Pancreatojejunostomy Technique Research Articles

Strategy and technique of pancreatojejunostomy in minimally invasive pancreaticoduodenectomy: clinical practice review

: With the spread of minimally invasive surgeries such as laparoscopic or robotic surgeries, they are increasingly being used for pancreaticoduodenectomy (PD) as well, however pancreaticojejunum (PJ) anastomosis is quite challenging to perform in a minimally invasive surgery. We need to know more about methods in minimally invasive surgery PJ anastomosis. In this clinical practice review article, we present several papers about the technical aspects of PJ anastomosis in on laparoscopic and robotic PD, including a comparison of their surgical results, as well as initial results from our institution. There were more papers on laparoscopic PJ anastomosis than robotic PJ anastomosis. Some reports have shown that robotic surgery has a better outcome, and our institution’s results showed that robotic surgery significantly outperformed in terms of blood loss and length of hospital stay. This article summarizes the technical methods and comparative results of Laparoscopic and robotic PD, especially in PJ anastomosis. The results of the PJ anastomosis in robotic pancreaticoduodenectomy (RPD) were seemed not inferior to those of the laparoscopic pancreaticoduodenectomy (LPD) in the past literature at least with respect to safety, and were superior than that of LPD in the results of our department. However, randomised controlled trial (RCT) is needed to clarify the true comparison between the results of LPD and RPD.

Clinical application of a modified pancreatojejunostomy technique for laparoscopic pancreaticoduodenectomy

BackgroundThe aim of this study was to present a modified pancreatojejunostomy technique for laparoscopic pancreaticoduodenectomy (LPD) and to evaluate its safety and reliability. MethodsClinical data from 67 patients who underwent LPD at a single center, from September 2016 to December 2017 were retrospectively collected and analysed. Of these patients, 31 cases were subjected to modified pancreatojejunostomy (modified group), and 36 cases received duct-to-mucosa pancreatojejunostomy (control group) for LPD. We compared and analysed the operative outcomes and postoperative complications between the patients in the two groups. ResultsAll LPDs were successfully completed. The mean operation time for pancreatojejunostomy in the modified group was obviously lower than that of the control group (30.9 ± 6.6 min vs 45.3 ± 6.1 min, P < 0.01), and the total operative time was also shorter (321.8 ± 63.6 min vs 362.2 ± 59.6 min, P < 0.05) in the modified group. The overall incidence of postoperative complications was similar (29.0% vs 30.6% P = 0.724). Clinically relevant grade B/C POPF occurred in 2 patients (6.5%) in the modified group and 3 patients (8.3%) in the control group (P = 0.947); All cases were cured using conservative treatment. ConclusionsOur modified pancreatojejunostomy technique is safe, effective and easy to manipulate and learn following LPD.

Combined Duct-to-Mucosa and Dunking Pancreatojejunostomy Technique

Summary: This video demonstrates a Duct-to-Mucosa combined with Dunking pancreatojejunostomy technique. We open the jejunum on the antimesenteric side approximately in similar size to pancreatic duct. Then we start to approximate the pancreas to the jejunum by stitching the posterior side of the duct to the posterior side of the intestine hole in all-layer manner. Afterwards, we stitched the pancreas parenchyma to the seromuscular layer of jejunum. Often, due to a very small-size duct, we found difficulties in doing the same technique on the anterior side. That is why we try different technique on the anterior side, Dunking technique. This combined technique ease surgeons to perform pancreaticojejunostomy especially on firm and stiff pancreas.

WITHDRAWN: A personal technical experience and results of a modified end-to-side technique of pancreatojejunostomy: A 350 patients retrospective cohort study

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Modified heidelberg technique for pancreatic anastomosis

Background: Pancreatic fistula is a major cause of morbidity and mortality after pancreatoduodenectomy. To prevent this complication, many technical procedures have been described. In this study, we present a novel technique based on slight modifications of the original Shrikhande technique. Methods: We introduce a modified pancreatojejunostomy technique for reconstruction of pancreatic stump after pancreatoduodenectomy in several steps (Transection of the pancreas, mobilization of the pancreatic remnant ,posterior duct-pancreatic suture, anterior duct- pancreatic suture, posterior outer layer, posterior inner layer, stent into the pancreatic duct, anterior inner layer, anterior outer layer, stay suture with the jejunum) and present initial results of 17 patients with no grade B and C pancreatic fistula. Results: In the period from July 2016 to June 2017, a total of 17 patients underwent pancreatoduodenectomy with this technique. There were 13 women patients (76.5%), and the median patient age was 54.1 years (range, 20–76 years). Ductal adenocarcinoma was observed in nine patients (52.9%); soft texture of the pancreas was present in six patients (35.2%); and duct size larger than 3 mm was found in nine patients (52.9%). Increased amylase in abdominal drainage (biochemical leak) was identified in four patients (23.5%), and resolved spontaneously within a week. Grade B or C fistula was not observed. No mortality occurred in this series. Conclusion: Our modification of the original technique described by Shrikhande et al. seems to be safe for soft or hard pancreas and any size of pancreatic duct. Early results of this technique confirm that it is simple, reliable, easy to perform, and easy to learn. These findings support this technique as useful to reduce the incidence of pancreatic fistula after pancreatoduodenectomy.

