**4. Changes in amylase level in the sump solution**

The amylase level in the two sump solutions was measured (**Table 2**). The two drains of eight cases were removed within 5 days after operation without PL. The drains of the other two cases were removed 7 days after the operation. The one in two cases had a PL of grade A.



The amylase level in the two drainage solutions of Winslow's foramen and posterior of PJ anastomosis was measured. All of the two drains in 8 cases were removed within 5 days after operation without PL. The drains of the other two cases were removed 7 days after operation. The one in two cases had grade A PL of ISGPF criteria.

**Table 2.** Changes of amylase in the sump solution after SSPPD with PSSGM.

#### **4.1. Changes in the frequency of pancreatic leakage compared among the three distinguished periods from 2004 to 2015 in our hospital**

Total frequency of PL was 39% in the 114 cases of PJ reconstruction of Group A from 2004 to 2015 (**Table 3**). Total frequency of PL of Group B and Group C was 31 and 9%, respectively, at the same period from 2014 to 2015. The frequency of grade C PL was 7.9% in Group A. Groups B and C had no grade C PL. Moreover, Group C had no grade B and grade C PL that underwent PSSGM.


Total frequency of PL was 39% in the 114 cases of PJ reconstruction of Group A from 2004 to 2015. Total frequency of PL of Group B and Group C was 31 and 9%, respectively, at the same period from 2014 to 2015. The frequency of grade C PL was 7.9% in Group A. Group B and Group C had no grade C PL. Moreover, Group C had no grade B and grade C PL that underwent PSSGM.

**Table 3.** Changes in frequency of pancreatic leakage in our hospital for three distinguished periods from 2004 to 2015.

#### **5. Discussion**

**3. Patients and perioperative data**

188 Challenges in Pancreatic Pathology

ISGPF classification (**Table 1**).

ISGPF criteria.

**anastomotic drain**

**3.1. PD with Shuriken‐shaped umbilicoplasty**

We experienced 10 cases of PD by real‐time moving window's method. Mean age was 72.6 ± 4.2 years old. Operative procedures were mentioned as described above. The pancreaticojejunos‐ tomy was done by our original stent slide guiding method. The patient's profile is demon‐ strated in **Figure 5**. Average of operative times was 528 ± 63 min. Average of operative blood was 795 ± 405 ml. Average of hospital stay was 33 ± 21 (17‐90). Two patients suffered from liver abscess, and their hospital stay was prolonged by 42 and 90 postoperative days, respectively. There were no cases that had bile leakage. Pancreatic leakage was only one case of grade A by

Ten cases were operated using the Shuriken‐shaped umbilicoplasty and one case by the usual open surgery. We divided the PD with PJ reconstruction into three groups from 2004 to 2015 in our center. There were 114 cases of PD with PJ reconstruction operated by the previous HPB surgeons in Group A from 2004 to 2013. There were 24 cases operated by present HPB surgeons from 2014 to 2015. Eleven cases in Group C were operated by the first author using PSSGM from 2014 to 2015. The 13 cases of Group B were operated by other surgeons without PSSGM. The PLs were compared among three groups according to the

The amylase level in the two sump solutions was measured (**Table 2**). The two drains of eight cases were removed within 5 days after operation without PL. The drains of the other two cases were removed 7 days after the operation. The one in two cases had a PL of grade A.

**drain**

**Case 1POD 3POD 5POD 7POD PF Case 1POD 3POD 5POD 7POD PF**

 637 90 34 0 2 507 126 15 – 108 23 14 0 3 126 19 14 – 99 115 13 14 0 4 153 37 21 16 – 43 52 28 0 5 210 141 16 – 7192 2453 1777 254 GradeA 6 1735 368 344 129 Grade

7 1034 83 18 0 7 539 281 14 –

**Levels of amylase in the sump solution of winslow's** 

A

**3.2. Pancreaticojejunostomy by punctured stent slide guiding method**

**4. Changes in amylase level in the sump solution**

1 142 47 0 1 137 45

**Levels of amylase in the sump solution of pancreatic** 

In 1994, Gagner and Pomp [5, 6] first introduced LPPPD in an advanced laparoscopic surgical trial in an effort to reduce postoperative morbidity. Since then, however, there have been few reports from centers with experience performing this procedure, and the reported clinical outcomes of LPD have remained unsatisfactory over the last decade [7, 8]. Technical progress in LPD was achieved by several pioneering laparoscopic surgeons, including hand‐assisted LPD [9, 10] as well as laparoscopically assisted [11, 12] and robot‐assisted PD [13]. However, some surgeons have recently reported favorable outcomes [14–17]. LPD has not been accepted as a generalized surgical method for the resection of pancreatic head lesions. LPD includes technically difficult surgeries with high rates for mortality and morbidity.

