Sealing Pancreaticojejunostomy in Combination with Duct Parenchyma to Mucosa Seromuscular One-Layer Anastomosis: A Novel Technique to Prevent Pancreatic Fistula after Pancreaticoduodenectomy

Application of single-layer continuous duct-to-mucosa pancreaticojejunostomy with two figure-of-eight sutures in total laparoscopic pancreaticoduodenectomy

INTRODUCTION

To investigate the application potential of single-layer continuous duct-to-mucosa pancreaticojejunostomy with two figure-of-eight sutures ("1 + 2" PJ) in total laparoscopic pancreaticoduodenectomy (TLPD). Explore the advantages of "1 + 2" PJ over the traditional double-layer interrupted duct-to-mucosa pancreaticojejunostomy (traditional PJ).

METHODS

We retrospectively collected the clinical data of 184 patients who were admitted in our department from Oct 2019 to Oct 2022, including 95 cases who underwent TLPD with "1 + 2" PJ and 89 cases who underwent TLPD with traditional PJ. The pre/intra/postoperation data were analyzed and compared.

RESULTS

The "1 + 2" PJ procedures were successfully performed in all the 95 cases. When compared with the traditional PJ group, there were no statistically significant variations between the pre-operative and pathological data. However, the "1 + 2" PJ group had a shorter operation time (235 (210, 300) minutes vs. 310 (270, 360) minutes in the traditional PJ group, P < 0.001), shorter pancreaticojejunostomy time (15 (10, 20) minutes vs. 50 (45, 55) minutes in the traditional PJ group, P < 0.001), lower pancreatic fistula (both grade B/C) rate (4.21% vs. 12.34% in the traditional group, P = 0.044), and abdominal infection rate (2.11% vs. 8.99% in the traditional group, P = 0.044), as well as reduced hospital stay (11 (9, 15) days vs. 13 (11, 15) days in the traditional PJ group, P = 0.013). In the "1 + 2" PJ group, the median diameter of the pancreatic duct was 3 (3, 4) mm; 82 cases (86.31%) had a normal pancreatic texture, while nine (9.47%) cases had a hard texture, and seven (7.37%) cases had a soft texture; the median intraoperative blood loss was 200 (100, 400) mL and 19 cases (20.00%) needed intraoperative transfusion; eight cases (8.4%) developed postoperative complications, including four cases (4.2%) of pancreatic fistula (including both grade B/C), one case (1.1%) of bile leakage, three cases (3.2%) of delayed gastric emptying, three cases (3.2%) of postoperative hemorrhage, two cases (2.1%) of abdominal infection, and one case (1.1%) of reoperation; the median hospital stay was 13 (8, 17) days; 25 cases were pathologically classified as pancreatic cancer, 35 cases as bile duct cancer, 23 cases as duodenal cancer, and 12 cases as ampullary cancer.

CONCLUSION

Single-layer continuous duct-to-mucosa pancreaticojejunostomy with two figure-of-eight sutures is a feasible and safe procedure that can be applied in TLPD.

Chen's penetrating-suture technique for pancreaticojejunostomy following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is the most serious complication and the main reason for morbidity and mortality after pancreaticoduodenectomy (PD). Currently, there exists no flawless pancreaticojejunal anastomosis approach. We presents a new approach called Chen's penetrating-suture technique for pancreaticojejunostomy (PPJ), which involves end-to-side pancreaticojejunostomy by suture penetrating the full-thickness of the pancreas and jejunum, and evaluates its safety and efficacy.

METHODS

To assess this new approach, between May 2006 and July 2018, 193 consecutive patients who accepted the new Chen's Penetrating-Suture technique after a PD were enrolled in this study. Postoperative morbidity and mortality were evaluated.

RESULTS

All cases recovered well after PD. The median operative time was 256 (range 208-352) min, with a median time of 12 (range 8-25) min for performing pancreaticojejunostomy. Postoperative morbidity was 19.7% (38/193) and mortality was zero. The POPF rate was 4.7% (9/193) for Grade A, 1.0% (2/193) for Grade B, and no Grade C cases and one urinary tract infection.

