Pancreatic-enteric Anastomosis Research Articles

Pancreatic Anastomosis in Robotic-Assisted Pancreaticoduodenectomy: Different Surgical Techniques

Robot-assisted pancreatoduodenectomy (R-PD) may provide challenges but potential benefits for pancreatic-enteric anastomosis fashioning. Despite numerous trials comparing different pancreatic-enteric anastomosis techniques, an ideal method is still missing. This study aims to describe different management strategies and surgical techniques of standardized pancreatic-enteric anastomoses during an R-PD. This study reported the robotic technical steps of the modified end-to-side Blumgart pancreaticojejunostomy, the Cattel-Warren duct-to-mucosa pancreatojejunostomy, with internal or external pancreatic duct stent, and the modified end-to-side, double-layer pancreogastrostomy. A dual-console da Vinci Xi Surgical System® (Intuitive Surgical Xi, Sunnyvale, CA) was used to perform all the R-PD. Different robotic pancreatic-enteric anastomosis techniques can be used during the reconstruction phase, possibly reproducing the open technique. The type of anastomosis and applied mitigation strategies should balance surgical strategy adaptability and operative technique standardization. R-PD should be performed in high-volume centers by surgeons with extensive experience in pancreatic and advanced MI surgery, enabling different but standardized anastomotic techniques based on patients’ risk factors and intraoperative findings. Future studies on robotic pancreatic anastomosis should focus on personalized approaches after adequate risk stratification.

Anterior pancreatic duct split prior to duct-to-mucosa pancreatico-jejunal anastomosis in pancreaticoduodenectomy.

A secure pancreatic-enteric anastomosis is widely accepted as the ‘Achilles heel’ in reconstruction following a pancreaticoduodenectomy. Most morbidity following the procedure is related to the failure of this anastomosis, resulting in intra-abdominal collections, secondary haemorrhage, delayed gastric emptying, need for radiological interventions and re-operation for some patients. Of several techniques available, the ‘duct-to-mucosa’ technique is widely employed for pancreaticojejunal anastomosis. Among several refinements to facilitate this anastomosis, viz; mobilization of pancreatic stump, magnification with loupes and modifications made on the jejunal side to enable a tension free anastomosis, none seems to address the pancreatic duct in particular. The operative technique of anterior pancreatic duct split described by us enables a wider, well visualized pancreatic duct for a secure duct to mucosa pancreaticojejunal anastomosis.

Alternative Reconstruction After Pylorus Preserving Pancreaticoduodenectomy

Pancreaticogastrostomy has been known as a method of reconstruction after pancreaticoduodenectomy. According to some published reports, the pancreatic fistula rate for pancreaticogastrostomy is significantly lower than pancreaticojejunostomy. The purpose of this study was to present the results of pancreaticogastrostomy after pancreaticoduodenectomy, feasibility of cannulating CBD after reconstruction and ability to control postoperative anastomotic bleed. Pylorus preserving pancreaticoduodenectomies were performed in 40 cases. The reconstruction was done by invaginating the cut end of the remnant pancreas into the posterior wall of stomach (end-to-side pancreaticogastrostomy). The divided jejunum was taken retrocolically and anastomosed with the stomach at the divided pylorus (end-to-end gastrojejunostomy). Hepaticojejunostomy was done about 10 cm from gastrojejunostomy in an end to side manner. Pancreaticogastrostomy was the method of choice for pancreatic-enteric anastomosis. Data was analyzed and presented as mean and SD and chi square test were used with p < 0.05 conferring statistically significance. Out of total 40 patients operated 7 (17.5%) patients developed postop complications. One (2.5%) developed biliary leak, 3 (7.5%) developed intraabdominal collection, upper GI bleed was seen in 1 (2.5%) patient and pancreatic fistula developed in 1(2.5%) patient and 1 (2.5%) developed cardiac complication (bradycardia). CBD cannulation was attempted in all patients but was successful without any major difficulty in 37 (92.5%) patients. One (2.5%) patient required operative intervention for pancreatic fistula and one (2.5%) patient died during the hospital stay.

