Pancreaticojejunostomy Research Articles

Comparisons of short-term outcomes of anastomotic methods of duct-to-mucosa pancreaticojejunostomy: out-layer continuous suture versus modified Blumgart method.

Postoperative pancreatic fistula (POPF) is the most troublesome complication after pancreaticojejunostomy (PJ). This study aimed to compare the short-term outcomes of 2 different methods of duct-to-mucosa PJ; out-layer continuous suture anastomosis (OCA) and the modified Blumgart method (mBM). This retrospective cohort study enrolled patients who underwent curative-intent, open PD between 2015 and 2020. In mBM, 2 transpancreatic U-sutures were performed between the pancreatic margin and jejunum, with reinforced sutures in the central region. Patient demographics, diagnosis, intraoperative factors, postoperative complications, and POPF defined by the International Study Group on Pancreatic Fistula were investigated. Clinically relevant POPF (CR-POPF) included grades B and C POPF. A total of 184 patients underwent OCA, and 96 patients underwent mBM. The mBM group had more patients who underwent neoadjuvant therapy. The fistula risk scores were comparable between the 2 groups. Both groups showed no significant differences in CR-POPF and overall surgical complication rates. The total operation time was comparable, although the operation time for PJ was shorter in mBM. No significant differences were observed in the postoperative outcomes between each group; the operation time for PJ in mBM was shorter. Therefore, mBM may be considered for utilization in duct-to-mucosa PJ.

Pancreaticogastrostomy (PG) Is Associated with a Higher Incidence of Grade C Postpancreatectomy Hemorrhage (PPH) Compared to Pancreaticojejunostomy (PJ): A Single-Center Prospective Cohort Study in 274 Patients

Introduction: PPH and postoperative pancreatic fistula (POPF) are the most life-threatening complications after pancreaticoduodenectomy (PD). The aim of this study is to compare the incidence of both between two reconstruction techniques: PG and PJ.

Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy.

PurposeThis study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).MethodsThis single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy.ResultsA total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months.ConclusionConversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.

Outcomes of Patients in Duct to Mucosa Pancreatico-Jejunostomy with Duct Size of 2mm or Less Following Pancreaticoduodenectomy

Background: Little is known about the outcomes of duct to mucosa(D-M) pancreaticojejunostomy(PJ) following pancreatico-duodenectomy(PD) in patients with a small main pancreatic duct(MPD). We evaluated the outcomes of patients undergoing D-M PJ in ≤2mm MPD following PD.

The development and clinical efficacy of simulation training of open duct-to-mucosa pancreaticojejunostomy using pancreas and intestine silicone models.

PurposeAs pancreaticojejunostomy (PJ) is a challenging anastomosis, an education program is needed to train young surgeons to perform PJ. This study evaluated the effects of simulation-based training of open PJ using pancreas and intestine silicone models.MethodsFive videos pancreatobiliary clinical fellows who did not perform PJ participated in this study. After watching the master video created by a senior pancreatobiliary surgeon, each trainee performed the PJ using silicone models and recorded them 10 times using a video camera. Of these videos, 5 were randomly duplicated due to the validation of the scoring system. The scoring system developed consisted of 20 scores. Three pancreatobiliary professors scored their performance by watching videos.ResultsThe mean procedure time of the 5 trainees was 25.4 minutes (range, 23.5–27.3 minutes) in the first video and 15.8 minutes (range, 13.8–19.1 minutes) in the 10th video. The mean score was 12.6 (range, 5–19) and 18.3 (range, 15–20) in the first and 10th videos, respectively. The scores were similar among the duplicated videos for each supervisor.ConclusionThis education system would help pancreatobiliary trainees to overcome learning curves efficiently without ethical issues related to animal models or direct practice to human patients.