CONCLUSION

PPJ is a simple, safe, and reliable technique with ideal postoperative clinical results.

A duct-to-mucosa pancreaticojejunostomy for small main pancreatic duct and soft pancreas in minimally invasive pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is often associated with significant morbidity and mortality after the Whipple operation. Patient-related factors associated with POPF include soft pancreatic texture and a small main pancreatic duct (MPD). The traditional duct-to-mucosa anastomosis was modified to be easily performed. The aim of the study was to evaluate the simplified pancreaticojejunostomy (PJ) method in the prevention of POPF after minimally invasive pancreaticoduodenectomy (PD).

METHODS

Ninety-eight patients who underwent laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD) with a simplified PJ procedure containing only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer in our center were retrospectively studied. Demographics and clinical short-term safety were assessed.

RESULTS

All LPD and RPD procedures were successfully performed. The median time of PJ was 17 min, and the median blood loss was 60 mL, with only one patient requiring transfusion. Four patients (4.1%) suffered from clinically relevant POPF (CR-POPF), including four grade B cases and no grade C cases. For patients with an MPD diameter of 3 mm or less, POPF was noted in two (4%) of the fifty patients, with all cases being grade B. Of the patients with a soft pancreas, only two (4.5%) patients suffered from grade B POPF. One patient (1.0%) experienced a 90-day mortality. Neither the main pancreatic diameter nor pancreatic texture had an impact on postoperative outcomes.

CONCLUSIONS

Our technique is a simple, safe and efficient alternative to prevent POPF after LPD and RPD. This method is suitable for almost all pancreatic conditions, including cases with a small main pancreatic duct and soft pancreas, and has the potential to become the preferred procedure in low-volume pancreatic surgery centers. Our modified duct-to-mucosa PJ, which contains only two duct-to-mucosa sutures and four penetrating-sutures to anastomose the pancreatic parenchyma and jejunal seromuscular layer, is ideal for small MPD and soft pancreas when performing minimally invasive PD and has a low rate of POPF. PJ pancreaticojejunostomy, MPD main pancreatic diameter, PD pancreaticoduodenectomy, POPF postoperative pancreatic fistula.

One-half layer pancreaticojejunostomy with the rear wall of the pancreas reinforced: A valuable anastomosis technique

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). To effectively reduce the incidence of POPF, we designed a new type of pancreaticojejunostomy (PJ), which was termed one-half layer PJ with the rear wall of the pancreas reinforced.

AIM

To explore the clinical application value of this new technique.

METHODS

We compared 62 patients who had undergone PD by either the traditional duct-to-mucosa anastomoses or the new one-half layer PJ with the rear wall of the pancreas reinforced method at our hospital from May 2015 to September 2019. All 62 patients were operated by the same surgeon experienced in both procedures. We retrospectively analyzed patient characteristics, perioperative outcomes, and surgical results.

RESULTS

There was no significant difference between the two groups in basic information except the postoperative hospital stays, 14.7 ± 5.4 d in the traditional duct-to-mucosa anastomoses group and 12.0 ± 4.2 d in the one-half layer PJ group (P = 0.042). In terms of postoperative complications, the one-half layer PJ group had a lower rate of POPF than the traditional group. The overall number of cases with POPF was 8 (24.2%) in the traditional group and 2 (6.9%) in the one-half layer group (P = 0.017). Additionally, the rate of grades B and C POPF was lower in the one-half layer group (3.4%) compared with that (12.1%) in the traditional group (P = 0.010). One patient died due to hemorrhage caused by severe pancreatic fistula in the traditional group.

CONCLUSION

One-half layer PJ with the rear wall of the pancreas reinforced is a safe and feasible procedure that can successfully reduce the rate of POPF. It may be a promising technique for PJ after PD.

Pancreaticojejunostomy Conducive to Biological Healing in Minimally Invasive Pancreaticoduodenectomy

BACKGROUND

Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in minimally invasive surgery is difficult to perform, more simplified methods are needed to guarantee a safe pancreatic anastomosis. The concept of "biological healing" proposed in recent years has changed the conventional understanding of the anastomosis, which recommends rich blood supply, low tension, and loose sutures in the reconstruction of the pancreatic outflow tract.

