History of pancreaticojejunostomy in pancreaticoduodenectomy: development of a more reliable anastomosis technique

The history of pancreaticojejunostomy in pancreaticoduodenectomy is described. Many types of operations have been devised in search of a more reliable method of anastomosis. To perform a safe and reliable pancreaticoenteric anastomosis it is necessary to understand the organ characteristics of the pancreas. We investigated factors required for a reliable pancreaticojejunostomy and devised a new surgical technique that meets those requirements. We introduce the theoretical substantiation and clinical usefulness of our new surgical technique while reviewing the history of pancreaticojejunostomy after pancreaticoduodenectomy. The unique aspect of our method is approximation of the pancreas stump and jejunal wall by six to eight interrupted sutures. It is speculated that too many sutures and tying too tight in the anastomosis may cause ischemia and necrosis of the pancreatic stump by restricting the tissue blood flow. Our method allows us not only to reduce the number of sutures, but also to avoid some of the complicated manipulations done in any other existing methods. The newly devised pancreaticojejunostomy is an excellent surgical technique with anastomotic failure seen in only two patients and no deaths out of 162 consecutive patients.     

Pancreaticojejunostomy without stent (with video)

There is a high risk of anastomotic leakage following pancreaticojejunostomy after pancreaticoduodenectomy or middle pancreatectomy in patients with a normal soft pancreas because of the abundant exocrine function. Therefore, pancreaticojejunostomy is generally performed using a stent tube (stented method). However, pancreaticojejunostomy with a certain duct-to-mucosa anastomosis does not always require a stent tube even in patients with a normal soft pancreas. We have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stent tube (nonstented method) and obtained good results. The objective of this technique is to maintain adequate patency of the anastomosis using a fine atraumatic needle and monofilament suture. The pancreas, including the pancreatic duct, is sharply transected with a scalpel. Any arterial bleeding points on the pancreatic cut end are repaired with fine nonabsorbable sutures. The end-to-side anastomosis between the pancreas and jejunum consists of two layers of sutures. The outer layer is composed of the capsular parenchyma of the pancreas and the jejunal seromuscularis, and the inner layer is composed of the pancreatic duct with an adequate pancreatic parenchyma and the whole jejunal wall. Complete pancreaticojejunostomy using duct-to-mucosa anastomosis does not require a stent tube. This nonstented method can be considered one of the basic procedures for pancreaticojejunostomy because of its safety and reliability.     

A novel reconstructive procedure after pancreaticoduodenectomy: J-pouch dunking pancreaticojejunostomy

Leakage of the pancreaticojejunostomy remains a major complication after pancreaticoduodenectomy. Several methods have been advocated in order to reduce anastomotic fistula but none of them reached a significant difference in preventing the leakage. We developed a new technique called "J-pouch dunking pancreaticojejunostomy". A "J" pouch is made from the distal 20 to 30 cm of jejunum by using a GIA linear stapler. A transverse incision is made on the jejunal base. As a result, we have enough jejunal stoma to anastomose the pancreatic remnant. A soft pancreas and small pancreatic size are known to be risk factors in pancreatic anastomosis. This technique is designed to eliminate the several factors related to pancreatic anastomotic leakage.     

Risk factors of pancreatic leakage after pancreaticoduodenectomy

AIM: To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage. METHODS: Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage. RESULTS: Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) developed postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical significance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P = 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy. CONCLUSION: Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.     

捆绑式胰肠吻合术100例报告

目的：探讨捆绑式胰肠吻合术在胰十二指肠切除术后预防胰肠吻合口漏的临床价值。方法：1996年1月－2000年1月间共施行100例捆绑式胰肠吻合术,并与同期94例用传统方法吻合的病例进行对比。捆绑式胰肠吻合手术方法为先将空肠断端向外反摺3cm,将外翻的粘膜用石炭酸破坏3cm;游离胰断端3cm,将其断端与距离空肠断端3cm的空肠粘膜缝合一圈,注意缝针不穿透浆肌层。将反摺的空肠复位后,胰断端就自然进入肠腔之中（长约3cm）,其表面被缺失粘膜的空肠所覆盖,距离断端1cm用可吸收缝线环绕空肠进行捆绑,令空肠与其腔内的胰残端紧密相贴,然后结扎完成手术,术后观察总体恢复情况,B超定期检查残端有无积液等。结果：全组100例,无一例发生胰漏,残端没有积液。结论：捆绑式胰肠吻合术十分安全,能够防止胰肠吻合口漏的发生,且操作简单,不论胰腺质地软硬或胰管有无扩张均可使用,值得进一步推广。     