Salvage Surgery after a Grade C Pancreatico-Jejunostomy Leak; Sparing the Remnant Pancreas

Introduction: Grade C pancreatic fistula is a feared complication after a pancreaticoduodenectomy, and carries a distinct risk of mortality in patients. Traditionally, this problem has been managed with completion pancreatectomy, or pancreas-preserving techniques that involve an external drainage procedure of the remnant pancreas followed by re-approximation of the pancreatico-jejunostomy (PJ) after an interval period, requiring two separate procedures. Our pancreas-preserving approach involves re-approximation of the PJ anastomosis over an externalized PJ stent through the biliary-pancreatic limb at re-exploration. Method:1.A silastic tube is brought into the abdomen via a stab incision in the abdominal wall approximately 2 fingerbreadths below the costal margin.2.The tube is introduced into the pancreatico-biliary limb through the jejunum and brought out through the disrupted PJ anastomosis. A glide wire may be needed to accomplish this step.3.The tube is threaded into the pancreatic duct and secured with PDS.4.The pancreatic parenchyma can then be re-approximated with the jejunum with the drain in place. Additional drains are placed around the anastomosis.5.The silastic tube is then secured with a purse string suture at the jejunal exit site and to the inner abdominal wall. The drain is placed on gravity drainage. Results: Two patients were treated using this technique. Both these patients required only one re-operative intervention. Median length of hospital stay was 22.5 days without readmission. Both patients have had complete resolution of the leak. Conclusion: Our technique has been effective in pancreas preservation and limits the number of operative interventions.

Modified Blumgart Pancretojejunostomy, a Simple Applicable and Safe Technique in Totally Laparoscopic Pancreaticoduodenectomy

Whipple is one of the most complicated surgery that we indicate for patient with periempullary tumor. The pancreato-enterostomy anastomosis is the most challenging technique in this surgery because of post operative pancreatic fistular still often happening and may leading to patient death. Nowadays, laparoscopic surgery has been developing significantly across almost all surgical specialties, bringing much benefits for patients with minimally invasive treatment. So we have to figure out the technique which is simple, feasible with less complications to perform pancreato-jejunostomy laparoscopically. Recently, Blumgart technique which include two-layer pancreaticojejunostomy characterized by transpancreatic sutures that invaginate the pancreatic into the jejunum and duct-to-mucosa anastomosis may be feasible with low pancreatic leakage. In this topic, we present to you how we perform laparoscopic pancreatico jejunostomy by modified Blumgart technique. It’s just a small modified point differ from conventional techniqe by the way we make U suture. We usually perform two to three full thickness transpancretic to jejunum sutures and the knot were place on jejunum wall to avoid pancreas parenchymal laceration when the suture were tightened. We present our surgical technique in detail by video. With innitial experience in laparoscopic modified Blumgart technique, we feel it’s simple and applicable in performing pancreto jejunostomy with potential lower pancreatic leakage. We need standadizing the technique, evaluating the results with higher volume and comparing with open surgery.

Two Case Reports of Symptomatic Pancreaticojejunal Anastomotic Stricture after Pancreaticoduodenectomy Managed by Longitudinal Pancreaticogastrostomy

Introduction: The management of symptomatic pancreaticojejunal anastomotic stricture has not been well established. Revision of pancreaticojejunostomy anastomosis, endoscopic dilation and stenting, modified Puestow procedure have all been described with variable outcomes. We present a case report of 2 patients of symptomatic pancreaticojejunal anastomotic stricture who were managed by longitudinal pancreaticogastrostomy without any complications and symptom resolution. Method: This is a case report of two patients who underwent pancreaticoduodenectomy, one for pancreatic ductal adenocarcinoma and the other for periampullary tubullovillous adenoma, and developed symptomatic pancreaticojejunal stricture after 21 months and 48 months respectively from the index operation. One patient developed recurrent pancreatitis with progressive dilation of main pancreatic duct distal to the pancreaticojejunostomy identified on CT. The other patient had worsening abdominal pain with progressive dilation of pancreatic duct and formation of pancreaticolith just distal to the pancreaticojejunostomy anastomosis. Both patients were managed with longitudinal pancreaticogastrostomy. The post op course was uneventful and patients developed resolution of symptoms. Results: The two patients who underwent longitudinal pancreaticogastrostomy have remained symptom free since their last surgery with a follow up period of 44 and 46 months respectively. Conclusions: Longitudinal pancreaticogastrostomy, as a management strategy for symptomatic pancreaticojejunal anastomotic stricture, provides a theoretical advantage in terms of favorable anatomy and less adhesions. Moreover, a pancreaticogastric anastomosis is accessible via endoscopy for any intervention that may be needed in the long run. We need more case reports/series and long term outcome data after pancreaticogastrostomy to make definitive conclusions.

Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers

Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO.Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months.Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive.Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.

Invaginated duct to mucosa pancreaticojejunostomy reduce postoperative pancreatic leakage: A matched case-controlled study.

Postoperative pancreatic leakage is an obstacle in pancreaticoduodenectomy, which always follows pancreaticojejunostomy (PJ) failure. Dozens of PJ procedures have been reported, and none have shown superiority over others. Therefore, the present study is conducted to assess the potential advantages of invaginated duct-to-mucosa (D-M) PJ.We retrospectively analyze the related data from patients who underwent pancreaticodedunostomy due to malignant tumors at the First Affiliated Hospital of Henan University of Science and Technology from January 2017 to August 2019. According to the different PJ procedures, the patients are divided into custom D-M group and invaginated D-M group. Matching by sex, age, pancreatic duct size, and pancreatic texture is performed. Pancreatic leakage and other complications are compared, and SPSS 16.0 is employed for analysis.A total of 48 pairs of patients are included. Patients in both groups has almost the same baseline characteristics in terms of sex (P = 1.000), age (P = .897), American Society of Anesthesiologists status (P = .575), body mass index (P = .873), pancreatic duct size (P = .932), pancreatic texture (P = 1.000) and tumor origin (P = .686). No significant difference is observed in operative outcomes, such as operative duration (P = .632), PJ duration (P = .748), blood loss (P = .617) and number of required transfusions (P = .523). Pancreatic leakage is significantly decreased in the invaginated D-M group (P = .005). The differences in other complications, such as bleeding (P = .617), biliary leakage (P = .646), pneumonia (P = .594) and thrombosis (P = .714), do not reach statistical significance. The postoperative hospitalization duration is almost the same for both groups (P = .764).Invaginated D-M PJ may reduce pancreatic leakage following pancreaticoduodenectomy.

Double purse-string telescoped pancreaticogastrostomy is not superior in preventing pancreatic fistula development in high-risk anastomosis: a 6-year single-center case-control study.

The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ). From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF. The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P < 0.001), even after a matching process on ua-FRS. In the multivariate analysis, the type of anastomosis (P = 0.88), body mass index (P = 0.47), or main pancreatic duct diameter (P = 0.7) did not influence CR-POPF occurrence. For patients with high-risk anastomosis, the double purse-string telescoped PG technique was not superior to the PJ technique for preventing CR-POPF.

Comparison of Two Pancreatic Anastomosis Techniques in terms of Postoperative Complications After Pancreaticoduodenectomy.

In this retrospective study, we compared the postoperative complications by using both the Clavien-Dindo classification and the Revised 2016 International Study Group on Pancreatic Surgery (ISGPS) classification methods after pancreaticoduodenectomy. The data of patients were retrospectively reviewed. Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) were performed on 41 and 40 patients, respectively. The patients were assigned into two groups for anastomosis types and compared with each other according to postoperative complications. The postoperative follow-up period of the patients was limited to 90 days. No significant difference was detected between the two groups in terms of gender (P = .581) and age (P = .809). According to the Clavien-Dindo classification system, grade 1 complication rates were 29.3% and 35.0% in PJ and PG groups, respectively. Also, grade 2 complication rates were 34.1% and 32.5% in PJ and PG groups, respectively. Besides, grade 3B complication rates were 9.8% and 17.5% in PJ and PG groups, respectively. No grade 3A, grade 4A, and grade 4B complications were detected in both groups. But, grade 5 complications rates were 2.4% and 5.0% in PJ and PG groups, respectively. Based on the ISGPS classification system, the pancreatic fistulas were classified. The biochemical leak rates were calculated as 26.8% and 37.5% in PJ and PG groups, respectively. The rates were 14.6% and 10% in PJ and PG groups, respectively, for grade B complications. Also, grade C complication rates were 9.75% and 12.5% in PJ and PG groups, respectively. No statistically significant differences were detected between the two groups for postoperative complications. The evidence from this retrospective study suggests that there is no difference between the two types of pancreatic anastomosis techniques (PJ or PG) in terms of the rate of postoperative complications.