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.

32 Consecutive Cases of Whipple's Operation with Single-Layer End to Side Dunking Pancreatojejunostomy Without Any Pancreatic Fistula: Our Institutional Experience.

The aim of this paper is to study the outcome of single-layer end to side dunking pancreatojejunostomy technique in 32 patients of malignant pancreatic disease undergoing Whipple's surgery in a tertiary care oncology centre in India. From January 2013 to January 2016, 32 consecutive patients who underwent pancreatoduodenectomy for malignant diseases were analysed retrospectively. All the patients underwent standard Whipple's operation. Pancreatojejunostomy was established in a single-layer end to side dunking manner with PDS 4-0. Various patient data, i.e. preoperative symptoms and demography, intra-operative time, blood loss and need of blood transfusion, postoperative hospital stay and complications, were noted. Mean operative time was 3.5h approximately. Mean blood loss was 328ml approx (range 150-600ml). Postoperative delayed gastric emptying was observed in 8 (25%) patients. Three (9.4%) patients developed superficial surgical site infection. Mean hospital stay was 16.5days (range 13-20days). There were no pancreatic leak or fistula and no perioperative mortality. It is a feasible technique. It achieved zero leak rates, zero mortality and minimal morbidity without compromising any oncologic principles.

P-224 - End to side dunking pancreatojejunostomy, thirty cases of Whipples procedure, our institutional experience

Introduction: Pancreatic adenocarcinoma is the 9th most common cancer diagnosed worldwide however pancreatic cancer death ranks 4th in cancer death each year. Despite all possible treatment the 5 year survival remains dismal and less than 5% patients survive. Once resection of the specimen is done three anastomoses are established, pancreato-enteric, biliary-enteric and gastro-enteric anastomosis. Among these three anastomoses the pancreato-enteric anastomosis is the most crucial one and its complications are responsible for most of the morbidity and mortality of pancreatoduodenectomy surgery. Dunking method can be used in ‘end to end’ and ‘end to side’ ways. Regardless of the choice of technique the complication rate ranges from 30-50% and overall mortality rate between 1.4-10%. But there is paucity of data from Indian studies. Herewith we report our own experience with single layer end to side dunking pancreatojejunostomy technique in a retrospective study and evaluate postoperative complications in a tertiary care oncology centre in central India. Methods: From January 2013 to January 2016, 30 consecutive patients were studied retrospectively who underwent pancreatoduodenectomy for malignant pancreatic disease. 19 patients were diagnosed to have periampullary carcinoma and 11patients had carcinoma head of pancreas. All the patients underwent standard Whipple’s operation. After resection of the specimen pancreatojejunal anastomosis was established in end to side dunking fashion. Results: 17 patients were male and 13 were female. Mean age of the patients were 53.9 years (range 19 – 70 years). Jaundice and weight loss were most common symptoms in these patients. Mean operative time was 3.5 hours approximately. And mean blood loss was 250 ml (range 150 – 400ml). None of the patients showed postoperative anastomotic leakage or pancreatic fistula. Mean hospital stay was 15 days (range 13 – 20 days). There was no peri-operative mortality. Conclusion: Anastomotic technique remains the most important factor to reduce the risk of pancreatic leak hence time to time many surgeons worldwide improvise upon the surgical technique. Despite many techniques none of the techniques yet have been proven to be superior to the others conclusively. In the present study all the cases were malignant pancreatic disease and majority had soft and friable pancreas. In soft and friable pancreas dunking technique appears to be better as compared to duct to mucosa technique which is better for fibrotic pancreas and dilated main pancreatic duct

Scoring System to Predict Pancreatic Fistula After Pancreaticoduodenectomy: A UK Multicenter Study.

To validate a preoperative predictive score of postoperative pancreatic fistula (POPF). Other risk factors for POPF were sought in an attempt to improve the score. POPF is the major contributor to morbidity after pancreaticoduodenectomy (PD). A preoperative score [using body mass index (BMI) and pancreatic duct width] to predict POPF was tested upon a multicenter patient cohort to assess its performance. Patients undergoing PD at 8 UK centers were identified. The association between the score and other pre-, intra-, and postoperative variables with POPF was assessed. A total of 630 patients underwent PD with 141 occurrences of POPF (22.4%). BMI, perirenal fat thickness, pancreatic duct width on computed tomography and at operation, bilirubin, pancreatojejunostomy technique, underlying pathology, T stage, N stage, R status, and gland firmness were all significantly associated with POPF. The score predicted POPF (P < 0.001) with a higher predictive score associated with increasing severity of POPF (P < 0.001). Stepwise multivariate analysis of pre-, intra-, and postoperative variables demonstrated that only the score was consistently associated with POPF. A table correlating the risk score to actual risk of POPF was created. The predictive score performed well and could not be improved. This provides opportunities for individualizing patient consent and selection, and treatment and research applications.

