How to perform laparoscopic duct-to-mucosa pancreatojejunostomy in high-risk score patients

Abstract

Background: According to prospective validated study score for pancreatic fistula, the main risk factors are gland texture, pathology, duct diameter and blood loss. While major blood loss usually is not an issue in laparoscopic surgery, we present our technique to safely perform pancreatojejunostomy in patients with soft gland and extremely small pancreatic ducts. Methods: This video presents laparoscopic duct-to-mucosa pancreato-jejunostomy in different scenarios. Small and extremely small pancreatic ducts, odd position of the pancreatic duct (position from posterior edge <3 mm) in patients with soft texture of pancreas are shown. Results: In most cases there is a difficulty in finding the main duct. The duct located near to the posterior edge needs pancreatic stump posterior face dissection in order to allow duct-to-mucosa anastomosis without compromise external layer. Internal stents are used for extremely small ducts (1 mm). Sometimes even pediatric feeding tubes are not small enough to be introduced and venous catheter may be used. Interrupted sutures are usually necessary. Forty-seven patients with high-risk score submitted to laparoscopic duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy or central pancreatectomy were studied. Pancreatic fistula occurred in 15 patients (35%) but only two patients with grades B and C. Conclusion: Laparoscopic duct-to-mucosa pancreatojejunostomy is feasible and safe even in patients with high-risk score for developing postoperative pancreatic fistula.