SS  Vol.5 No.10 , October 2014
A Simple and Dependable Technique for Pancreatic-Enteric Anastomosis with a Soft Pancreas and Nondilated Duct
Background: Pancreatic anastomotic leakаgе is one of the most serious complications following pancreaticoduodenectomy (PD). The most significant riskfactors for pancreatic leakage are pancreatic texture, main pancreatic duct (MPD) size and anastomotic technique. Herewith we describe our technical modifications for single-layer pancreaticojejunostomy (PJ) with a soft pancreas and nondilated MPD for reconstruction after PD. Methods: We report our early experience using this technique in 52 patients who underwent PD between May 2009 and December 2012. Results: Overall postoperative mortality rate was1.92%. Postoperative morbidity rate was 32.69%, with major complications occurring in three patients (5.77%). Pancreatic leak was diagnosed in sixpatients (11.54%). Three patients with pancreatic fistulae (PF) of Grades A and B were managed conservatively, whereas three other patients with PF of Grade C required relaparotomy. Conclusions: According to our early experience with this modified technique for PJ, usage of horizontal mattress sutures, “everting” of MPD and incorporation of its wall into a single layer pancreatic-enteric anastomosis result in a low pancreatic anastomotic leakagerate after PD. This technique for PJ with a soft pancreas and nondilated ductensures ideal preconditions for anastomosis healing. They consist of an excellent blood supply, an anatomical position with tension-free approximation and unobstructed pancreatic juice flow from the pancreas into the jejunal loop.

Cite this paper
Kostov, D. , Kobakov, G. , Yankov, D. and Kirov, K. (2014) A Simple and Dependable Technique for Pancreatic-Enteric Anastomosis with a Soft Pancreas and Nondilated Duct. Surgical Science, 5, 444-453. doi: 10.4236/ss.2014.510069.

[1]   Buchler, M.W., Friess, H., Wagner, M., Kulli, C., Wagener, V. and Z’Graggen, K. (2000) Pancreatic Fistula after Pancreatic Head Resection. British Journal of Surgery, 87, 883-889.

[2]   Makowiec, F., Riediger, H., Euringer, W., Uhl, M., Hopt, U.T. and Adam, U. (2005) Management of Delayed Visceral Arterial Bleeding after Pancreatic Head Resection. Journal of Gastrointestinal Surgery, 9, 1293-1299.

[3]   Choi, S.H., Moon, H.J., Heo, J.S., Joh, J.W. and Kim, Y.I. (2004) Delayed Hemorrhage after Pancreatico-Duodenoctomy. Journal of the American College of Surgeons, 199, 186-191.

[4]   Shrikhande, S., Kleeff, J., Büchler, M. and Friess, H. (2007) Pancreatic Anastomosis after Pancreaticoduo Denectomy: How We Do It. Indian Journal of Surgery, 69, 224-229.

[5]   Bassi, C., Falconi, M., Molinari, E., Mantovani, W., Butturini, G., Gumbs, A.A., et al. (2003) Duct-to-Mucosa versus End-to-Side Pancreaticojejunostomy Reconstruction after Pancreaticoduodenectomy: Results of a Prospective Randomized Trial. Surgery, 134, 766-771.

[6]   Takano, S., Ito, Y., Watanabe, Y., Yokoyama, T., Kubota, N. and Iwai, S. (2000) Pancreaticojejunostomy versus Pancreatico-Gastrostomy in Reconstruction Following Pancreaticoduodenectomy. British Journal of Surgery, 87, 423-427.

[7]   Caronna, R., Peparini, N., Russillo, G., Rogano, A., Dinatale, G. and Chirletti, P. (2012) Pancreaticojejuno Anastomosis after Pancreaticoduodenectomy: Brief Pathophysiological Considerations for a Rational Surgical Choice. International Journal of Surgical Oncology, 2012, 1-4.

[8]   Yang, S., Dou, K., Sharma, N. and Song, W. (2011) The Methods of Reconstruction of Pancreatic Digestive Continuity after Pancreaticoduodenectomy: A Meta-analysis of Randomized Controlled Trials. World Journal of Surgery, 35, 2290-2297.

[9]   Hayashibe, A. and Kameyama, M. (2008) Duct-to-Mucosa Pancreaticojejunostomies with a Hard Pancreas and Dilated Pancreatic Duct and Duct-to-Mucosa Pancreatico-Jejunostomies with a Soft Pancreas and Non-Dilated Duct. HPB (Oxford), 10, 54-57.

[10]   Cho, A., Yamamoto, H., Kainuma, O., Muto, Y., Park, S., Arimitsu, H., et al. (2014) Performing Simple and Safe Dunking Pancreaticojejunostomy Using Mattress Sutures in Pure Laparoscopic Pancreaticoduodenectomy. Surgical Endoscopy, 28, 315-318.

[11]   Hughes, S.J., Neichoy, B. and Behrns, K.E. (2014) Laparoscopic Intussuscepting Pancreaticojejunostomy. Journal of Gastrointestinal Surgery, 18, 208-212.