Most of risky complications are leakages of pancreatic duct anastomosis and hepaticojejunos‐ tomy in the PD inspite of open or laparoscopic. Their reconstruction might be very stressful and fatigue for surgeons because of the limitations of laparoscopic approach and long operation.

In our operative procedure, the final main operative abdominal wound by Shuriken‐shaped umbilicoplasty is almost 2 cm round around the navel except the three wounds for drainage tubes in our new device of operation. The length of subcutaneous upper abdominal incision is longer than that of the complete untinatectomy which was reported elsewhere. Although the opening window of abdomen using GelPort is small, the favorable operative window could be exposed by the real‐time sliding window's method with two Kent retractors and two of surgical arms.

Otherwise, our techniques could bring their anastomosis under direct vision. Although our clinical research was very small number, the results of the only one case of pancreatic leak‐ age of Grade A in ISGPF might be enough to verify the availability of our device. Moreover, all of surgical manipulations could be completely done under direct vision including ability to palpate the lesion and the vascular reconstructions as well as those of the open PD (OPD).

Therefore, our new device might be same as the OPD at the viewpoint of minimum invasive surgery and same as LPD at the viewpoint of cosmetic merit. However, that might be as same as the OPD at the viewpoint of safety.

In this chapter, we demonstrated the new device of PL by PSSGM. The causes for PL are shown in **Table 4**. We would consider that the origins of PL are divided into two parts, host's factor and surgeon's factor. The major cause for PL of PJ might be surgeon's technical problems. The PL from the anastomosis of the PJ and a cut stump of pancreas are the main origins, and we would consider that the difference of caliber of PJ anastomosis and the inside out of the jejunal mucosa are major obstacles. The only puncture by pancreatic stent to jejunum without burns must prevent from both the inside out of the jejunal mucosa and the difference of caliber of PJ anastomosis.The mixture of pancreatic juice and intestinal juice would deteriorate the PL and the local infection after the PL. Because the mixture of jejunal juice and pancreatice juice activate the inactivate pancreatic juice and activate pancreatic juice promote the PL. The above risk might be low in our new device. The other merit of our device is an easy anastomosis by the stent slide guiding method. If the pancreatic duct is small at the soft pancreas, the suture would be easy by handling of the needle using the guide of stent sliding. However, the comparison among three periods was retrospective and the surgeons also were various with the exception of Group C, the PL of Group C was low level in the frequency and the severity. Two major PJ reconstructions of Kakita method and Blumgart's technique have been reported [18–21]. Oda et al. reported that the rate of ISGPF grade B+C PF was 29/78 (37.2%) in the Kakita group and 16/78 (20.5%) in the Blumgart group (*P* = 0.033) [22]. The principal technique of these two methods is a tight adaptation of pancreatic parenchyma and duodenal seromusuclaris. Their device is not for the anastomosis of the pancreatic duct to mucosa. Our technique would be countermeasures against the difference of caliber of PJ anastomosis and the inside out of jejunal mucosa. Moreover, our device might prevent the mixture of pancreatic juice and jejunal juice, which deteriorate the local infection following PL. I performed this PJ anastomosis by PSSGM at the living related partial pancreas transplantation as a first case of enteric drainage in Japan and the hetero‐ topic pancreas autotransplantation [23, 24]. This technique is thought to be useful for soft pancreas. Although the number of our studies about PL was very small, they included the retrospective data in the same period. Therefore, we confirm that our new device is theoretically useful and effective.


**Table 4.** Causes for pancreatic leakage.

outcomes of LPD have remained unsatisfactory over the last decade [7, 8]. Technical progress in LPD was achieved by several pioneering laparoscopic surgeons, including hand‐assisted LPD [9, 10] as well as laparoscopically assisted [11, 12] and robot‐assisted PD [13]. However, some surgeons have recently reported favorable outcomes [14–17]. LPD has not been accepted as a generalized surgical method for the resection of pancreatic head lesions. LPD includes

Most of risky complications are leakages of pancreatic duct anastomosis and hepaticojejunos‐ tomy in the PD inspite of open or laparoscopic. Their reconstruction might be very stressful and fatigue for surgeons because of the limitations of laparoscopic approach and long operation.