Simplified Invagination Pancreatojejunostomy During Pancreatoduodenectomy Which can be Safe in the Training of Young Surgeons

Background: Invagination is one of the useful reconstruction method for pancreatic enteric anastomosis during pancreatoduodenectomy (PD), but it is unclear what is the best. On the other hand, a safe and easy procedure is needed for the stable outcomes and the safe training for young surgeon. The aim of this study was to evaluate our simplified invagination pancreaticojejunostomy. Methods: This is a pilot study about a modified technique. Between January 2012 and March 2015, 22 consecutive cases of pancreatoduodenectomy performed with invagination pancreaticojejunostomy were eligible for inclusion. We retrospectively analyzed the operative courses. Results: The median surgical time was 496 minutes (range 232–755). The median blood loss was 600 ml (range 75–4335). The soft pancreas was nine patients (40.9%). Only one patient developed postoperative pancreatic fistula (Grade B) (4.5%). The median follow-up period was 13 months (range 2–29), and there were no cases of occlusion at the anastomotic site. When comparing inexperienced and skilled surgeons, no statistical significance was observed in the clinical and operative parameters. Conclusion: Our invagination PJ can be an easy and simple method which carries a low incidence of POPF, and safe for training of young surgeons.

Surgical experience and the practice of pancreatoduodenectomy

Experienced surgeons demonstrate improved pancreatoduodenectomy outcomes, but little is known about what distinguishes their practice. Furthermore, the concept of experience has been variably interpreted in the surgical literature. We investigated how 4 interpretations of experience influence pancreatoduodenectomy management decisions. A survey assessing pancreatoduodenectomy practice patterns was distributed by 6 surgical societies. Regression analysis identified behaviors associated with 4 forms of experience: years in practice, surpassing the learning curve (≥50 pancreatoduodenectomies), high annual volume (≥25 pancreatoduodenectomy/year), and high career volume (>200 pancreatoduodenectomy). In the study, 861 surgeons responded, representing 6 continents. Senior surgeons were more likely to use pancreatogastrostomy, dunking/invagination, and external stents (all P<.05). Sixty-five percent of respondents surpassed the learning curve, and these surgeons were more likely to use a 2-layer pancreatic enteric anastomosis, stents, and the Fistula Risk Score (all P<.05). High annual volume surgeons were more likely to use the same reconstruction on every case and autologous tissue patches but less likely to use the Roux limb technique and multiple drains (all P<.05). High career volume surgeons mirrored the behaviors of those surpassing the learning curve except for using the Fistula Risk Score. Experience encompasses several components, each of which seems to influence decision making in different ways.

In Brief

Experienced surgeons demonstrate improved pancreatoduodenectomy outcomes, but little is known about what distinguishes their practice. Furthermore, the concept of experience has been variably interpreted in the surgical literature. We investigated how 4 interpretations of experience influence pancreatoduodenectomy management decisions.A survey assessing pancreatoduodenectomy practice patterns was distributed by 6 surgical societies. Regression analysis identified behaviors associated with 4 forms of experience: years in practice, surpassing the learning curve (≥50 pancreatoduodenectomies), high annual volume (≥25 pancreatoduodenectomy/year), and high career volume (>200 pancreatoduodenectomy).In the study, 861 surgeons responded, representing 6 continents. Senior surgeons were more likely to use pancreatogastrostomy, dunking/invagination, and external stents (all P < .05). Sixty-five percent of respondents surpassed the learning curve, and these surgeons were more likely to use a 2-layer pancreatic enteric anastomosis, stents, and the Fistula Risk Score (all P < .05). High annual volume surgeons were more likely to use the same reconstruction on every case and autologous tissue patches but less likely to use the Roux limb technique and multiple drains (all P < .05). High career volume surgeons mirrored the behaviors of those surpassing the learning curve except for using the Fistula Risk Score.Experience encompasses several components, each of which seems to influence decision making in different ways.