[12]   Chen, L. (2013) Applying Transductal Invaginational Pancreaticojejunostomy to Decrease Pancreatic Leakage after Pancreaticoduodenectomy. Hepatogastroenterology, 60, 1018-1020.

[13]   Kakinoki, K., Okano, K., Oshima, M., Suto, H., Kashiwagi, H., Yamamoto, N., et al. (2014) A Novel Triple Secured Technique for Pancreatic Reconstruction Following Pancreaticoduodenectomy for a Soft Pancreas. Hepatogastroenterlogy, 61, 469-474.

[14]   Bassi, C., Dervenis, C., Butturini, G., Fingerhut, A., Yeo, C., Izbicki, J., et al. (2005) Postoperative Pancreatic Fistula: An International Study Group (ISGPF) Definition. Surgery, 138, 8-13.

[15]   Wente, M.N., Veit, J.A., Bassi, C., Dervenis, C., Fingerhut, A., Gouma, D.J., et al. (2007) Post-Pancreatectomy Haemorrhage (PPH): An International Study Group of Pancreatic Surgery (ISGPS) Definition. Surgery, 142, 20-25.

[16]   Vincent, J.L. (2008) Clinical Sepsis and Septic Shock—Definition, Diagnosis and Management Principles. Langenbeck’s Archives of Surgery, 393, 817-824.

[17]   Wente, M.N., Bassi, C., Dervenis, C., Fingerhut, A., Gouma, D.J., Izbicki, J.R., et al. (2007) Delayed Gastric Emptying (DGE) after Pancreatic Surgery: A Suggested Definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery, 142, 761-768.

[18]   Dindo, D., Demartines, N. and Clavien, P.A. (2004) Classification of Surgical Complications: A New Proposal with Evaluation in a Cohort of 6336 Patients and Results of a Survey. Annals of Surgery, 240, 205-213.

[19]   Reid-Lombardo, K.M., Farnell, M.B., Crippa, S., Barnett, M., Maupin, G., Bassi, C., et al., Pancreatic Anastomotic Leak Study Group (2007) Pancreatic Anastomotic Leakage after Pancreaticoduodenectomy in 1,507 Patients: A Report from the Pancreatic Anastomotic Leak Study Group. Journal of Gastrointestinal Surgery, 11, 1451-1458.

[20]   van Berg Henegouwen, M.I., de Wit, L.T., van Gulik, T.M., Obertop, H. and Gouma, D.J. (1997) Incidence, Risk Factors and Treatment of Pan Creatic Leakage after Pancreaticoduodenectomy: Drainage versus Resection of the Pancreatic Remnant. Journal of the American College of Surgeons, 185, 18-24.

[21]   Yeo, C.J., Cameron, J.L., Lillemoe, K.D., Sauter, P.K., Coleman, J., Sohn, T.A., et al. (2000) Does Prophylactic Octreotide Decrease the Rates of Pancreatic Fistula and Other Complications after Pancreatico-Duodenectomy? Results of a Prospective Randomized Placebo-Controlled Trial. Annals of Surgery, 232, 419-429.

[22]   Munoz-Bongrand, N., Sauvanet, A., Denys, A., Sibert, A., Vilgrain, V. and Belghiti, J. (2004) Conservative Management of Pancreatic Fistula after Pancreatico-Duodenectomy with Pancreaticogastrostomy. Annals of Surgery, 199, 198-203.

[23]   Poon, R.T., Fan, S.T., Lo, C.M., Ng, K.K., Yuen, Y.K., Yeung, C. and Wong, J. (2007) External Drainage of Pancreatic Duct with a Stent to Reduce Leakage Rate of Pancreaticojejunostomy after Pancreaticoduodenectomy: A Prospective Randomized Trial. Annals of Surgery, 246, 425-433.

[24]   Zhou, Y., Yang, C., Wang, S., Chen, J. and Li, B. (2011) Does External Pancreatic Duct Stent Decrease Pancreatic Fistula Rate after Pancreatic Resection? A Meta-Analysis. Pancreatology, 11, 362-370.

[25]   Tien, Y.W., Lee, P.H., Yang, C.Y., Ho, M.C. and Chiu, Y.F. (2005) Risk Factors of Massive Bleeding Related to Pancreatic Leak after Pancreatico-Duodenectomy. Journal of the American College of Surgeons, 201, 554-559.

[26]   Shinchi, H., Takao, S., Maemura, K. and Aikou, T. (2006) A New Technique for Pancreaticogastrostomy for the Soft Pancreas: The Transfixing Suture Method. Journal of Hepato-Biliary-Pancreatic Surgery, 13, 212-217.

[27]   Nakahara, O., Takamori, H., Ikeda, O., Kuroki, H., Ikuta, Y., Chikamoto, A., Beppu, T., Yamashita, Y. and Baba, H. (2012) Risk Factors Associated with Delayed Haemorrhage after Pancreatic Resection. HPB (Oxford), 14, 684-687.

[28]   Denbo, J., Orr, W., Zarzaur, B. and Behrman, S. (2012) Toward Defining Grade C Pancreatic Fistula Following Pancreaticoduodenectomy: Incidence, Risk Factors, Management and Outcome. HPB (Oxford), 14, 589-593.