A novel anastomosis technique facilitates pancreaticojejunostomy in total laparoscopic pancreaticoduodenectomy (with video).

While the best technique for pancreatic anastomosis during Whipple's procedure remains controversial, laparoscopic pancreaticoduodenectomy (LPD) has been rapidly increasing in popularity. Because of their feasibility and reliability, new pancreatic anastomosis techniques may have vital roles when adapted for LPD. Here, we describe a new pancreaticojejunostomy (PJ) technique using three sutures (termed the "three sutures" PJ technique), which facilitates pancreatic anastomosis during total LPD. A total of 149 patients who underwent LPD using the "three sutures" PJ technique at three hospitals were included in this study (81 patients at Guangdong Provincial People's Hospital [GDPH], 60 patients at Sun Yat-Sen Memorial Hospital [SMH], and 8 patients at Affiliated Hospital of Guangdong Medical University [AHGMU]). Data on the demographic characteristics, operative outcomes, and postoperative results (pancreatic fistula rate, mortality rate, and length of hospital stay) of these patients were collected and analyzed. A surgical video showing the details of the "three sutures" PJ method was included. The mean operation times at GDPH, SMH, and AHGMU were 4.08 ± 0.99h, 4.65 ± 1.53h, and 4.67 ± 0.64h, respectively, and the average PJ times were 17.96 ± 3.49min, 18.19 ± 2.63min, and 22.5 ± 3.96min, respectively. The numbers of grade B pancreatic fistulas were 9 (11.11%), 2 (3.33%), and 1 (12.50%), respectively, and two patients had grade C fistulas, one each at GDPH and SMH. The numbers of clinically relevant postoperative pancreatic fistula (CR-POPF) were 10 (12.35%), 3 (5.00%), and 1 (12.50%) in each center, respectively. The overall rate of CR-POPF was 9.40% (14/149) among patients of all three centers. The perioperative mortality rate was 0%. The "three sutures" PJ technique for total LPD is a safe and reliable method, with a low risk of pancreatic fistula, short anastomosis time, and steep learning curve.

To compare the outcomes of pancreaticojejunostomy and pancreaticogastrostomy reconstruction after pancreaticoduodenectomy: A prospective observational study

BackgroundWe have been in constant search of novel innovations to decrease the high morbidity after Pancreaticoduodenectomy (PD). Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the two different methods of reconstruction after PD. However, the existing data is ambiguous in supporting either of them as the preferred technique of reconstruction. MethodsThis was a single-center prospective observational study that included 64 patients who underwent PD over two years. We compared PG with PJ as a method of reconstruction after PD. The primary objective was to assess whether PG decreases the rate of postoperative pancreatic fistula (POPF) rates or not. Secondary objectives comprised analysis of perioperative outcomes, 30-day and 90-day mortality. ResultsPancreatic fistula was significantly lower in PG as compared to the PJ group (24% vs. 47%) with a p-value of 0.027. The incidence of clinically pertinent (grade B) fistula was only 3% in the PG group and 32% in the PJ group. PG group had a higher incidence of post pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE). No statistically significant difference was seen between either group need for blood transfusion, re-exploration, re-admissions, ICU stay, or length of hospital stay, and 30-day and 90-day mortality. Pancreatic texture and high BMI were independent predictors for pancreatic fistula. ConclusionPG when compared to PJ for reconstruction after PD, decreases the rate of POPF significantly; however, it is associated with an elevated risk of DGE and PPH. There was no difference in 30-day and 90-day mortality between both the treatment groups.