Lateral Pancreatogastrostomy for Stenotic Pancreatojejunostomy After Pancreatoduodenectomy: A Case Report

There is a large body of literature that describes the short-term complications (e.g., pancreatic or biliary anastomotic leaks) that occur after PD, but little has been published regarding long-term anastomotic complications. Stenosis of the anastomosis is often asymptomatic but symptomatic and painful presentations are difficult to treat, and the optimal treatment is not currently defined. The aim of this work is to report case of pancreatojejunostomy stenosis. The Pancreatic enteric anastomosis stenosis was diagnosed following presentation with pancreatitis that developed following pancreatoduodenectomy. The patient was treated surgically by fashioning side to side pancreatogastrostomy.

Inmedate Feeding Tolerance in Patients with Mild Acute Biliary Pancreatitis

There is a large body of literature that describes the short-term complications (e.g., pancreatic or biliary anastomotic leaks) that occur after PD, but little has been published regarding long-term anastomotic complications. Stenosis of the anastomosis is often asymptomatic but symptomatic and painful presentations are difficult to treat, and the optimal treatment is not currently defined. The aim of this work is to report case of pancreatojejunostomy stenosis. The Pancreatic enteric anastomosis stenosis was diagnosed following presentation with pancreatitis that developed following pancreatoduodenectomy. The patient was treated surgically by fashioning side to side pancreatogastrostomy.

Chronic fibrous-degenerative pancreatitis with involvement of adjacent organs and their dysfunction: contemporary approaches to surgical treatment.

Presently, there is no single opinion concerning the method preferable for surgical treatment of chronic pancreatitis (CP) with dysfunction of adjacent organs. Surgical treatment was applied to 144 patients with CP. In 54 (37.5%) patients, CP was complicated by dysfunction of adjacent organs. Particularly these were biliary hypertension (BH) in 36 (25%) patients and chronic duodenal obstruction (CDO) in 8 (5.5%) patients. In 5 (3.5%) patients, BH was combined with CDO, and another 5 (3.5%) patients had a combination of BH, CDO and venous hypertension (VH) of the portomesenteric area. In 24 patients with BH, we applied intraoperative monitoring of biliary pressure (IOM BP) in the process of performing duodenum-preserving pancreas resections. Frey's procedure was applied in 26 (48.1%) cases, where CP was complicated by the development of CDO, BH or CDO + BH. To correct BH, Frey's procedure was supplemented by application of hepatico-entero anastomosis (HEA) in 10 patients, pancreas lingual was excised; internal biliopancreatic anastomosis was applied in two patients. Beger's procedure was used in 2 (3.7%) patients, in which CP was complicated by BH + CDO + VH. Pancreaticoduodenal resection (PDR) according to Whipple was used in 5 (9.2%) cases. Longitudinal pancreatic-enteric anastomosis (LPEA) supplemented by HEA due to BH was applied to 8 (14.8%) patients. The results of chronic treatment were traced in 23 (42.5%) patients throughout the period of 6 to 36 months. Life quality indicators appeared to be the best among the patients who underwent resection surgeries on the pancreas. The method selected to treat surgically the patients with CP that involves adjacent organs and causes their dysfunction is duodenum-preserving resection surgeries on pancreas head, which in some cases should be supplemented by application of biliodigestive anastomosis or biliopancreatic diversion in the area of pancreas resection to eliminate the BH.