METHODS

A literature search was conducted in PubMed for articles on pancreaticojejunostomy published between January 2014 and December 2021. After following a due selection process, several techniques developed in accordance with the concept of biological healing that were found suitable for minimally invasive surgery and their related clinical outcomes were described in this review.

RESULTS

The incidence of clinically relevant pancreatic fistula associated with the presented techniques did not exceed 15.9%, indicating superior results compared to Cattell-Warren double-layer duct-to-mucosa anastomosis (incidence: approximately 20%). The features and drawbacks of these approaches have been enumerated from the viewpoint of biological healing.

CONCLUSIONS

This review described several modified pancreaticojejunostomy techniques with the advantages of a simplified procedure and a lower incidence of pancreatic fistula. Surgeons can choose to apply them in clinical practice to improve patient prognosis.

Effect of six-stitch pancreaticojejunostomy on pancreatic fistula: A propensity score-matched comparative cohort study

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most common and severe complication after pancreaticoduodenectomy (PD). Despite the development of numerous anastomotic surgical techniques to minimize CR-POPF, more than 30% of patients who undergo PD develop CR-POPF. Herein, we propose a novel pancreaticojejunostomy (PJ) technique and evaluate its efficacy and safety compared to traditional PJ.

METHODS

This retrospective study enrolled 164 consecutive patients who underwent PJ after PD between January 2012 and June 2017. Of them, 78 (47.6%) underwent traditional PJ and 86 (52.4%) underwent six-stitch PJ. The primary outcome was CR-POPF at 1-month follow-up defined according to the revised 2016 International Study Group on Pancreatic Fistula definition. To adjust for baseline differences and selection bias, patients were matched by propensity scores, which left 63 patients with traditional PJ and 63 with six-stitch PJ.

RESULTS

Compared to patients who underwent traditional PJ (mean age 56.2 ± 9.4 years), patients who underwent six-stitch PJ (mean age 57.4 ± 11.4 years) had a lower CR-POPF rate. The risk of CR-POPF among patients who underwent six-stitch PJ was decreased by 81.7% after adjustment for age, sex, body mass index, and disease severity compared to patients who underwent traditional PJ. Additionally, the surgery time was reduced from 29 min for traditional PJ to 15 min for six-stitch PJ (P <0.001). Adverse effects such as abdominal fluid collection, abdominal bleeding, and wound infection were similar between two groups.

CONCLUSION

Six-stitch PJ may be an effective and efficient PJ technique for patients who undergo PD surgery.

Pancreaticojejunostomy-a review of modern techniques

Background

Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared to the other methods.

Purpose

The aim of this review was to provide a concise and illustrated description of the most recent methods of pancreaticojejunostomy. Their development was directly related to the still ongoing search by surgeons for such a technique of anastomosis that would eliminate the problem of POPF.

Conclusions

Knowledge of various techniques of anastomosis may help the surgeon to find the most suitable and optimal method of pancreatic-intestinal anastomosis for the patient.

Selection of pancreaticojejunostomy technique after pancreaticoduodenectomy: duct-to-mucosa anastomosis is not better than invagination anastomosis: A meta-analysis

BACKGROUND

One of the most clinically significant current discussions is the optimal pancreaticojejunostomy (PJ) technique for pancreaticoduodenectomy (PD). We performed a meta-analysis to compare duct-to-mucosa and invagination techniques for pancreatic anastomosis after PD.

METHODS

A systematic search of PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to June 1, 2018 was performed. Randomized controlled trials (RCTs) comparing duct-to-mucosa versus invagination PJ were included. Statistical analysis was performed using RevMan 5.3 software.