Validation of Mucosal Sutureless Pancreatojejunostomy after Pancreatoduodenectomy

Although duct-to-mucosa pancreatojejunostomy has been considered safer than other techniques, this procedure is particularly difficult when the pancreatic duct is small. It has therefore become increasingly necessary to develop a simple mucosal sutureless pancreatojejunostomy technique to replace the conventional hand-sewing one. Two hundred fourteen patients who underwent mucosal sutureless pancreatojejunostomy were classified into two groups: those with a normal pancreatic duct diameter (less than 3 mm, n = 97) and those with a dilated pancreatic duct (3 mm or greater, n = 117). The rate of clinically significant pancreatic fistula (Grade B or C by the International Study Group on Pancreatic Fistula definition) among the patients as a whole was 8 per cent. The overall incidence of pancreatic fistula was significantly higher in the patients with a pancreatic duct diameter of less than 3 mm than in those with a pancreatic duct diameter of 3 mm or greater. However, the incidence of clinically significant pancreatic fistula did not differ between the groups (less than 3 mm, 11%; 3 mm or greater, 5%; P = 0.09). Grade C pancreatic fistula developed in one patient with a pancreatic duct diameter of less than 3 mm and in two with a pancreatic duct diameter 3 mm or greater. Although two patients required reoperation, all of the fistulas were cured and the postoperative mortality rate related to pancreatoduodenectomy was zero. Mucosal sutureless pancreatojejunostomy combined with pancreatic duct stenting is associated with a low rate of clinically significant pancreatic fistula even in patients with a small pancreatic duct diameter less than 3 mm.

Pancreato-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis

BackgroundDifferent methods of pancreatic stump closure after distal pancreatectomy (DP) have been described to decrease the incidence of pancreatic fistula (PF) which still represents one of the most common complications in pancreatic surgery. We retrospectively compared the pancreato-jejunostomy technique with the hand-sewn closure of the pancreatic stump after DP, and analyzed clinical outcomes between the two groups, focusing on PF rate.MethodsThirty-six patients undergoing open DP at our institution between May 2005 and December 2011 were included. They were divided in two groups depending on pancreatic remnant management: in 24 cases the stump was closed by hand-sewn suture (Group A), while in 12 earlier cases a pancreato-jejunostomy was performed (Group B). We analyzed postoperative data in terms of mortality, morbidity and length of hospital stay between the two groups.ResultsPF occurred in 7 of 24 (29.1%) cases of group A (control group) compared to zero fistula rate in group B (anastomosis group) (p=0.005). Operative time was significantly higher in the anastomosis group (p=0.024). Mortality rate was 0% in both groups. Other postoperative outcomes such as hemorrhages, infections, medical complications and length of hospital stay were not significant between the two groups.ConclusionDespite a higher operative time, the pancreato-jejunostomy after DP seems to be related to a lower incidence of PF compared to the hand-sewn closure of the pancreatic remnant.

Emprego da anastomose pancreatojejunal tipo ducto-mucosa sem cateter transanastomótico em pâncreas de consistência mole e ducto fino: experiência inicial do Instituto Nacional de Câncer

OBJETIVO: O objetivo deste trabalho foi relatar a morbimortalidade associada à técnica de reconstrução pancreática utilizando anastomose pancreato-jejunal tipo ducto-mucosa, sem cateter transanastomótico, em pâncreas de consistência mole e ducto de Wirsung menor que três mm. MÉTODOS: Analisamos consecutivamente os resultados de 16 pacientes submetidos à GDP com técnica de anastomose pancreato-jejunal tipo ducto-mucosa no Serviço de Cirurgia Abdômino-pélvica do INCA. Todos pacientes eram portadores de pâncreas de consistência mole e ducto pancreático fino (&lt; 3mm). RESULTADOS: Dos 16 pacientes analisados, oito eram do sexo masculino e com mediana de idade de 55 anos. No período pós-operatório um paciente apresentou fístula pancreática e houve um caso que evoluiu para óbito. CONCLUSÃO: Acreditamos que é possível a realização de anastomose pancreática tipo ducto-mucosa, sem cateter transanastomótico, em pacientes com ducto pancreático menor que três mm sem aumento da morbimortalidade.