Comparison of clinical effects of different methods of intestinal anastomosis in patients with pancreatic and duodenal resection

Objective To compare and discuss the clinical application effect of the end-to-end anastomosis of pancreatic and intestinal anastomosis, binding type of pancreatic and intestinal anastomosis, end-to side pancreatic duct anastomosis and modified pancreatic duct jejunum anastomosis. Methods Collected pancreatoduodenectomy in 95 cases, the end-to-end pancreatico duodenal sleeve type anastomosis in 23 cases, binding type pancreatic enteric anastomosis in 18 cases, end to side pancreaticojejunostomy anastomosis in 28 cases, improvement of the pancreatic duct jejunum end to side anastomosis in 26 cases, compared with four groups of patients with pancreatic enteric anastomosis time and postoperative complications. Results Anastomosis time: A group (34.0±4.6) min, B group (31.0±5.8) min, C group (32.0±6.3) min, D group (14.0±4.2) min(P=0.037, P 0.05). Improvement of the pancreatic tube jejunum end to side coincident with a low incidence of pancreatic fistula, but different pancreatic enteric anastomosis way pancreatic fistula rate difference was not statistically significant, improvement of the pancreatic duct and jejunum mucosa end side group pancreatic enteric anastomosis anastomosis time significantly shorter in the three groups, the difference was statistically significant (P<0.05). Conclusion Improvement of pancreatic duct jejunum end to side anastomosis with short operation time, low incidence of pancreatic fistula, and the operation is simple and practical, safe. Key words: Resection of pancreas and duodenum; Intestinal anastomosis; Pancreatic anastomosis time; Clinical curative

A modified pancreaticogastrostomy technique to minimize pancreatic fistulae

Introduction: Despite significant morbidity and mortality associated with pancreatic fistulae, there is no established consensus on the ideal pancreatic-enteric anastomosis following a pancreatoduodenectomy (PD). Objective: To review incidence of pancreatic fistulae, morbidity and mortality associated with a single surgeon's modified pancreaticogastrostomy (PG) technique. Methodology: All PG anastomoses by a single surgeon (KSH) between January2007 and September2015 were identified. The modified PG anastomosis is a tension-free technique between the pancreatic cut surface, duct and posterior gastric wall. To minimize movement and tension at the anastomotic surface, the anterior pancreatic body capsule and posterior gastric wall is fixated with sutures. Two-layers of sutures are then placed between the superior and inferior cut pancreatic parenchymal surface and duct to approximate the gastrostomy via duct-to-gastrostomy and parenchyma-to-gastrostomy sutures. Lastly, the posterior pancreatic surface is gently invaginated into the gastrostomy with further fixating sutures between the parenchyma adjacent to the cut surface and the peri-gastrostomy serosa. Results: 108 modified PG anastomoses were performed following PD, with 59.2% (n = 64) for ductal adenocarcinoma. 60.2% (n = 65) underwent standard PD procedures, whilst 37.9.5% (n = 41) and 1.8% (n = 2) patients required extended and non-continuous organ resection with PD respectively. 31.5% (n = 34) underwent vascular reconstruction. Postoperatively, 1.9% (n = 2) of patients experienced Grade A fistulae, with no Grade B or Grade C fistulae experienced. There was a 14.8% minor and 8.3% major complication rate, and zero 90 day mortality. Conclusion: A low incidence of Grade A pancreatic fistulae was experienced with the modified PG technique. Low morbidity and no mortality was demonstrated.

Application of duct-to-mucosa continuous anastomosis in the pancreaticojejunostomy

