Jejunal Seromuscular Layer Research Articles

A duct-to-mucosa pancreaticojejunostomy for small main pancreatic duct and soft pancreas in minimally invasive pancreaticoduodenectomy

BackgroundPostoperative pancreatic fistula (POPF) is often associated with significant morbidity and mortality after the Whipple operation. Patient-related factors associated with POPF include soft pancreatic texture and a small main pancreatic duct (MPD). The traditional duct-to-mucosa anastomosis was modified to be easily performed. The aim of the study was to evaluate the simplified pancreaticojejunostomy (PJ) method in the prevention of POPF after minimally invasive pancreaticoduodenectomy (PD).MethodsNinety-eight patients who underwent laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD) with a simplified PJ procedure containing only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer in our center were retrospectively studied. Demographics and clinical short-term safety were assessed.ResultsAll LPD and RPD procedures were successfully performed. The median time of PJ was 17 min, and the median blood loss was 60 mL, with only one patient requiring transfusion. Four patients (4.1%) suffered from clinically relevant POPF (CR-POPF), including four grade B cases and no grade C cases. For patients with an MPD diameter of 3 mm or less, POPF was noted in two (4%) of the fifty patients, with all cases being grade B. Of the patients with a soft pancreas, only two (4.5%) patients suffered from grade B POPF. One patient (1.0%) experienced a 90-day mortality. Neither the main pancreatic diameter nor pancreatic texture had an impact on postoperative outcomes.ConclusionsOur technique is a simple, safe and efficient alternative to prevent POPF after LPD and RPD. This method is suitable for almost all pancreatic conditions, including cases with a small main pancreatic duct and soft pancreas, and has the potential to become the preferred procedure in low-volume pancreatic surgery centers.Graphical abstractOur modified duct-to-mucosa PJ, which contains only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer, is ideal for small MPD and soft pancreas when performing minimally invasive PD and has a low rate of POPF. PJ pancreaticojejunostomy, MPD main pancreatic diameter, PD pancreaticoduodenectomy, POPF postoperative pancreatic fistula

Modified Blumgart mattress suture versus conventional interrupted suture in pancreaticojejunostomy during pancreaticoduodenectomy: randomized controlled trial

Introduction: Several retrospective studies reported that mattress suture of Blumgart anastomosis in pancreaticojejunostomy (PJ) during pancreaticoduodenectomy (PD) could reduce postoperative pancreatic fistula (POPF) rates. Therefore, we conducted a randomized controlled trial (RCT) to evaluate whether mattress suture of pancreatic parenchyma and the seromuscular layer of jejunum (modified Blumgart method) during PJ decreases the incidence of clinically relevant POPF after PD. Method: Between June 2013 and May 2017, 224 patients scheduled for PD were enrolled in this study in Wakayama Medical University Hospital. Enrolled patients were randomized to either interrupted suture or modified Blumgart mattress suture of pancreatic parenchyma and the seromuscular layer of jejunum. The primary endpoint was the incidence of Grade B/C POPF based on the International Study Group on Pancreatic Fistula criteria. This RCT was registered with ClinicalTrials.gov (NCT01898780). Result: Patients were randomized to either interrupted suture (103 patients) or modified Blumgart mattress suture (107 patients) and were analyzed by intention-to-treat. Grade B/C POPF occurred in 7 patients (6.8%) in the interrupted suture group and 11 (10.3%) in the mattress suture group (P=0.367). Mortality within 90 days was zero in both groups. There were no significant differences in all postoperative complications between the interrupted suture group and the modified Blumgart mattress suture group. Conclusion: Mattress suture of pancreatic parenchyma and the jejunal seromuscular layer during PJ (modified Blumgart technique) did not reduce clinically relevant POPF compared with interrupted suture.

MODIFIED HEIDELBERG TECHNIQUE FOR PANCREATIC ANASTOMOSIS.

