Technique Of Pancreaticojejunostomy Research Articles

The “Colonial Wig” pancreaticojejunostomy: zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) remains common and morbid after pancreaticoduodenectomy (PD). A major advance in the study of POPF is the fistula risk score (FRS). We analyzed 48 consecutive patients undergoing PD. The "Colonial Wig" pancreaticojejunostomy (CWPJ) technique was used in the last 22 PDs, we compared 22 CWPJ to 26 conventional PDs. Postoperative morbidity was 49% (27% Clavien grade >2). The median length of hospital stay was 11 days. In the first 26 PDs, the PJ was performed according to standard techniques and the clinically relevant POPF (CR-POPF) rate was 15%, similar to the FRS-predicted rate (14%). In the next 22 PJs, the CWPJ was employed. Although the FRS-predicted rates were similar in these two groups (14% vs 13%), the CR-POPF rate in the CWPJ group was 0 (P=0.052). Early experience with the CWPJ is encouraging, and this anastomosis may be a safe and effective way to lower POPF rates.

Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis.

ObjectiveWe aimed to compare the two most commonly used pancreatico-jejunostomy reconstruction techniques—duct-to-mucosa and invagination.MethodsDatabases, including MEDLINE, EMBASE, Cochrane Library, and several clinical trial registration centers were searched. Randomized controlled trials that compared duct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were included and analyzed.ResultsIn total, seven RCTs were included, involving 850 patients. The difference in postoperative pancreatic fistula rate between the duct-to-mucosa and invagination pancreaticojejunostomy was not significant (RR = 1.03, 95% CI = 0.76-1.39, P = 0.86). There was no significant difference in clinically relevant postoperative pancreatic fistula between the two groups (RR = 0.78, 95% CI = 0.15-3.96, P = 0.77). The overall morbidity, overall mortality, delayed gastric emptying, intra-abdominal collection, reoperation rate, and length of hospital stay between the two groups were not significantly different. Sensitivity analysis showed that the meta-analysis was stable. Further, no significant publication bias was seen.ConclusionsDuct-to-mucosa and invagination pancreaticojejunostomy techniques after pancreaticoduodenectomy were comparable in terms of postoperative pancreatic fistula incidence and other parameters.

Imbedding pancreaticojejunostomy used in pure laparoscopic pancreaticoduodenectomy for nondilated pancreatic duct.

LPD has been cautiously regarded as feasible and safe for resection and reconstruction. However, anastomosis of the remnant pancreas is still thought to be a critical obstacle to the dissemination of LPD in general practice. This study presents a new technique of pancreaticojejunostomy for nondilated pancreatic duct and evaluates its safety and reliability. From July 2014 to June 2015, a total of 52 patients underwent LPD with the new technique. A modified technique of duct-to-mucosa PJ was performed with transpancreatic interlocking mattress sutures, named the imbedding duct-to-mucosa PJ. Then the morbidity and mortality was calculated. This technique was applied in 52 patients after LPD all with nondilated pancreatic duct (1-3mm). The mean operation time was 4.6h (range, 3.5-8.3h) and the median time for the anastomosis was 37min (range, 24-53min). Operative mortality was zero, and morbidity was 21.2% (n=11), including hemorrhage (n=3, 5.8%), biliary fistula (n=1, 1.9%), pulmonary infection (n=1, 1.9%), delayed gastric emptying (n=2, 3.8%), abdominal abscess caused by biliary fistula or PF formation (n=2, 3.8%), and POPF (n=2, 3.8%). Two patients developed a pancreatic fistula (one type A, one type B) classified according to the International Study Group on Pancreatic Fistula. The described technique is a simple and safe reconstruction procedure after LPD, especially for patients with nondilated pancreatic duct.

Effect of end-to-side inverted mattress pancreaticojejunostomy following central pancreatectomy on the prevention of pancreatic fistula.