Objective: Pancreaticojejunostomy is the most important anastomosis in Whipple operations, it's closely related to the pancreatic fistula. Present a variety of pancreatic enteric anastomosis methods have advantages and disadvantages, this study was to explore a method of pancreaticojejunostomy in pancreaticoduodenectomy. Methods: Clinical data from June 2013 to June 2015 of 165 pancreaticoduodenectomy resection patients were retrospectively analyzed, at the FourthHospital ofHebeiMedicalUniversity,HepatobiliarySurgery.Of the patients, 53 patients with Prolene line continuous duct-to-mucosa, and 112 patients with end-to-side of pancreatic anastomosis were used. Diagnostic criteria referenced the International pancreatic fistula Study Group (ISGPF) defined in 2005. Statistical analysis was performed with the c2 test. A probability value of less than 0.05 was considered statistically significant. Descriptionof operateprocess: Select themainpancreatic ductdiameterover 1.5mm patients. Briefly, upon completion of the PD, the pancreatic remnant was mobilized for 1e2 cm to allow adequate placement of the posterior outer-layer sutures.Find the main pancreatic duct, and suture the bleeding section. The posterior outer-layer anastomosis was performed by using continuous suture technique. Generally, double needle 4-0 prolene sutures were placed starting at the pancreatic remnant andwere continued through the seromuscular layer of the backwall of the jejunum.A 2mmdiameter hole was poked on the jejunum nearing the main pancreatic duct. Double needle 5-0 prolene line continuous suture the whole jejunal wall and the paries posterior of pancreatic duct. Select appropriate diameter internal plastic stent, the end of the stent was positioned within the pancreatic duct. Place the other end of the stent into the jejunum. Then the similar process was performedwith 5-0 prolene line continuous suturing the whole jejunal wall and the antetheca of pancreatic duct. Finally 4-0Prolene continuous suture the seromuscular layer of the jejunum and the anterior wall of pancreas. Results: The incidence of pancreatic fistulas in patients with prolene line continuous suture was 3.8%(2/53), and in those with end-to-side suture it was 15.2% (17/112) (P < 0.05). According to the international clinical grading system, grade A of POPF was found in 2 patients of the prolene line continuous suture group, and were successfully discharged under the conservative treatment. Conclusion: This method of duct-to-mucosa anastomosis with Prolene line continuous suturing is simple and time-saving with obviously reducing incidence of pancreatic fistula. It's continuous anastomosis of main pancreatic duct and the whole jejunum layer, exactly, not easy to occur pancreatic fistula, less affected by the pancreas texture. The Prolene thread and Needle as a whole, lines of smooth, less friction, is suitable for continuous anastomosis. This method of anastomosis is proved to be safe and efficient in preventing pancreatic fistula.

Early hyperlactatemia predicts pancreatic fistula after surgery.

BackgroundPostoperative pancreatic fistula (POPF) is a major complication after pancreatic surgery and results from an impaired healing of the pancreatic enteric anastomosis. Whether perioperative hemodynamic fluid management aiming to provide an adequate tissue perfusion could influence the occurrence of POPF is unknown. Serum lactate level is a well-recognized marker of decreased tissue perfusion and is known to be associated with higher morbidity and mortality in various postoperative settings. We aimed to determine in a retrospective high-volume center’s cohort whether postoperative hyperlactatemia could predict POPF occurrence.MethodWe conducted a retrospective analysis of 96 consecutive patients admitted in the intensive care unit (ICU) after pancreaticoduodenectomy or distal pancreatectomy. Univariate analysis was conducted to compare lactate levels at 6 h between patients evolving with versus without POPF. A logistic regression model was developed and included potential confounding factors.ResultsPOPF occurred in 28 patients (29 %). Serum lactate level 6 h after admission was significantly higher in the POPF group (2.8 mmol/L [95 % confidence interval (CI): 2.1–3.5] versus 1.8 mmol/L [95 % CI: 1.8–2.4], p-value = 0.04) whereas it did not differ at ICU admission or at 12 h. Despite similar cumulative fluid balance, fluid intake and vasopressor use, hyperlactatemia > 2.5 mmol/L (Odds ratio (OR): 3.58; 95 % CI: 1.22–10.48; p-value = 0.020) and red blood cells transfusion (OR: 1.24; 95 % CI: 1.03–1.49; p-value = 0.022) were found to be independent predictive factors of POPF occurrence.ConclusionIn patients undergoing partial pancreatectomy, hyperlactatemia measured 6 h after ICU admission is a predictive factor for the occurrence of POPF. Inflammatory changes after surgery may account for this observation and should be further evaluated.