Comparisons of short-term outcomes of anastomotic methods of duct-to-mucosa pancreaticojejunostomy: Out-layer continuous suture vs. modified Blumgart method

Postoperative pancreatic fistula (POPF) is the most common and troublesome complication after pancreaticoduodenectomy (PD). To reduce POPF, various types of pancreaticojejunostomy (PJ) anastomosis have been introduced. The study aimed to compare the short-term outcomes of two different anastomotic methods of duct-to-mucosa PJ, out-layer continuous suture anastomosis (OCA) and modified Blumgart method (mBM). In this retrospective cohort study, patients who underwent curative-intent open PD between 2015 and 2020 were enrolled. In in-layer anastomosis, duct-to-mucosa anastomosis using 5-6 interrupted sutures were performed. In mBM, two transpancreatic U-sutures was done in both dorsal and ventral side of jejunal loop with reinforced suture in the central part. Patient's demographics, diagnosis and intraoperative factors, postoperative complications, and POPF defined by the International Study Group on Pancreatic Fistula were investigated. Clinically-relevant POPF (CR-POPF) included grade B, C POPF. OCA was performed in 184 patients (65.7%) and mBM was performed in 96 patients (34.3%). There were no significant differences between the OCA and mBM group in CR-POPF rates (7.1% vs. 7.3%; p = 0.944), and overall surgical complication rates (21.7% vs. 30.2%; p = 0.097). Total operation time (242 vs. 233 minutes; p = 0.103) were comparable, but operation time for PJ is shorter in mBM (20.0 vs. 18.1 minutes; p < 0.001). No significant differences were shown in postoperative outcome between OCA and mBM groups, but operation time for PJ in mBM was shorter. Since mBM is safe, relatively simple, and time-saving technique, it can be a good choice when duct-to-mucosa PJ is performed.

Techniques to improve the limited degree of freedom inherent from laparoscopic surgery during laparoscopic duct-to-mucosa pancreaticojejunostomy

Although an increasing number of reports have shown favorable outcomes of laparoscopic pancreaticoduodenectomy (LPD), the penetration rate of LPD is still low due to concerns about complex procedure. Particularly laparoscopic pancreatojejunostomy (PJ) is a highly technical demanding procedure due to reduced degree of freedom inherent to laparoscopic instruments. Here we describe our technique for overcoming technical difficulties of laparoscopic PJ. Six trocars are placed: four trocars on both sides of the upper abdomen in a curvilinear shape with the infra-umbilical trocar in the center and one 12-mm trocar in the epigastrium. The operator stands between both legs of the patient and the laparoscopic camera is introduced through the right lower trocar. We perform a two-layer, duct-to-mucosa PJ in an end-to-side fashion. For the outer layer anastomosis between the pancreas parenchyma and jejunum, the left lower trocar which is in alignment with the pancreatic transection line is used for the needle to be placed perpendicular to the anastomosis line. For the duct-to-mucosa anastomosis, three trocars (left lower, left upper, umbilical) is alternatively used to make various angles of suture. This technique increses the degree of freedom of the straight laparoscopic needle holder when only one trocar is used for duct-to-mucosa anastomosis. The trocar position perpendicular to the anastomosis line and alternatve use of multiple trocars is useful to encompass the 360-degree anastomosis for laparoscopic duct-to-mucosa PJ.

Impact of additional duodenojejunosotmy- site colonopexy on reduction delayed gastric emptying following pylorus-preserving pancreaticoduodenectomy: A prospective, randomized controlled study

Delayed gastric emptying (DGE) is a major complication after pylorus-preserving pancreaticoduodenectomy (PPPD). Although various hypotheses have been addressed as a cause of DGE following PPPD, the exact mechanism is still unknown. Gastric outlet angle resulted from retraction of duodenojejunostomy (DJ) site toward pancreaticojejunostomy (PJ) site during wound healing process of PJ can lead to mechanical disturbance of ingested food passage. Therefore, additional DJ-colon pexy procedure may reduce the incidence of DGE following PD. From February 2016 to March 2019, 78 patients were recruited for this randomized controlled trial. The incidence of DGE was analyzed according to whether or not DJ-colon pexy was used after PPPD. PPPD without DJ-colon pexy (No DJ-pexy group) was performed in 39 patients, and 39 patients underwent PPPD with DJ-colon pexy (DJ-pexy group). A comparative analysis between the two groups showed no differences in age, sex, diagnosis, operation time, hospital stay, or postoperative complications, including pancreatic fistula (p > 0.05). Overall, DGE developed in seven patients (17.9%) in the No DJ-pexy group and in 10 patients (25.6%) in the DJ-pexy group (p = 0.411). The clinically relevant DGE (grades B and C) was also similar between two groups (12.8% vs. 17.9%, p = 0.530). The day that patients could eat more than half of the solid oral intake amount was marginally earlier in the Braun group (8.7 vs. 12.4 days, p = 0.054). The incidence and severity of DGE did not differ between DJ-pexy and No DJ-pexy group after PPPD.