Stenting is unnecessary in duct-to-mucosa pancreaticojejunostomy even in the normal pancreas

Background: There is a high risk of anastomotic leakage after pancreaticojejunostomy after pancreaticoduodenectomy (PD) in patients with a normal pancreas because of the high degree of exocrine function. These PD are therefore generally performed using a stenting tube (stented method). In recent years, we have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stenting tube (nonstented method) and obtained good results. Methods: The point of this technique is to preserve adequate patency of the pancreatic duct by carefully picking up the pancreatic duct wall with a fine atraumatic needle and monofilament thread. The results of end-to-side pancreaticojejunostomy of the normal pancreas were compared between the nonstented method (n = 109) and the stented method (n = 39). Results: There were no differences in background characteristics between the groups, including age, gender and disease. The mean duration to complete pancreati-cojejunostomy was 26.6 min in the nonstented group and 29.2 min in the stented group. The mean durations of surgical procedure and intraoperative blood loss were also similar in the groups. Morbidity rates due to early postoperative complications were 20.2 and 23.1%, with pancreatic leakage occurring in 7.3 and 7.7% of patients, respectively. These differences were not statistically significant. One patient in the stented group died of sepsis following leakage of pancreaticojejunostomy. There were also no significant differences in the mean time to initiation of solid food intake or postoperative hospital stay. Conclusion: We conclude that a stenting tube is unnecessary if the duct-to-mucosa anastomosis is completely performed. This operative technique can be considered a basic procedure for pancreaticojejunostomy because of the low risk.     

A modified reconstruction method to prevent critical complications after pancreatoduodenectomy

BACKGROUND/AIMS: A new method of reconstructing the pancreatic stump after pancreatoduodenectomy (PD) is necessary to improve the postoperative mortality rate. Thus, we modified the pancreatoenteric procedure to reduce anastomotic leakage from the pancreatic stump after PD, and we conducted a study to evaluate the usefulness of the new procedure on the basis of patients' postoperative condition. METHODOLOGY: We compared the postoperative condition of 21 patients who underwent PD with the new separated loop (SL) reconstruction (6 men, 11 women; mean age, 67.7+/-7.2 years) to that of 31 patients (12 men, 19 women; mean age, 66.8+/-10.3 years) who underwent PD with pancreatogastrostomy (PG). In the SL reconstruction procedure, the proximal jejunum is brought up behind the colon, and an end-to-side choledochojejunostomy is made with a single layer of interrupted sutures. Approximately 20cm of the jejunum is fitted with a fixed stomach tube for postoperative enteral feeding, and the cut proximal jejunum is positioned next to the pancreatic stump. A pancreatic tube is inserted into the lumen of the pancreatic duct and fixed without closing the pancreatic duct. Pancreatojejunostomy is achieved as an end-to-end anastomosis with the pancreatic stump telescoping into the proximal jejunum. Approximately 20cm of the jejunum is anastomosed side-to-end to the stomach, and end-to-side jejunojejunostomy is made to complete a Y-type reconstruction. Each patient's postoperative condition was also assessed on the basis of serum albumin (ALB), cholinesterase and total cholesterol (T-CHO) levels on postoperative days (PODs) 14 and 28. RESULTS: A high level of amylase in drainage fluid was noted in two (6.5%) and delayed gastric emptying in four (12.9%) of the patients in the PG group. There were no complications in the SL group. Postoperative levels of ALB on POD 14 and T-CHO on POD 28 were significantly higher than in the PG group. CONCLUSIONS: The SL method is safe and does not induce complications after PD. Our results indicate that this method may provide a favored outcome.     