Pancreaticogastrostomy in pure laparoscopic pancreaticoduodenectomy—A novel pancreatic-gastric anastomosis technique -

BackgroundAlthough many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not commonly performed because of the technical difficulty of pancreatic resection and the associated reconstruction procedures. Several pancreatic-enteric anastomosis techniques for LPD have been reported, but most are adaptations of open procedures. To accomplish pure LPD, we consider it necessary to establish new pancreatic-enteric anastomosis techniques that are specifically developed for LPD and are safe and feasible to perform.ResultsOne patient developed a postoperative pancreatic fistula (International Study Group of Pancreatic Fistula criteria, grade B) and subsequent postoperative delayed gastric emptying (International Study Group of Pancreatic Surgery criteria, grade C). No other major complications occurred. We developed a novel pancreatic-gastric anastomosis technique that enabled us to safely perform pure LPD. The main pancreatic duct was stented with a 4-Fr polyvinyl catheter during pancreatic resection. A small hole was created in the posterior wall of the stomach and was bluntly dilated. A 5-cm incision was made in the anterior stomach, and the pancreatic drainage tube was passed into the stomach through the hole in the posterior wall. The remnant pancreas was pulled into the stomach, and was easily positioned and secured in place with only four to six sutures between the pancreatic capsule and the gastric mucosa. We used this technique to perform pure LPD in five patients between December 2012 and July 2013.ConclusionsOur new technique is technically easy and provides secure fixation between the gastric wall and the pancreas. This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized. Although this technique requires further investigation as it may increase the risk of delayed gastric emptying, it may be a useful method of performing pancreaticogastrostomy in pure LPD.Trial registrationISRCTN16761283. Registered 16 January 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s12893-015-0061-x) contains supplementary material, which is available to authorized users.

Pancreaticojejunostomy with double-layer continuous suturing is associated with a lower risk of pancreatic fistula after pancreaticoduodenectomy: A comparative study

Background: Postoperative pancreatic fistula (POPF) remains a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). Thus, a number of technical modifications regarding the pancreatoenteric anastomosis after PD have been proposed to reduce POPF rate. In this article we focused on evaluating whether the double layer continuous suture technique was better than the double layer interrupted suture technique in pancreatic–enteric anastomosis after PD. Material and methods: From 2012 to 2013, 114 patients (67 men and 47 women) underwent a pancreatic–enteric anastomosis after PD were analysed. There were 79 patients using the double layer continuous suture technique and 35 patients were using the double layer interrupted suture technique. The operation time, intraoperative blood loss, initial postoperative day of oral feeding, postoperative hospital stay and the presence of main early complications (pancreatic fistulas) were evaluated by chi-square test or unpaired t-test in this study. Results: Pancreatic fistulas occurred in patients with double layer continuous suture was 17.14%(6/35), and in those with interrupted suture was 39.24%(31/79) (p < 0.05). Grade A of POPF was found in 4 patients (4/35, 11.43%) of the double layer continuous suture group and in 5 patients (5/79, 6.33%) of the double layer interrupted suture group. Grade B of POPF was identified only in 1 patients (1/35, 2.83%) of the double layer continuous suture group and in 23 patients (23/79, 29.11%) of the double layer interrupted suture group. The presence of Grade C pancreatic fistulas was only documented in one patient in the double layer continuous suture group and 3 patients in the interrupted suture group. No operative or in-hospital deaths occurred. Conclusions: The double-layer continuous suturing after PD is safe, reliable, rapid, favorable and associated with a lower risk of pancreatic fistula than the double layer interrupted suture.

