post-operative morbidity rate in the present study was 46.7%. There was no statistically significant difference in the overall morbidity rate between both study groups.
There was no statistically significant difference between both study groups as regards the incidence of POPF.
Postpancreatectomy hemorrhage (PPH) was encountered in three patients (10%) in the present study. Two patients (13.37%) in the m-Blumgart group developed PPH compared to one patient (6.7%) in the Kakita group with the difference being statistically insignificant.
Delayed gastric emptying (DGE) was encountered in three patients (20%) in the Kakita group. These three patients (20%) had POPF Grade B and developed secondary DGE as a consequence. With the resolution of the intra-abdominal collections, the condition resolved spontaneously. Primary DGE was not encountered in the present study.
The perioperative mortality rate in the present study was 10%. Three patients (20%) in the m-Blumgart group died compared to no patient in the Kakita group with the difference being statistically non-significant (p=0.224), death not related to POPF was encountered in two patients (13.3%). The first died from acute respiratory failure while the second patient died from sepsis-induced multiple organ failure secondary to leak at the duodeno-jejunal anastomosis. Death related to POPF was encountered in the third patient (6.7%) who died from PPH on the tenth postoperative day. Consequently, the POPF related mortality rate in the present study was 3.3%.