PurposeCentral pancreatectomy (CP) may be indicated for the treatment of benign or low-grade malignant tumor in the neck and proximal body of the pancreas. Pancreatic fistula is one of the most common complications after CP. In this study, we suggested an inverted mattress pancreaticojejunostomy (IM-PJ) technique to decrease the risk of pancreatic fistula.MethodsBetween 2010 and 2015, CP was performed with IM-PJ for 10 consecutive patients with a benign or low-grade malignant tumor in the neck and proximal body of the pancreas. All clinical and pathological data were analyzed retrospectively.ResultsMedian age was 56.4 years (range, 17–75 years). Median surgery duration was 286 minutes (range, 205–410 minutes). In all cases, the distal stump was reconstructed using the IM-PJ method. Median duration of hospital stay was 23.8 days (range, 9–53 days). No patient mortality occurred. Pancreatic fistula developed in 9 cases (90%); however, all fistulas were grade A and resolved without surgical or radiological intervention. Nine patients remain well with no recurrence or new endocrine or exocrine dysfunction.ConclusionOur results demonstrate that the outcomes of CP with IM-PJ are reasonable for prevention of pancreatic fistula following CP.

A Comparative Study between Duct-to-Mucosa and Invagination Technique for Reconstruction after Pancreaticoduodenectomy: Aprospective Study

Background: The pancreaticojejunostomy has notoriously been known to carry a high rate of operative complications,morbidity,and mortality mainly due to anastomotic leak and ensuing septic complications. Patients and methods: From January 2012 to October 2015, we presented a prospective study which included 24 patients who underwent pancreaticoduodenectomy (PD) operation through either Whipple resection or modified Whipple(pylorus-preserving).Patients were reviewed and divided into 2 groups (A,B) according to the type of pancreaticojejunostomy (PJ), (invagination vs duct-to-mucosa ). Results: 12 patients in each group were operated on: Group A patients had invagination technique for PJ ,while all the 12 patients in group B had duct –to-mucosa anastomotic technique for PJ. 1 (8.3%)case in group A developed pancreatic fistula (PF),while 3 (25%) cases in group B developed PF, and 1 case (8.3%) in group A had mild anastomotic leak which was managed conservatively,while 3 cases (25%) in group B developed moderate to severe anastomotic leak with intra-abdominal collection which required CT-guided percutaneous drainage and operative intervention. Average age was (mean ±SD) = (55 ±12),average operative time was (245 ±75) min. Conclusion: PF after PD represents a critical trigger of potentially life-threatening complications. Although the best method for dealing with the pancreatic stump after PD remains controversial, recent reports described the invagination technique todecrease the rate of PF significantly compared to the duct-to-mucosa technique. Our results appeared to be closely related to the published literature.

A modified technique of pancreaticojejunostomy during pancreaticoduodenectomy: impressive early results

A modified technique of pancreaticojejunostomy during pancreaticoduodenectomy: impressive early results

Shen's Whole-Layer Tightly Appressed Anastomosis Technique for Duct-to-Mucosa Pancreaticojejunostomy in Pancreaticoduodenectomy.

BackgroundPostoperative pancreatic fistulas (POPFs) due to anastomotic leaks are always closely related to significant morbidity and mortality following pancreaticoduodenectomy (PD). A series of modified anastomotic methods have been proposed. The object of our study was to provide a novel anastomotic method for operations involving the Child technique, termed the “whole-layer tightly appressed anastomosis technique”.Material/MethodsAn improved pancreatic whole-layer suture technique was used when we performed the duct-to-mucosa pancreaticojejunostomies; this method ensured the tight joining of the pancreatic stump and jejunum and decreased the pinholes in the pancreatic stump. This new method was used in 41 patients, and was compared with the traditional duct-to-mucosa anastomosis technique that was used in 50 patients as controls.ResultsThe POPF rate was much lower in the new method group than in the control group (6, 14.63% and 20, 40.00%, respectively, P=0.010). There were 5 grade A POPF patients and 1 grade B POPF patient in the study group. In the control group there were 12 grade A POPFs patients, 7 grade B POPFs patients, and 1 grade C POPF patient. The study group exhibited a lower morbidity rate (7, 17.07% vs. 16, 32.00%, P=0.022) and a reduced hospital stay (17.16 d vs. 22.92 d, P=0.001).ConclusionsThe whole-layer tightly appressed anastomosis technique presented in our study is a safer anastomotic method than the traditional duct-to-mucosa pancreaticojejunostomy technique. This new technique effectively reduced the incidence of POPF after PD and decreased the postoperative morbidity.