Pancreaticojejunostomy using duct-to-mucosa anastomosis without a stenting tube

Background Purpose

There is a high risk of anastomotic leakage after pancreaticojejunostomy following pancreaticoduodenectomy in patients with a normal soft pancreas because of the high degree of exocrine function. Therefore, pancreaticojejunostomy is generally performed using a stenting tube (stented method). However, pancreaticojejunostomy with a certain duct-to-mucosa anastomosis does not always require a stenting tube, even in patients with a normal soft pancreas. Recently, we have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stenting tube (nonstented method) and obtained good results.

Methods

The point of this technique is to maintain adequate patency of the anastomosis using a fine atraumatic needle and monofilament thread. The results of end-to-side pancreaticojejunostomy of the normal soft pancreas using the nonstented method (n = 123) were compared with those using the stented method (n = 45).

Results

There were no differences in background characteristics between the groups, including age, gender, and disease. The mean times to complete pancreaticojejunostomy were around 30?min in the two groups and the rates of morbidity and leakage of pancreaticojejunostomy were 26.8% and 5.7% in the nonstented group and 22.2% and 6.7% in the stented group, respectively. These differences were not statistically significant. One patient in the stented group died of sepsis following leakage of pancreaticojejunostomy. There were also no significant differences in the mean time to initiation of solid food intake or postoperative hospital stay.

Conclusions

In conclusion, complete pancreaticojejunostomy using duct-to-mucosa anastomosis for a normal soft pancreas does not require a stenting tube. This nonstented method can be considered one of the basic procedures for pancreaticojejunostomy because of its safety and certainty.     

A new technique for pancreaticogastrostomy for the soft pancreas: the transfixing suture method

Background/Purpose

Pancreatic anastomotic leakage remains a persistent problem after pancreaticoduodenectomy (PD). The presence of soft, nonfibrotic pancreatic tissue is one of the most important risk factors for pancreatic leakage. Accordingly, we devised a pancreas-transfixing suture method for pancreaticogastrostomies in patients with a soft, nonfibrotic pancreatic remnant.

Methods

The pancreas-transfixing method was applied in 103 consecutive patients after either standard PD (49 patients) or pylorus-preserving pancreaticoduodenectomy (PPPD) (54 patients) for malignant or benign disease. Of these 103 patients, 65 had a soft, nonfibrotic pancreatic remnant. For the pancreaticogastrostomy technique, an ultrasonically activated scalpel was used for transecting the pancreas. The inner layer involves a duct-to-mucosa anastomosis with an internal stent and the outer layer involves a single row of pancreas-transfixing sutures between the pancreatic remnant and the posterior gastric wall.

Results

Operative mortality was zero and morbidity was 22%. Only two patients (2%) developed pancreatic leaks; both resolved nonoperatively with the continuation of closed drainage.

Conclusions

This technique is simple and appears to reduce the risk of pancreatic leakage, possibly by decreasing the risk of suture injury of the pancreas and by embedding the transected stump into the wall of the stomach. This novel pancreaticogastrostomy technique is an effective reconstructive procedure, especially for patients with a soft, nonfibrotic pancreas.     

Pancreaticojejunostomy versus pancreaticogastrostomy

Background/Purpose

In the majority of reports morbidity after pancreaticoduodenectomy remains high and leakage from the pancreatic stump still accounts for the majority of surgical complications. Many technical modifications of the pancreaticoenteric anastomosis to decrease the pancreatic leakage rate have been suggested.

Methods

A Medline search for surgical guidelines, prospective randomized controlled trials, systematic meta-analyses, and clinical results was performed with regard to technical aspects of reconstruction, i.e., pancreaticojejunostomy versus pancreaticogastrostomy, after pancreaticoduodenectomy. Here we illustrate the different approaches to reconstruction, with an emphasis on technical aspects and their details.

Conclusions

Pancreaticojejunostomy appears to be the most widely performed reconstruction, but pancreaticogastrostomy is a reasonable alternative. However, in the analysis of the clinical results it is important to know which specific pancreaticoenteric anastomosis is considered; for example, end-to-end, dunking, invagination of the pancreatic stump, or duct-to-mucosa. It is hoped that collaborative trials will provide high-level data to allow tailoring of the operative technique, depending on the risk factors for pancreatic leakage in any particular patient.     

