Three Steps for a Safe Pancreaticoduodenectomy: Neither Pancreatic Texture nor Duct Size Matters

Abstract

Background: I have designed a Q-shape biliary diversion pancreaticoduodenectomy (PD) to prevent delayedhemorrhage in case of pancreaticojejunostomy (PJ) leakage. However, eliminating PJ leakage is the ultimate goal. A PJ anastomosis technique, irrespective of soft pancreatic texture or duct-size, has been found. Methods: Nine PDs were included. An end-to-side anastomosed proximal jejunal loop (30 cm), divided by a GIA stapler at its top and reapproximated using serosal sutures, was used for a choledochojejunostomy and PJs (4 fistulation, 2 duct-to-mucosa, 1 conventional and 2 whole-thickness mattress end-to-side sutures) at each divided loop. Finally, a gastro/duodenojejunostomy was made 30 cm distal to this looped jejunojejunostomy. Results: There was no mortality. One minor PJ leakage healed spontaneously. One major PJ leakage had a delayed-hemorrhage crisis salvaged by continuous normal saline irrigation to neutralize the pH condition for bile and pancreatic juice interaction. The clinical courses were surprisingly uneventful and without fear of leakage in two PJs using whole-thickness mattress sutures. Secure ties without tearing were possible in the soft pancreatic texture. Conclusion: Current evolutional strategies of biliary diversion reconstruction with whole-thickness-mattress PJ sutures plus normal saline irrigation can increase the safety of a pancreaticoduodenectomy by reducing PJ leakage and preventing the activation of pancreatic juice to eliminate a lethal delayed-hemorrhage.