ABSTRACT Background : Pancreatic fistula is a major cause of morbidity and mortality after pancreatoduodenectomy. To prevent this complication, many technical procedures have been described. Aim: To present a novel technique based on slight modifications of the original Heidelberg technique, as new pancreatojejunostomy technique for reconstruction of pancreatic stump after pancreatoduodenectomy and present initial results. Method: The technique was used for patients with soft or hard pancreas and with duct size smaller or larger than 3 mm. The stitches are performed with 5-0 double needle prolene at the 2 o’clock, 4 o’clock, 6 o’clock, 8 o’clock, 10 o’clock, and 12 o’clock, positions, full thickness of the parenchyma. A running suture is performed with 4-0 single needle prolene on the posterior and anterior aspect the pancreatic parenchyma with the jejunal seromuscular layer. A plastic stent, 20 cm long, is inserted into the pancreatic duct and extended into the jejunal lumen. Two previously placed hemostatic sutures on the superior and inferior edges of the remnant pancreatic stump are passed in the jejunal seromuscular layer and tied. Results : Seventeen patients underwent pancreatojejunostomy after pancreatoduodenectomy for different causes. None developed grade B or C pancreatic fistula. Biochemical leak according to the new definition (International Study Group on Pancreatic Surgery) was observed in four patients (23.5%). No mortality was observed. Conclusion : Early results of this technique confirm that it is simple, reliable, easy to perform, and easy to learn. This technique is useful to reduce the incidence of pancreatic fistula after pancreatoduodenectomy.

Application value of end-to-side closed in situ pancreaticojejunostomy in pancreaticoduodenectomy

Objective To explore the application value of end-to-side closed in situ pancreaticojejunostomy in pancreaticoduodenectomy. Methods The clinical data of 22 patients with obstructive jaundice who were admitted to the Second Affiliated Hospital of Harbin Medical University from January to March 2014 were retrospectively analyzed. All the patients were explored whether tumors invaded inferior vena cava, superior mesenteric vein and portal vein after gallbladder decompression under general anesthesia by tracheal intubation. The standard or extended pancreaticoduodenectomy was applied according to the intraoperative results. The method of pancreaticojejunostomy was end-to-side closed in situ anastomosis of pancreatic duct and jejunal seromuscular layer. The operation time, intraoperative blood loss, postoperative gastrointestinal function recovery time, amylase concentration of drainage at postoperative day 1, 3, 5, postoperative complication, pathological classification and duration of hospital stay were observed. Patients were followed up by outpatient examination and telephone interview till May 2014. The out-patient follow-up included color Doppler ultrasound examination of effusion near the pancreatic stump, and the telephone interview included whether there were diarrhea of exocrine pancreatic insufficiency. Measurement data with normal distribution were presented as ±s (range), and measurement data with skewed distribution as M(range). Results All the 22 patients underwent successfully the operation, including 17 undergoing standard pancreaticoduodenectomy and 5 undergoing extended pancreaticoduodenectomy, with end-to-side closed in situ anastomosis of pancreatic duct and jejuna seromuscular layer. The operation time of pancreaticoduodenectomy and end-to-side closed in situ pancreaticojejunostomy were (313±37)minutes (range, 228-360 minutes) and(13±4)minutes (7-22 minutes), respectively. The intraoperative blood loss was (400±207)mL (range, 100-800 mL). The mean tumor size was 3.69 cm2 (range, 0.72-1.68 cm2). The recovery time of gastrointestinal function was (5±2)days (range, 4-7 days). The serum amylase at postoperative day 1, 3, 5 in the 21 patients was (145±30)U/L (range, 116-180 U/L), (136±40)U/L (range, 105-176 U/L), (147±38)U/L (range, 110-175 U/L), and the drainage amylase was (220±56)U/L (range, 172-289 U/L), (240±54)U/L (range, 192-300 U/L), (245±52)U/L (range, 190-298 U/L), respectively. The serum amylase at postoperative day 1, 3, 5 in the patient with pancreatic fistula was 156 U/L, 178 U/L and 177 U/L, and the drainage fluid amylase was 500 U/L, 620 U/L and 605 U/L, respectively. There was 1 patient in the 22 patients with pancreatic duct stent and without death. Among the 4 patients with postoperative complications, 1 patient with grade A postoperative pancreatic fistula recovered after continuous external drainage, the other 3 including 1 case of infection, 1 case of pneumonia and 1 of stress ulcer bleeding also recovered after symptomatic and supportive treatment. Postoperative pathological examinations of the 22 patients showed 12 cases of ductal adenocarcinoma, 2 of neuroendocine tumors, 1 of simple cyst, 1 of cystadenocarcinoma, 1 of squamous carcinoma, 1 of adenocarcinoma, 1 of ampullary carcinoma, 1 of tubular adenoma, 1 of leiomyoma and 1 of atypical intraductal hyperplasia. The average length of hospital stay was (11±3)days (range, 2-15 days). There were no effusion near the pancreatic stump showed in color Doppler ultrasound examination and diarrhea of exocrine pancreatic insufficiency. Conclusion End-to-side closed in situ pancreaticojejunostomy is safe and feasible, and can be applied to any pancreatic duct size and texture. Key words: Obstructive jaundice; Pancreaticoduodenectomy; Closed pancreaticojejunostomy; Pancreatic fistula