Open pancreatic stenting with duct-to-mucosa anastomosis for pancreatic-duct obstruction after pancreaticoduodenectomy with pancreaticogastrostomy

Pancreatic-duct dilatation is frequently observed in the patients who have undergone pancreaticoduodenectomy (PD). Pancreaticodigestive anastomotic stricture may occasionally develop after PD. Stenosis of the pancreaticoenterostomy induces obstructive chronic pancreatitis, which occurs due to primary stenosis or obstruction of the main pancreatic duct and causes in inflammation of the distal pancreas. The patency of the pancreaticoenterostomy is one of the most important factors affecting the functioning of the remnant pancreas and the quality of life. Endoscopic dilatation is one of the treatment options for stenosis of pancreaticogastrostomy (PG). However, the failure of endoscopic dilatation necessitates surgical approaches. We have described our technique of open pancreatic stenting with a duct-to-mucosa anastomosis for a case which the stenosis of PG could not be resolved by endoscopic dilatation. This technique dose not require re-resected PG or side-to-side pancreaticojejunostomy: the risk of anastomotic leakage is quite low and the procedure is minimally invasive.     

Appraisal of two-staged pancreatoduodenectomy: its technical aspects and outcome

BACKGROUND/AIMS: Leakage from the pancreaticoenteric anastomosis after pancreatoduodenectomy is closely associated with intraabdominal hemorrhage, thus contributing to mortality. Recently, two-staged pancreatoduodenectomy including exteriorization of the pancreatic juice and second-look pancreaticojejunostomy was performed in high-risk patients. METHODOLOGY: The authors reviewed 24 patients who underwent two-staged pancreatoduodenectomy from November 1994 to April 1999. RESULTS: Oral intake could be instituted on the 6th (mean) postoperative day. In 23 of the 24 patients, the pancreatic juice leakage stopped within a mean of 10 days without any complications. In the remaining 1, the leakage lasted over 4 weeks and intraabdominal bleeding from the gastroduodenal artery occurred. The median interval between pancreatoduodenectomy and the second operation was 124 days (range: 93-323 days). In 15 patients, a stent tube was placed at the site of pancreaticojejunostomy: 1 patient developed acute pancreatitis due to dislocation of the stent tube, in 3, pancreatic juice leakage necessitated exteriorization of the juice, and the remaining 11 recovered uneventfully. In the other 9 patients, the pancreatic juice was exteriorized: 1 patient had leakage and the other 8 recovered uneventfully. Overall, there was no mortality. CONCLUSIONS: Our two-staged pancreatoduodenectomy is considered to make pancreatoduodenectomy performable safely without any mortality. This procedure is recommended for selected patients, including those who require concomitant major hepatectomy or resection of other organs or who have liver cirrhosis, and may be indicated for patients who have a soft and fragile pancreas or pancreatic trauma.     

Pancreatic fistula after pancreaticoduodenectomy： A comparison between the two pancreaticojejunostomy methods for approximating the pancreatic parenchyma to the jejunal seromuscular layer： Interrupted vs continuous stitches

AIM： The purpose of this study is to find a better operative technique by comparing interrupted stitches with continuous stitches for the outer layer of the pancreaticojejunostomy, i.e. the stitches between the stump parenchyma of the pancreas and the jejunal seromuscular layer, and other risk factors for the incidence of pancreatic leakage.
METHODS： During the period January 1997 to October 2004, 133 patients have undergone the end-to-side and duct-to-mucosa pancreaticojejunostomy reconstruction after pancreaticoduodenectomy with interrupted suture for outer layer of the pancreaticojejunostomy and 170 patients with a continuous suture at our institution by one surgeon.
RESULTS： There were no significant differences between the two groups in the diagnosis, texture of the pancreas, use of octreotide and pathologic stage. Pancreatic fistula occurred in 14 patients （11%） among the interrupted suture cases and in 10 （6%） among the continuous suture cases （P = 0.102）. Major pancreatic leakage developed in three interrupted suture patients （2%） and zero continuous suture patients （P = 0.026）. In multivariate analysis, soft pancreatic consistency （odds ratio, 5.5; 95% confidence interval 2.3-13.1） and common bile duct cancer （odds ratio, 3.7; 95%CI 1.6-8.5） were＇predictive of pancreatic leakage.
CONCLUSION： Pancreatic texture and pathology are the most important factors in determining the fate of pancreaticojejunal anastomosis and our continuous suture method was performed with significantly decreased occurrence of major pancreatic fistula. In conclusion, the continuous suture method is more feasible and safer in performing duct-to-mucosa pancreaticojejunostomy.     

