A new simple and safe technique of end-to-end invaginated pancreaticojejunostomy with transpancreatic U-sutures—early postoperative outcomes in consecutive 88 cases

Addition of Mesh Reinforcement for Pancreatic Stump and Braun Enteroenterostomy after Pancreaticoduodenectomy: A Single Institution Experience

The morbidity rate after pancreaticoduodenectomy (PD) remains high and a modified digestive reconstruction may affect the postoperative complications. We investigated a new modification of PD by adding mesh reinforcement for the pancreatic stump and Braun enteroenterostomy with the aim of reducing postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE), respectively. From November 2010 to April 2015, 81 consecutive patients who underwent modified PD were retrospectively reviewed. The clinically relevant POPF and DGE rates were 4.9 and 6.1 per cent, respectively. The overall mortality rate was 2.4 per cent. The incidence of overall postoperative complications was 46.9 per cent, with 17.2 per cent considered as major complications (Clavien grades 3–5). The median postoperative length of hospital stay was 17 days (range 10–119 days). For patients who had major complications, median postoperative length of hospital stay increased significantly (22 vs 13 days, P = 0.001), as compared with those patients with no complications. The new modified digestive reconstruction after PD seems safe and reliable with low clinically relevant POPF and DGE rates. Further prospective controlled trials are essential to support these results.

Surgical management of the pancreatic stump following pancreato-duodenectomy

Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.

A comparison of two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy

Background. The aim of the study was to compare two invagination techniques for pancreatojejunostomy after pancreatoduodenectomy. Methods. For effective prevention of the development of pancreatic leakage, we modified invagination technique that we term the "serous touch." We analysed the diameter of the main pancreatic duct, the texture of the remnant pancreas, the method of the reconstruction, pancreatic external drainage, anastomotic procedure time, histopathological examination, and postoperative complications. Results. Fifty-two patients underwent pancreatoduodenectomy with pancreatojejunostomy using "serous touch" technique (ST group) and 52 classic pancreatojejunostomy (C group). In the ST group one patient (1.9%) was diagnosed as grade B pancreatic fistula, and no patient experienced fistula grade A or C. In the C group 6 patients (11.5%) were diagnosed as fistula grade A, 1 (1.9%) patient as fistula grade B, and 1 (1.9%) patient as fistula grade C. There was a significant statistical difference in incidents of pancreatic fistula (P < 0.05) and no statistical difference in other postoperative complications or mortality in comparison group. Anastomosis time was statistically shorter in the ST group. Conclusions. "Serous touch" technique appeared to be easy, safe, associated with fewer incidences of pancreatic fistulas, and less time consuming in comparison with classical pancreatojejunostomy.

Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature

Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.

Pancreaticojejunostomy sleeve reconstruction after pancreaticoduodenectomy in laparoscopic and open surgery

This report suggests that sleeve-joint pancreaticojejunostomy reduces the rate of postoperative pancreatic fistula.

Introduction:

Laparoscopic procedures for pancreatic surgery have been significantly improved recently; however, only a limited number of successful laparoscopic or laparoscopy-assisted pancreaticoduodenectomy (PD) have been reported. The limitations could be attributed to the complexity of the reconstruction procedures under laparoscopic observation and the high incidence of complications. Postoperative pancreatic fistula (POPF) has been regarded traditionally as the most frequent major complication and is a potentially serious and life-threatening event. It remains the single most important cause of morbidity after PD and contributes significantly to prolonged mortality. Several modified methods of pancreas anastomosis were introduced to prevent POPF. However, few methods with a satisfactory leakage rate have yet to be seen. Collating principle of theoretical mechanics, we introduce a new method of reconstruction by performing an asymmetric sleeving-joint pancreaticojejunostomy (SJPJ). The aim of this study is to summarize the results of a new technique that is designed to decrease the POPF.

Methods:

From January 2004 to December 2010, SJPJ was performed on 86 patients undergoing PD by 1 surgeon: a laparoscopic reconstruction was completed in 9 cases, a hand-assisted laparoscopic reconstruction in 2 cases, and an open SJPJ reconstruction in 75 cases.

Discussion:

We used SJPJ, an asymmetric pancreaticojejunostomy (PJ). The time of operation ranged from 300 minutes to 640 minutes. Postoperatively there were no major morbidities and no deaths. Although POPF was observed in the laparoscopic SJPJ group with pancreatic adenocarcinoma, 3 patients developed POPF in the open SJPJ group with ampullary adenocarcinoma (n=1) and pancreatic adenocarcinoma (n=2). The POPF rate was 9.30% in the open SJPJ group and 9.10% in the laparoscopic SJPJ group. The SJPJ procedure facilitates PJ, both laparoscopically and in open surgery. It is safe, effective, and feasible in experience hands.

Does the type of pancreaticojejunostomy after Whipple alter the leak rate?

Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.