Modified Blumgart Anastomosis for Pancreaticojejunostomy: Technical Improvement in Matched Historical Control Study

BackgroundPostoperative pancreatic fistula (POPF) is the main cause of fatal complications after pancreatoduodenectomy. There is still no universally accepted technique for pancreaticoenterostomy, especially in patients with soft pancreas. MethodsBetween July 2008 and June 2013, 240 patients who underwent pancreatoduodenectomy were enrolled in this single-institution matched historical control study. To approximate the pancreatic parenchyma to the jejunal seromuscular layer, 120 patients underwent anastomosis using the Kakita method (three or four interrupted penetrating sutures) and 120 underwent anastomosis using the modified Blumgart anastomosis (m-BA) method (one to three transpancreatic/jejunal seromuscular sutures to completely cover the pancreatic stump with jejunal serosa). ResultsThe rate of clinically relevant POPF formation was significantly lower in the m-BA group than that in the Kakita group (2.5 vs 36 %; p < 0.001). The duration of drain placement and the length of postoperative hospital stay were significantly shorter in the m-BA group. Multivariate analysis showed that m-BA was an independent predictor of non-formation of POPF (hazard ratio, 0.02; 95 % confidence interval, 0.01–0.08; p < 0.001). ConclusionThe m-BA method is safe and simple and improves postoperative outcomes. We suggest that the m-BA is suitable for use as a standard method of pancreaticojejunostomy after pancreatoduodenectomy.

Personalized cartridge selection according to pancreas thickness for distal pancreatectomy with an endopath stapler

s / Pancreatology 13 (2013) S1–S80 S60 the duct/parenchyma and jejunal whole layer were continuous running sutured in parachuting fashion. After the suturewas tightened and tiedwith multiple throws but was not cut, the inner duct-to-mucosal anastomosis was completed, by which the pancreatic duct was tightly in touch with the jejunal mucosa via a matching stent tube. The outer pancreas-to-seromuscular jejunal anastomosis was completed by continuous running suture using the previous suture, which ensured the jejunal seromuscular layer in close contact with the pancreas stump. Results: We have developed of this novel pancreaticojejunostomy in 90 patients. Pancreatic fistula according to the International Study Group on Pancreatic Fistula criteria occurred in only 10 (11.1%) patients. No patient died. Conclusions: An entirely continuous running suture of two-layer pancreaticojejunostomy using only one polypropylene monofilament suture is simple, rapid, safe, and reliable technique.

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

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. 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. 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. 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.

Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size.

Selection of proper pancreaticojejunostomy techniques according to pancreatic texture and the main duct size reduces the pancreatic fistula rate. Data from 50 consecutive patients undergoing pancreatoduodenectomy with 3 different anastomotic techniques prospectively used according to pancreatic texture and the main duct size were analyzed. Duct-invagination anastomosis was selected for pancreata with a small duct (n = 34 [29 with a soft texture and 5 with a hard texture]). Stitches between the stump parenchyma and the jejunal seromuscular layer were added to this anastomosis procedure only for the hard pancreata. Pancreata with a large duct were reconstructed with a conventional duct-to-mucosa anastomosis (n = 16). A university hospital department of digestive surgery. The morbidity was 40% (20 of 50 patients) in this series. Four patients (8%) with a soft pancreas and a small duct developed a pancreatic stump leak after duct-invagination anastomosis, but all of them were removed without sequelae. No pancreatic anastomotic leak was seen in this series, which resulted in no mortality, no remnant pancreatectomy, and only 1 relaparotomy in the consecutive 50 patients. The proper selection of pancreatic reconstruction techniques according to our criteria may reduce the pancreatic fistula rate, eliminate risky pancreatic anastomotic leaks, and result in excellent outcomes for those undergoing pancreatoduodenectomy.

Characterization of contractile and non-contractile protein synthesis in the stomach, small and large intestine and caecum of the rat, and response to acute ethanol dosage.