Clinical application of "Double R" anastomosis technique in laparoscopic pancreaticoduodenectomy procedure.

Laparoscopic pancreaticoduodenectomy (LPD) is widely used as a treatment for periampullary tumors and pancreatic head tumors. However, postoperative pancreatic fistula (POPF), which significantly affects mortality and length of hospital stay of patients, remains one of the most common and serious complications following LPD. Though numerous technical modifications for pancreaticojejunostomy (PJ) have been proposed, POPF is still the “Achilles heel” of LPD.To reduce POPF rate and other postoperative complications following LPD by exploring the best approach to manage with the pancreatic remnant, a novel duct-to-mucosa anastomosis technique named Double Layer Running Suture (Double R) for the PJ was established. During 2018 and 2020, a totally 35 patients who underwent LPD with Double R were included, data on the total operative time, PJ duration, estimated blood loss, recovery of bowel function, postoperative complications, and length of hospital stay were collected and analyzed.The average duration of surgery was (380 ± 69) minutes. The mean time for performing PJ was (34 ± 5) minutes. The average estimated blood loss was (180 ± 155) mL. The overall POPF rate was 8.6% (3/35), including 8.6% (3/35) for the biochemical leak, 0% (0/35) for Grade B, and 0% (0/35) for Grade C. No patient suffered from biliary fistula, post-pancreatectomy hemorrhage, and intra-abdominal infection, the 30-day mortality was 0%.Double R anastomosis is potentially a safe, reliable, and rapid anastomosis with a low rate of POPF and post-pancreatectomy hemorrhage. It provides surgeons more options when performing LPD. However, its safety and effectiveness should be verified further by a larger prospective multicenter study.

Rate of Post-Operative Pancreatic Fistula after Robotic-Assisted Pancreaticoduodenectomy with Pancreato-Jejunostomy versus Pancreato-Gastrostomy: A Retrospective Case Matched Comparative Study.

Background: Different techniques of pancreatic anastomosis have been described, with inconclusive results in terms of pancreatic fistula reduction. Studies comparing robotic pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are scarcely reported. Methods: The present study analyzes the outcomes of two case-matched groups of patients who underwent PG (n = 20) or PJ (n = 40) after pancreaticoduodenectomy. The primary aim was to compare the rate of post-operative pancreatic fistula. Results: Operative time (375 vs. 315 min, p = 0.34), estimated blood loss (270 vs. 295 mL, p = 0.44), and rate of clinically relevant post-operative pancreatic fistula (12.5% vs. 10%, p = 0.82) were similar between the two groups. PJ was associated with a higher rate of intra-abdominal collections (7.5% vs. 0%, p = 0.002), but lower post-pancreatectomy hemorrhage (2.5% vs. 10%, p = 0.003). PG was associated with a lower rate of post-operative pancreatic fistula (POPF) (33.3% vs. 50%, p = 0.003) in the high-risk group of patients. Conclusions: The outcomes of post-operative pancreatic fistula are comparable between the two reconstruction techniques. PG may have a lower incidence of POPF in patients with high-risk of pancreatic fistula.

Wrapping double-mattress anastomosis for pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy can significantly reduce postoperative pancreatic fistula rate compared with conventional pancreaticojejunostomy in open surgery: An analysis of a propensity score-matched sample

BackgroundMinimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD. MethodsThe current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group. ResultsThe patients’ preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004). ConclusionThe novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.