Insulin-producing cells derived from the immortalized pancreatic stem cells

Aim: There is lot of controversy regarding which method of pancreaticojejunostomy should be used in whipple's procedure. Aim of this study is to compare two methods of pancreaticojejunostomy in whipple's procedure : dunking vs duct-to-mucosa. Materials and methods: In this retrospective study of 61 patients of pancreatic head cancer including both male and female of age ranging from 45 to 74 years from june 2003 to february 2013 were subjected to Whipple's procedure. Pancreaticojejunostomy in 30 patients was done by two layered duct-to-mucosa technique and in 31 dunking was used. These patients were followed for a period of 24 months assessing duration of surgery, anastomosis leak, hospital stay and morbidity. Results: Duration of surgery was 196.6 ± 10.4 minutes in duct-tomucosa group and 180 ± 8.8 min in dunking group. Mean hospital stay was 10 (range: 8-14) days. There was postoperative complication in the form of anastomosis leak that occurred in 8 patients in dunking group & 2 in duct to mucosa group. There were no recurrences in any group. Morbidity was greater in dunking group as leak occurred in 8 patients. Conclusion: We conclude that duct-to-mucosa technique of pancreaticojejunostomy gives superior results in regards to safety of anastomosis and its resultant morbidity in whipple's procedure.

胰十二指肠切除术中胰肠吻合术式的研究进展

胰十二指肠手术是胰头部肿瘤、壶腹部占位性病变、胆总管下端肿瘤等疾病的常见手术方式，然而术后胰漏常常是患者死亡的主要原因，所以胰肠吻合的方式及其技术尤为重要。胰肠吻合的方式种类多，本文就胰肠吻合常见的术式进行了综述，并简述了各自的优缺点，为临床医生提供参考和借鉴。 Panereatieoduodenectomy is a common surgical operation which is performed to cure tumor of pancreatic head, ampullary space-occupying lesion, tumor of the lower extremitas common bile duct, etc. However, postoperative pancreatic fistula is usually the main cause of the death in these patients, so the methods and techniques of pancreaticojejunostomy are particularly significant. There are various methods of pancreaticojejunostomy, and this thesis is going to summarize the common methods, with their advantages and disadvantages respectively presented to provide cli-nicians with reference.

Oncogene-mediated mouse pancreatic stem cell shows pancreatic cancer stem cell phenotype

Aim: There is lot of controversy regarding which method of pancreaticojejunostomy should be used in whipple's procedure. Aim of this study is to compare two methods of pancreaticojejunostomy in whipple's procedure : dunking vs duct-to-mucosa. Materials and methods: In this retrospective study of 61 patients of pancreatic head cancer including both male and female of age ranging from 45 to 74 years from june 2003 to february 2013 were subjected to Whipple's procedure. Pancreaticojejunostomy in 30 patients was done by two layered duct-to-mucosa technique and in 31 dunking was used. These patients were followed for a period of 24 months assessing duration of surgery, anastomosis leak, hospital stay and morbidity. Results: Duration of surgery was 196.6 ± 10.4 minutes in duct-tomucosa group and 180 ± 8.8 min in dunking group. Mean hospital stay was 10 (range: 8-14) days. There was postoperative complication in the form of anastomosis leak that occurred in 8 patients in dunking group & 2 in duct to mucosa group. There were no recurrences in any group. Morbidity was greater in dunking group as leak occurred in 8 patients. Conclusion: We conclude that duct-to-mucosa technique of pancreaticojejunostomy gives superior results in regards to safety of anastomosis and its resultant morbidity in whipple's procedure.

