J.A. McKean1, G. Tushoski1, G. Thompson1, K. Herremans1, I. Nassour1, S. Han1, S. Hughes1 1University Of Florida, Department Of Surgery, Gainesville, FL, USA
Introduction: Postoperative pancreatic fistula is more prevalent after distal pancreatectomy than pancreaticoduodenectomy (PD), yet postoperative hemorrhage from vascular pseudoaneurysm is virtually exclusive to PD. We hypothesize that enterokinase, produced by the reconstructive intestinal limb, drives trypsin activation necessary for pseudoaneurysm formation, and determining the distance to minimal enterokinase production in the jejunum could mitigate this devastating complication.
Methods: Fresh PD samples were procured in the operating room from multiple locations of the small intestine: proximal duodenum, ligament of Treitz (LOT), ligament of Treitz +5cm (LOT+5cm), ligament of Treitz +10cm (LOT +10cm), ligament of Treitz +15cm (LOT +15cm) and ligament of Treitz +20cm (LOT+20cm). Separately, terminal ileum was collected as a control. Enterokinase mRNA and protein abundance at these anatomic points was quantified using qRT-PCR and immunohistochemistry. Comparisons were performed using Wilcoxon Rank Sum Test.
Results: By qRT-PCR, we observed a significant difference in the expression of enterokinase mRNA when comparing the LOT+20cm to the proximal duodenum, and LOT (p=0.035, p=0.008 respectively). The terminal ileum had significant differences in enterokinase mRNA expression between all locations. No significant differences were observed between LOT+10cm and LOT+20cm (p=0.309). However, we also observed a marked difference in the abundance of enterokinase immunostaining at LOT+15cm when compared to the proximal duodenum, LOT, and LOT+5cm with staining intensity decreasing distally.
Conclusion: There is differential expression of enterokinase mRNA in the duodenum compared to the proximal jejunum with heterogeneity between patients and discordance with mRNA quantities with decreasing protein moving distal to the LOT. Our data would suggest resection of at least 20 cm of jejunum distal to the LOT to ensure minimal enterokinase activity at the pancreatojejunostomy.