Modified pancreatic invagination into the jejunum with a double intestinal segment--a new technique.

A new technique for pancreaticojejunostomy after pancreaticoduodenectomy, Nagakawa's modified pancreatic invagination with a double intestinal segment, is described: in this method a double intestinal segment is prepared by an automatic instrument and the stump of the pancreas is invaginated into it. Suture of the stump of the pancreas and the jejunum is performed using a technique previously developed by the author. It is hoped that this technique will be widely applicable in pancreatic surgery.     

家猪贯穿缝合式胰肠吻合实验模型的建立

目的 建立家猪贯穿缝合式胰肠吻合的动物实验模型.方法 选取10头小型家猪,全麻后剖腹暴露胰腺,于胰腺左叶肠系膜上血管水平横断胰腺,胰腺近侧残端缝闭,远侧残端与空肠行端侧贯穿缝合式胰肠吻合,Roux-en-Y式重建消化道.结果 10头家猪行贯穿缝合式胰肠吻合手术均获成功.胰腺残端横径平均2.5 cm,胰管直径平均1.5 mm.手术时间为1.0～2.5 h,平均1.8h,其中胰肠吻合时间平均为8 min.术中平均出血量为25 ml.术后2头猪发生腹泻,1头猪发生切口感染,均经相应处理后治愈.术中未发生意外,术后未发生胰瘘,无死亡.结论 成功建立家猪贯穿缝合式胰肠吻合的实验模型.     

Risk factors influencing pancreatic leakage and the mortality after pancreaticoduodenectomy in a medium-volume hospital

BACKGROUND/AIMS: This study was designed to evaluate risk factors influencing pancreatic leakage and pancreatic leakage-related mortality in a medium-volume hospital. METHODOLOGY: We retrospectively reviewed the clinical records of 107 patients who underwent pancreaticoduodenectomy at the Kobe University Hospital. Fourteen predictive factors for pancreatic leakage and the pancreatic leakage-related mortality were evaluated using univariate and multivariate logistic regression models. RESULTS: In univariate analysis, the degree of pancreatic fibrosis, type of resection (PD/PPPD), anastomosis techniques (invagination or duct-to-mucosa anastomosis), anastomosis sites (jejunum/stomach), and the presence of congestion in anastomosis sites significantly influenced pancreatic leakage, and the degree of pancreatic fibrosis influenced pancreatic leakage-related mortality. Multivariate logistic regression analysis revealed that congestion in anastomosis sites was the strongest parameter for pancreatic leakage. Univariate analysis of the patients with normal/mild fibrosing pancreas revealed that pancreatic leakage was influenced by type of resection, anastomosis techniques, anastomosis sites, congestion in anastomosis sites and the management of pancreas parenchyma. CONCLUSIONS: In a medium-volume hospital, reconstruction after pancreaticoduodenectomy should be performed with careful attention to pancreas and anastomosis sites. In the patients with normal/mild fibrosing pancreas, duct-to-mucosa anastomosis without suturing the pancreas parenchyma may be a useful technique for reconstruction.     