[29]   Aroori, S., Puneet, P., Bramhall, S., Muiesan, P., Mayer, A., Mirza, D., Buckels, J. and Isaac, J. (2011) Outcomes Comparing a Pancreaticogastrostomy (PG) and a Pancreaticojejunostomy (PJ) after a Pancreatico-Duodenectomy (PD). HPB (Oxford), 13, 723-731.

[30]   Denost, Q., Pontallier, A., Rault, A., Ewald, J., Collet, D., Masson, B. and Sa-Cunha, A. (2012) Wirsungostomy as a Salvage Procedure after Pancreaticoduodenectomy. HPB (Oxford), 14, 82-86.

[31]   Shukla, P.J. and Barreto, S.G. (2008) Improving the Safety and Outcome of Uncinate Process Dissection in Surgery on the Pancreatic Head. HPB (Oxford), 10, 214.

[32]   Diener, M.K., Rahbari, N.N., Fischer, L., Antes, G., Büchler, M.W. and Seiler, C.M. (2008) Duodenum-Preserving Pancreatic Head Resection versus Pancreatoduodenectomy for Surgical Treatment of Chronic Pancreatitis. A Systematic Review and Meta-Analysis. Annals of Surgery, 247, 950-961.

[33]   Shrikhande, S.V., Barreto, G. and Shukla, P.J. (2008) Pancreatic Fistula after Pancreaticoduodenectomy: The Impact of a Standardized Technique of Pancreatico-Jejunostomy. Langenbecks Archives of Surgery, 393, 87-91.

[34]   Blanc, T., Cortes, A., Goere, D., Sibert, A., Pessaux, P., Belghiti, J. and Sauvanet, A. (2007) Haemorrhage after Pancreaticoduodenectomy: When Is Surgery Still Indicated? American of Surgery, 194, 3-9.

[35]   Denbo, J.W., Orr, W.S., Zarzaur, B.L. and Behrman, S.W. (2012) Toward Defining Grade C Pancreatic Fistula Following Pancreaticoduodenectomy: Incidence, Risk Factors, Management and Outcome. HPB (Oxford), 14, 589-593.

[36]   Veillette, G., Dominguez, I., Ferrone, C., Thayer, S.P., McGrath, D., Warshaw, A.L., et al. (2008) Implications and Management of Pancreatic Fistulas Following Pancreaticoduodenectomy. Archives of Surgery, 143, 476-481.

[37]   Denost, Q., Pontallier, A., Rault, A., Ewald, J.A., Collet, D., Masson, B. and Sa-Cunha, A. (2012) Wirsungostomy as a Salvage Procedure after Pancreaticoduodenectomy. HPB (Oxford), 14, 82-86.

[38]   Fuks, D., Piessen, G., Huet, E., Tavernier, M., Zerbib, P., Michot, F., et al. (2009) Life-Threatening Postoperative Pancreatic Fistula (Grade C) after Pancreatico-Duodenectomy: Incidence, Prognosis and Risk Factors. American of Surgery, 197, 702-709.

[39]   Kawai, M., Kondo, S., Yamaue, H., Wada, K., Sano, K., Motoi, F., et al. (2011) Predictive Risk Factors for Clinically Relevant Pncreatic Fistula Analysed in 1239 Patients with Pancreaticoduodenectomy: Multicentre Data Collection as a Project Study of Pancreatic Surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. Journal of Hepato-Biliary-Pancreatic Sciences, 18, 601-608.

[40]   Eshuis, W.J., Tol, J.A., Nio, C.Y., Busch, O.R., van Gulik, T.M. and Gouma, D.J. (2014) Leakage of the Gastroenteric Anastomosis after Pancreato-Duodenectomy. Surgery, 156, 75-82.

[41]   El Nakeeb, A., Salah, T., Sultan, A., El Hemaly, M., Askr, W., Ezzat, H., et al. (2013) Pancreatic Anastomotic Leakage after Pancreatico-Duodenectomy. Risk Factors, Clinical Predictors and Management (Single Center Experience). World Journal of Surgery, 37, 1405-1418.

[42]   Gaujoux, S., Cortes, A., Couvelard, A., Noullet, S., Clavel, L., Rebours, V., Lévy, P., Sauvanet, A., Ruszniewski, P. and Belghiti, J. (2010) Fatty Pancreas and Increased Body Mass Index Are Risk Factors of Pancreatic Fistula after Pancreaticoduodenectomy. Surgery, 148, 39-47.

[43]   Tsai, S., Choti, M.A., Assumpcao, L., Cameron, J.L., Gleisner, S.L., Herman, J.M., Eckhauser, F., Edil, B.H., Schulick, R.D., Wolfgang, C.L. and Pawlik, T.M. (2010) Impact of Obesity on Perioperative Outcomes and Survival Following Pancreaticoduodenectomy for Pancreatic Cancer: A Large Single-Institution Study. Journal of Gastrointestinal Surgery, 14, 1143-1150.