Clinical application of modified parachute-like pancreaticojejunostomy for pancreatoduodenectomy

Objective To explore the effect of modified parachute-like pancreaticojejunostomy on incidence of pancreatic fistula after pancreatoduodenectomy. Methods The clinical data of 123 patients undergoing pancreatoduodenectomy with application of duct-to-mucoca pancreaticojejunostomy were analyzed retrospectively. Interrupted suture technique and modified parachute suture technique were performed in 61 and 62 patients, respectively. Postoperative complications, data during and after pancreatoduodenectomy between two groups were compared. Results There were no significant differences in pancreatic texture, pylorus preservation, pancreatic duct drainage, intraoperative blood loss, and operating time between two groups (P>0.05). No significant differences between two groups were observed on postoperative morbidity of gastrointestinal or intraabdominal hemorrhage, delayed gastric emptying, and intraabdominal abscess (P>0.05). Although there was no significant difference in the incidence of postoperative pancreatic fistula (P>0.05), the grades B/C postoperative pancreatic fistula in modified parachute suture group was significantly less than in interrupted suture group (P<0.05). Conclusions Modified parachute-like pancreaticojejunostomy technique in pancreatoduodenectomy can reduce the incidence of severe postoperative pancreatic fistula. Key words: Pancreaticojejunostomy/MT; Pancreaticoduodenectomy/AE; Pancreatic fistula/ET/PC; Intestinal fistula/ET/PC

A simple pancreaticojejunostomy technique for hard pancreases using only two transpancreatic sutures with buttresses: a comparison with the previous pancreaticogastrostomy and dunking methods.

PurposeIn this study, we introduced a novel technique, the pancreaticojejunostomy (PJ), which uses only two transpancreatic sutures with buttresses (PJt), and compared the surgical outcomes with previously used methods, especially for hard pancreases.MethodsA total of 101 patients who underwent pancreaticoduodenectomy with hard pancreases were enrolled and divided into 3 groups according to the method of pancreaticoenteric anastomosis: 30 patients (29.7%) underwent the conventional dunking method (Du), 31 patients (30.7%) underwent pancreaticogastrostomy using transpancreatic sutures (PGt) and 40 patients (39.6%) underwent PJ using transpancreatic sutures (PJt). The surgical outcomes were compared according to the type of anastomosis to analyze the feasibility and ease of each technique.ResultsThe overall operative time was shorter in the PJt group (325.1 ± 63.8 minutes) than in the PGt group (367.3 ± 70.5 minutes) or the Du group (412.0 ± 38.2 minutes, P < 0.001). In terms of pancreaticoenteric anastomosis time, it was also shorter in the PJt group (10.3 ± 3.5 minutes) than in the Du group (20.7 ± 0.7 minutes) or the PGt group (16.8 ± 5.4 minutes, P = 0.005). Significant postoperative pancreatic fistula (POPF) developed in 2 cases (6.7%) in the Du group, whereas there were no POPF cases in the PGt or PJt groups (P = 0.086). Overall postoperative morbidities occurred in 31 cases (30.7%), and there were no significant differences among the 3 groups (P = 0.692).ConclusionThe novel PJ technique, which uses only two transpancreatic sutures with buttresses, is a very simple, easy and secure method for hard pancreases and can be performed in a shorter amount of time compared with conventional methods.