An investigation was made into the relative composition and synthesis rates of smooth muscle contractile proteins in vivo in different regions of the rat gastrointestinal tract. There was considerable homogeneity in the composition of sarcoplasmic proteins in the small bowel (i.e. 54-58 mg/g) but considerable variability in the large bowel, i.e. highest in the caecum (97 mg/g) and lowest in the colon (21 mg/g). The myofibrillary protein concentration was constant throughout the gastrointestinal tract, i.e. 20-34 mg/g. Stromal fractions varied from 6 to 39 mg/g and was highest in the cardiac region of the stomach and lowest in the duodenum. Fractional rates of protein synthesis were measured with a flooding dose of L-[4-(3)H]phenylalanine. In control rats synthesis rates in sarcoplasmic protein fractions were relatively much higher (43-107%/day) than myofibrillar (27-52%/day) or stromal (6-26%/day) proteins. Fractional rates of stromal protein synthesis showed the greatest variability while myofibrillar synthesis rates the least, throughout the alimentary tract. Jejunal seromuscular layer myofibrillar proteins had the highest synthesis rates (49%/day). In response to acute ethanol injection, protein synthesis in all jejunal fractions fell by 20-30%. Contractile and non-contractile proteins from the cardiac region of the stomach, duodenal seromuscular layer and large bowel seromuscular layer were insensitive to ethanol administration. Protein synthesis of sarcoplasmic proteins from the antrum, ileum seromuscular layer and myofibrillar proteins from the ileum seromuscular layer and caecum were also significantly depressed as a result of ethanol treatment.

The effects of thyroidectomy on intestinal protein metabolism in vivo.

Thyroid hormones are known to influence intestinal function [ 1-21, Marked constipation and motility disorders are common features of hypothyroidism which may be due to loss of intestinal contractile proteins. However, there is a paucity of information regarding the mechanisms whereby intestinal contractile protein composition is controlled. In this study we investigated the effects of hypothyroidism on rates of protein synthesis in the whole jejunum and the jejunal seromuscular layer. Male Wistar rats (140-150 g initial body weight) were

MODIFIED TECHNIQUE FOR PANCREATICOJEJUNOSTOMY FOLLOWING PANCREATICODUODENECTOMY

Panceraticoduodenectomy is a complex procedure associated with considerable mortality and morbidity. Pancreaticojejunostomy is the main cause of morbidity, and controversy concerning the best type of reconstruction persists. In this report we describe a modified pancraticojejunostomy technique for Billroth I reconstruction. An Fourend-to-side anastomosis of the pancreatic duct and jejunal mucosal layer was performed. Four patients whose pancreatic duct was less than 2 mm in diameter, the duct and the jejunal mucosal layer were anastomosed with a continuous running suture made of Polyglyconate absorbable material. An anastomosis between the pancreas and the jejunal seromuscular layer, using interrupted suture made of a monofilament material, and fibrin glue attachment was performed without complications. This pancreaticojejunostomy technique is reasonable for patients with soft glands and small ducts following pancreaticoduodenectomy.

CONTRACTILE AND NON-CONTRACTILE PROTEINS AND NUCLEIC ACIDS IN THE STOMACH, WHOLE JEJUNUM ANI SEROMUSCULAR LAYERS OF THE DUODENUM, JEJUNUM: ILEUM AND LARGE INTESTINE IN RESPONSE TO CHRONIC ETHANOL FEEDING

Rats were fed a nutritionally adequate liquid diet containing 35% of the total calories as ethanol (treated), or identical amounts of the same diet in which ethanol was replaced with isocaloric glucose (controls). At 6 weeks, rats were killed and the stomach (cardiac region), duodenum, jejunum, ileum and the large intestine (combined colon and rectum) were dissected. Seromuscular layers were prepared from the duodenum, jejunum, ileum and the large intestine. After 6 weeks of chronic ethanol feeding the wet weights of the stomach and whole jejunum were reduced by 31%. The wet weights of the duodenum, jejunum and distal ileum seromuscular layers were reduced by 19-25%. The wet weight of the large intestine seromuscular layer was unaltered. The total amounts of contractile and non-contractile protein in the small intestinal seromuscular layers were reduced by 16-52%. In jejunal serosa, the RNA contents were reduced by 29%, but total RNA contents in the serosa of the ileum and duodenum were not significantly altered. Total DNA content was reduced in jejunal and ileal serosal layers by 22 and 33%, respectively, but remained unchanged in duodenal serosa. In the stomach, total contractile and non-contractile protein was reduced by 26-52% and similarly total RNA and DNA were also decreased by 47 and 34%, respectively. Chronic ethanol feeding had no apparent effect on either contractile or non-contractile total protein, total RNA or DNA contents in colonic and rectal serosa. In the combined mucosal and seromuscular layers of the jejunum, much greater effects due to ethanol feeding were observed when compared with the jejunal seromuscular layer alone.(ABSTRACT TRUNCATED AT 250 WORDS)