In our operative procedure, the final main operative abdominal wound by Shuriken‐shaped umbilicoplasty is almost 2 cm round around the navel except the three wounds for drainage tubes in our new device of operation. The length of subcutaneous upper abdominal incision is longer than that of the complete untinatectomy which was reported elsewhere. Although the opening window of abdomen using GelPort is small, the favorable operative window could be exposed by the real‐time sliding window's method with two Kent retractors and two of surgical arms.

Otherwise, our techniques could bring their anastomosis under direct vision. Although our clinical research was very small number, the results of the only one case of pancreatic leak‐ age of Grade A in ISGPF might be enough to verify the availability of our device. Moreover, all of surgical manipulations could be completely done under direct vision including ability to palpate the lesion and the vascular reconstructions as well as those of the open PD (OPD). Therefore, our new device might be same as the OPD at the viewpoint of minimum invasive surgery and same as LPD at the viewpoint of cosmetic merit. However, that might be as same

In this chapter, we demonstrated the new device of PL by PSSGM. The causes for PL are shown in **Table 4**. We would consider that the origins of PL are divided into two parts, host's factor and surgeon's factor. The major cause for PL of PJ might be surgeon's technical problems. The PL from the anastomosis of the PJ and a cut stump of pancreas are the main origins, and we would consider that the difference of caliber of PJ anastomosis and the inside out of the jejunal mucosa are major obstacles. The only puncture by pancreatic stent to jejunum without burns must prevent from both the inside out of the jejunal mucosa and the difference of caliber of PJ anastomosis.The mixture of pancreatic juice and intestinal juice would deteriorate the PL and the local infection after the PL. Because the mixture of jejunal juice and pancreatice juice activate the inactivate pancreatic juice and activate pancreatic juice promote the PL. The above risk might be low in our new device. The other merit of our device is an easy anastomosis by the stent slide guiding method. If the pancreatic duct is small at the soft pancreas, the suture would be easy by handling of the needle using the guide of stent sliding. However, the comparison among three periods was retrospective and the surgeons also were various with the exception of Group C, the PL of Group C was low level in the frequency and the severity. Two major PJ reconstructions of Kakita method and Blumgart's technique have been reported [18–21]. Oda et al. reported that the rate of ISGPF grade B+C PF was 29/78 (37.2%) in the Kakita group and 16/78 (20.5%) in the Blumgart group (*P* = 0.033) [22]. The principal technique of these two methods is a tight adaptation of pancreatic parenchyma and duodenal seromusuclaris. Their device is not for the anastomosis of the pancreatic duct to mucosa. Our technique would be

technically difficult surgeries with high rates for mortality and morbidity.

as the OPD at the viewpoint of safety.

190 Challenges in Pancreatic Pathology

Many authors mentioned the necessity of learning periods for LPD. This complex procedure requires a relatively long training period to ensure technical proficiency.

Wang et al. [25] reported that based on the cumulative sum (CUSUM) and the risk‐adjusted CUSUM analyses, the learning curve for LPD was grouped into three phases: phase I was the initial learning period, phase II represented the technical competence period, and phase III was regarded as the challenging period. There were no significant differences in terms of postoperative complications or the 30‐day mortality among the three phases. More challeng‐ ing cases were encountered in phase III. To attain technical competence for performing LPD, a minimum of 40 cases are required for laparoscopic surgeons with a degree of laparoscopic experience. Therefore, the acquisition of LPD might be not so easy, especially, in the center with a small amount of PD operations. Our device could be done by complete minilaparot‐ omy so the usual HPB surgery might perform without the long learning period. Because the PJ and the HJ anastomosis could be done under direct vision as well as open surgery.

Of course, according to the learning curve, our operation could change from the complete minilaparotomy to the hybrid laparoscopic procedure or to complete LPD. Our procedure might be useful as a way of learning for LPD.

As other subjects, there is medical cost. Tan et al. reported that the mean total cost was higher in the total LPD (TLPD) group compared to the OPD group. When the total cost was bro‐ ken down, TLPD was noted to result in significant increases in the cost of both surgery and anesthesia, but a decrease in the cost of admission evaluation. The higher cost of surgery and anesthesia in the TLPD group was due to the required surgical equipment and supplies and longer surgical time. The lower cost of admission evaluation in the TLPD group was due to a shorter hospital stay and reduced requirement for parenteral alimentation. From the thinking of learning cost, the cost of admission evaluation also must not decrease compared with OPD. Our operation could be done without any laparoscopic supplies.