The effects of the end-to-side inverted mattress pancreaticojejunostomy on postoperative pancreatic fistula: a single surgeon's experience

PurposeVarious pancreaticojejunostomy (PJ) techniques have been devised to minimize the rate of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). This study describes a modification of the mattress suture PJ technique, which we call "inverted mattress PJ (IM)". The results of an IM group and a historical consecutive control group were compared to determine how the IM technique affected POPF.MethodsFrom 2003 to 2010, 186 consecutive patients underwent PD. A former group of 52 consecutive patients who underwent conventional duct-to-mucosa PJ (DM) was used as a historical control group. The IM technique was utilized for the IM group (134 patients). The clinicopathological features and surgical outcomes of the 2 groups were compared, with a particular focus on postoperative POPFs.ResultsThe average surgery duration was shorter in the IM group (580.3 minutes vs. 471 minutes, P < 0.001). Grades B and C POPFs occurred less frequently in the IM group, but the difference was not statistically significant (17.3% vs. 9.7%, P = 0.200). However, no grade C POPF occurred in the IM group compared with 5.8% of grade C POPFs (3/52) in the DM group (P = 0.020). Three patients died (1 in the DM group and 2 in the IM group). The causes of death were arrhythmia in 2 cases and Candida sepsis in 1 case. POPF was not causally related to the 3 deaths.ConclusionIM end-to-side PJ shortened operation time and increased safety with no incidence of grade C POPF.

Continuous versus interrupted suture techniques of pancreaticojejunostomy after pancreaticoduodenectomy

BackgroundPostoperative pancreatic fistula (POPF) has traditionally been a source of significant morbidity and potential mortality after pancreaticoduodenectomy (PD). Both patient-derived and technical factors contribute to pancreatic anastomotic failure. The continuous suture duct-to-mucosa pancreaticojejunostomy (PJ) described previously is associated with a low rate of POPF. The aim of the present study was to observe whether the new technique would effectively reduce the POPF rate in comparison with conventional interrupted suture duct-to-mucosa PJ. MethodsData on 255 consecutive patients, who underwent the two methods of PJ after standard PD by one group of surgeons between 2006 and 2013, were collected retrospectively from a prospective database. The primary end point was the POPF rate. The risk factors of POPF were investigated by using univariate and multivariate analyses. ResultsA total of 120 patients received continuous suture PJ and 135 underwent interrupted suture PJ. Rate of POPF for the entire cohort was 12.5%. There were 9 fistulas (7.5%) in the continuous anastomosis group and 23 fistulas (17%) in the interrupted anastomosis group (P = 0.022). The rates of major complications (Clavien grades 3–5) were less in the continuous anastomosis group (5%) compared with the interrupted anastomosis group (13.3%) (P = 0.023). The greatest risk factor for a POPF was pancreatic duct diameter: POPF developed in only 3 patients (3.6%) with large pancreatic ducts (≥3 mm) and in 29 patients (16.9%) with small pancreatic ducts (<3 mm). There were four postoperative (in-hospital) deaths (both in the interrupted anastomosis group); two of which had POPF as the proximate cause of death, followed by bleeding and sepsis. ConclusionsThe continuous suture duct-to-mucosa PJ effectively reduces the POPF rate after PD in comparison with interrupted anastomosis. The results confirm increased POPF rates in patients with pancreatic duct diameter <3 mm compared with pancreatic duct diameter ≥3 mm.

Pancreatico-jejunal anastomosis with invaginating Jenunal “J”-Loop. Preliminary report of a new technique

IntroductionThe pancreatic anastomosis is the most demanding step after pancreaticoduodenectomy (PD) and the pancreatic fistula (PF) is the most dreaded complication.Many techniques have been investigated to assess the best way to deal with the pancreatic stump after PD and none of these has shown to be superior in terms of statistically significant reduction of PF rate. We report the preliminary experience of a new technique of pancreaticojejunostomy (PJ). MethodsFifteen patients underwent PD for neoplasms with end-to-side PJ with dunking jejunal “J”-loop, between July 2011 and March 2014. The data about their post-operative outcomes were analyzed. ResultsThere were no intra-operative neither post-operative deaths. One patient had a grade A PF (6.7%). Total post-operative complications occurred in 6 patients (40%), major post-operative complications occurred in 3 patients (20%). ConclusionThe new “sandwich” technique for dunking PJ after PD that we describe proved to be easy to perform and sure. It appears to be suitable for a dunking PJ when the diameter of the jejunum is too small than this of the pancreatic stump.