An easier method for performing a pancreaticojejunostomy for the soft pancreas using a fast-absorbable suture

AIM： To clarify the usefulness of a new method for performing a pancreaticojejunostomy by using a fast-absorbable suture material irradiated polyglactin 910, and a temporary stent tube for a narrow pancreatic duct with a soft pancreatic texture.METHODS： Among 63 consecutive patients with soft pancreas undergoing a pancreaticoduodenectomy from 2003 to 2006, 35 patients were treated with a new reconstructive method. Briefly, after the pancreatic transaction, a stent tube was inserted into the lumen of the pancreatic duct and ligated with it by a fast-absorbable suture. Another tip of the stent tube was introduced into the intestinal lumen at the jejunal limb, where a purse-string suture was made by another fast-absorbable suture to roughly fix the tube. The pancreaticojejunostomy was completed by ligating two fast-absorbable sutures to approximate the ductal end and the jejunal mucosa, and by adding a rough anastomosis between the pancreatic parenchyma and the seromuscular layer of the jejunum. The initial surgical results with this method were retrospectively compared with those of the 28 patients treated with conventional duct-to-mucosa anastomosis.RESULTS： The incidences of postoperative morbidity including pancreatic fistula were comparable between the two groups （new; 3%-17% vs conventional; 7%-14% according to the definitions）. There was no mortality and re-admission. Late complications were also rarely seen.CONCLUSION： A pancreaticojejunostomy using an irradiated polyglactin 910 suture material and a temporary stent is easy to perform and is feasible even in cases with a narrow pancreatic duct and a normal soft pancreas.     

Pancreaticogastrostomy: a pancreas-transfixing method with duct-to-mucosa anastomosis (with video)

Pancreatic fistula still remains a persistent problem after pancreaticoduodenectomy. We have devised a pancreas-transfixing suture method of pancreaticogastrostomy with duct-to-mucosa anastomosis. This technique is simple and reduces the risk of pancreatic leakage by decreasing the risk of suture injury of the pancreas and by embedding the transected stump into the wall of the stomach. This novel technique of pancreaticogastrostomy is an effective reconstructive procedure following pancreaticoduodenectomy, especially for patients with a soft and fragile pancreas.     

Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications

Pancreatic fistula after pancreaticoduodenectomy represents a critical trigger of potentially life-threatening complications and is also associated with markedly prolonged hospitalization. Many arguments have been proposed for the method to anastomosis the pancreatic stump with the gastrointestinal tract, such as invagination vs. duct-to-mucosa, Billroth I (Imanaga) vs. Billroth II (Whipple and/or Child) or pancreaticogastrostomy vs. pancreaticojejunostomy. Although the best method for dealing with the pancreatic stump after pancreaticoduodenectomy remains in question, recent reports described the invagination method to decrease the rate of pancreatic fistula significantly compared to the duct-to-mucosa anastomosis. In Billroth I reconstruction, more frequent anastomotic failure has been reported, and disadvantages of pancreaticogastrostomy have been identified, including an increased incidence of delayed gastric emptying and of pancreatic duct obstruction due to overgrowth by the gastric mucosa. We review recent several safety trials and methods of treating the pancreatic stump after pancreaticoduodenectomy, and demonstrate an operative procedure with its advantage of the novel reconstruction method due to our experiences.     

Safe management of the pancreatic remnant with prolamine duct occlusion after extended pancreaticoduodenectomy

BACKGROUND/AIMS: Occlusion of the pancreatic duct system has been used to prevent pancreatic leakage by abolishing pancreatic exocrine secretion in pancreatic surgery. However, ductal occlusion has not proved satisfactory for preventing pancreatic fistulas in pancreaticoduodenectomy (PD). METHODOLOGY: Pancreatic duct occlusion with a watertight drainage system around the pancreatic stump was performed following extended PD in 17 patients with (n=12) or without (n=5) a dilated pancreatic duct. RESULTS: Transient pancreatitis during the early postoperative period occurred in all patients with a nondilated pancreatic duct. No patient developed pancreatic fistula or any other serious complication in both groups. CONCLUSIONS: Pancreatic duct occlusion may minimize the risk of pancreatic leakage in patients with a nondilated pancreatic duct and a normal pancreas as well as in those with a dilated, obstructed pancreatic duct without compromising the postoperative quality of life. This is a safe and reliable technique for managing the pancreatic remnant in patients undergoing extended PD for advanced pancreaticobiliary malignancy.