Reconstruction of pancreatic enteric anastomosis after pancreaticoduodenectomy

Pancreatic enteric anastomosis is an important step during pancreaticoduodenectomy. Based on the anastomosis site, pancreatic enteric anastomosis is classified as pancreaticojejunostomy anastomosis and pancreaticogastrostomy. Depending on the jejunum site, reconstruction can be perform as end-to-end or end-to-side anastomosis. Previous randomized clinical trials, showed no significant differences between pancreaticojejunostomy and pancreaticogastrostomy. Binding pancreaticojejunostomy and binding pancreaticogastrostomy are easy to perform. The rate of pancreatic leakage is related to the texture of the pancreas and the size of the pancreatic duct. It is helpful to reduce pancreatic leakage by placing a pancreatic duct stent. The simple and effective pancreatic enteric reconstruction is the future direction for minimizing leakage.

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.

Performing simple and safe dunking pancreaticojejunostomy using mattress sutures in pure laparoscopic pancreaticoduodenectomy

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic pancreatic resection, laparoscopic pancreaticoduodenectomy still presents major technical difficulties, such as when performing pancreatic-enteric anastomosis. Laparoscopic dunking pancreaticojejunostomy using mattress sutures was performed in 15 consecutive patients with a soft pancreas and a nondilated pancreatic duct between October 2011 and December 2012. According to the International Study Group on Pancreatic Fistula criteria, 3 patients developed PF (grade A), whereas the remaining 12 patients did not. Dunking pancreaticojejunostomy using mattress sutures is considered to be a feasible and safe method for performing pure laparoscopic pancreaticoduodenectomy.

A New Technique of Mesh-Reinforced Pancreaticogastrostomy: Report of 13 Initial Cases

Pancreatic anastomotic leakage is a common problem after pancreaticoduodenectomy and is a leading cause of postoperative morbidity and mortality. It is important to establish a safe and simple technique of pancreatic-enteric anastomosis to minimize pancreatic leakage. From July 2009 to February 2012, a new method of mesh-reinforced pancreaticogastrostomy was performed in 13 patients after completion of the pancreaticoduodenal resection. Patient demographic data, pathology of lesions, operative parameters, and postoperative outcomes were analyzed. The mean operative time was 6.9 hours (range, 5-11 hours), and the mean time for pancreaticogastrostomy was 25 minutes (range, 22-35 minutes). Intraoperative tests showed all pancreatic anastomoses were watertight. There was no postoperative death. No patient developed clinically significant pancreatic leakage (grade B or C) after operation; 1 patient (7.7%) was recognized to have a grade A pancreatic leakage. No significant complication (hemorrhage, intra-abdominal abscess, or cholangitis) was observed. The mean postoperative hospital stay was 20 days (range, 11-30 days). After discharge, all patients recovered well in the 4-week follow-up period without emergency room visit or re-admission. The mesh-reinforced pancreaticogastrostomy provides a new way to perform pancreatic-enteric drainage after pancreaticoduodenectomy and has the advantages of simplicity, ease of handling, and applicability to all types of pancreatic remnants.

Dunking pancreaticojejunostomy versus duct‐to‐mucosa anastomosis

Following the resectional aspect of pancreaticoduodenectomy, three anastomoses are used to reestablish gastrointestinal continuity. The pancreatic-enteric anastomosis is by far the most problematic, and has been considered by many the Achilles heel of the pancreaticoduodenal resection. Multiple clinical trials have been published focusing on improving outcomes of the pancreatic-enteric anastomosis, including elements such as the use of prophylactic octreotide, the use of sealants, stenting of the pancreatic duct, and surgical technique. There are two widely used methods to accomplish an end-to-side pancreaticojejunostomy (PJ) after pancreaticoduodenectomy: either invagination PJ or duct-to-mucosa PJ. Two prospective randomized trials have evaluated these techniques, the first a trial by Bassi and co-authors, and the second a trial by Berger et al. In this article we will focus on our current technique for both invagination pancreaticojejunostomy and duct-to-mucosa pancreaticojejunostomy, recognizing that careful surgical technique, surgeon experience, and surgical volume are factors that are important in yielding the best outcomes.