Minimizing Shear and Compressive Stress During Pancreaticojejunostomy

The failure of the pancreaticojejunal anastomosis remains an important and potentially lethal postoperative complication after pancreaticoduodenectomy. During the pancreaticojejunostomy, creation of compressive and shear forces during suture placement and knot tying may cause deformation of and cutting through the fragile pancreatic parenchyma. We sought to understand the mechanics of needle-pancreas interaction and make adjustments to our pancreaticojejunostomy technique so that the creation of shear and compressive stress could be minimized. We provide a detailed description, a mathematical model, and analysis of the outcomes of our new technical modifications.

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.

Wound Healing after Mesh Inner Embedding and Outer Binding Pancreaticojejunostomy in Piglets

The aim of this study was to introduce a novel technique of pancreaticojejunostomy, namely, mesh inner embedding and outer binding pancreaticojejunostomy, and to evaluate wound healing after this operation in piglets. Thirty-six domestic piglets were randomly divided into 2 groups after pancreaticoduodenectomy: the mesh inner embedding and outer binding pancreaticojejunostomy group (n = 18) and the conventional double-deck invaginated pancreaticojejunostomy group (n = 18). Bursting pressure and breaking strength were assessed on the operative day and on days 7 and 14 postoperatively. The pathologic findings and collagen content of the anastomotic site were evaluated on days 7 and 14 postoperatively. Both the bursting pressure and breaking strength were significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 0, 7, and 14 (P < .01). The collagen content of the anastomotic site was significantly higher in the mesh inner embedding and outer binding pancreaticojejunostomy group than in the double-deck invaginated pancreaticojejunostomy group on days 7 and 14 postoperatively (P < .01). The anastomotic site was more completely repaired by connective and granulation tissue in the mesh inner embedding and outer binding pancreaticojejunostomy group on day 7 than in the double-deck invaginated pancreaticojejunostomy group. Mesh inner embedding and outer binding pancreaticojejunostomy significantly enhanced the anastomotic firmness and sped up the wound healing process compared with conventional mesh inner embedding and outer binding pancreaticojejunostomy. Therefore, it may decrease the risk of pancreatic fistulas after pancreaticoduodenectomy.

Continuous running stitch with one polypropylene monofilament suture – A novel safe technique for pancreaticojejunostomy

Continuous running stitch with one polypropylene monofilament suture – A novel safe technique for pancreaticojejunostomy

A new pancreaticojejunostomy technique: A battle against postoperative pancreatic fistula

To present a new technique of end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and insertion of a silicone stent. We present an end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and the insertion of a silicone stent. This technique was performed in thirty-two consecutive patients who underwent a pancreaticoduodenectomy procedure by the same surgical team, from January 2005 to March 2011. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity. There were 32 patients who underwent end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation. Thirteen of them were women and 19 were men. These data correspond to 40.6% and 59.4%, respectively. The mean age was 64.2 years, ranging from 55 to 82 years. The mean operative time was 310.2 ± 40.0 min, and was defined as the time period from the intubation up to the extubation of the patient. Also, the mean time needed to perform the pancreaticojejunostomy was 22.7 min, ranging from 18 to 25 min. Postoperatively, one patient developed a low output pancreatic fistula, three patients developed surgical site infection, and one patient developed pneumonia. The rate of overall morbidity was 15.6%. There was no 30-d postoperative mortality. This modification appears to be a significantly safe approach to the pancreaticojejunostomy without adversely affecting operative time.