RESULTS

Eight RCTs involving 1099 patients were included in the meta-analysis. The rate of postoperative pancreatic fistula (POPF) was not significantly different between the duct-to-mucosa PJ (110/547, 20.10%) and invagination PJ (98/552, 17.75%) groups in all 8 studies (risk ratio, 1.13; 95% CI, 0.89-1.44; P = .31). The subgroup analysis using the International Study Group on Pancreatic Fistula criteria showed no significant difference in POPF between duct-to-mucosa PJ (97/372, 26.08%) and invagination PJ (78/377, 20.68%). No significant difference in clinically relevant POPF (CR-POPF) was found between the 2 groups (55/372 vs 40/377, P = .38). Additionally, no significant differences in delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, operation time, or length of stay were found between the 2 groups. The overall morbidity and mortality rates were not significantly different between the 2 groups.

CONCLUSION

The duct-to-mucosa technique seems no better than the invagination technique for pancreatic anastomosis after PD in terms of POPF, CR-POPF, and other main complications. Further studies on this topic are therefore recommended.

Outcome of Pancreaticoduodenectomy at Low-Volume Centre in Tier-II City of India

Currently, pancreaticoduodenectomy (PD) is considered a common and feasibly performed surgery for periampullary tumours, but it is still a high-risk surgical procedure with potential morbidity and mortality rates. Previously, it was emphasised for the need of high-volume centres to perform specialised surgery such as PD. The authors have made an attempt to know the relation between low-volume centre and outcomes of PD. The study was conducted in a Tier-II city referral hospital located in Karnataka, India. A total of 37 patients with suspected periampullary neoplasms underwent surgical exploration with curative intent over a period of 4 years, i.e. from May 2012 to May 2016. Out of 37 patients, 26 underwent PD, either classic Whipple resection (n = 01) or pylorus-preserving modification (n = 25). In 11 patients, resection was not possible, where biliary and gastric drainage procedures were done. All patients were treated by standardised post-operative care protocols for pancreatic resection used at our centre. We recorded the perioperative outcome along with demographics, indications for surgery, and pre- and intra-operative factors of PD. Post-operative pancreatic fistulae were evident in 4 patients. Two patients had hepaticojejunostomy leak. One patient had chyle leak. Three patients had infection at the surgical site. One patient had post-operative pneumonia leading to mortality. None of the patients had post-op haemorrhage. The surgeon volume and surgeon experience may have minimal contributing factor in post-operative morbidity, especially if there is availability of well-equipped ICU and imaging facilities, along with well-experienced personnel like oncosurgeon, anaesthesiologist, intensivist, radiologist, and nursing staff. There is a need of a multicentre study from Tier-II city hospitals/low-volume centres and high-volume centres to come with perioperative surgical outcomes following PD.

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.

Pancreatic parenchymal injection of ethanol and octreotide to induce focal pancreatic fibrosis in rats: Strategies to eliminate postoperative pancreatic fistula

BACKGROUND

Postoperative pancreatic fistula (POPF) is more likely to occur in a soft pancreas compared to a hard pancreas in which fibrosis has progressed. There is almost no leakage at the anastomosis site or cut surface of a hard pancreas. The aim of this study was to induce localized fibrosis at the cut surface of the pancreas in a rat model.

METHODS

Thirty-six rats were divided into three groups (group S: normal saline group; group E: ethanol group; and group O: octreotide group). Each rat was directly injected with a particular compound at the duodenal lobe of the pancreatic parenchyma. Each group was divided into three subgroups according to the time of post-injection sacrifice (1, 2, or 4 weeks). The hardness, suture holding capacity (SHC), and histological fibrosis grade of each pancreas were measured.

RESULTS

The hardness, SHC, and fibrosis grade of groups E and O were increased at week 1, with greater increases in group E (all P < 0.001). In a subgroup comparison, the hardness, SHC, and fibrosis grade of group E tended to decrease gradually over time, with no regular pattern evident in group O. A comparison between the injected site (duodenal lobe) and non-injected site (splenic lobe) of the pancreas revealed increases in the three parameters of group E only in the duodenal lobe, with increases in group O at both the duodenal and splenic lobes.

CONCLUSIONS

Parenchymal injection of ethanol and octreotide increased pancreatic fibrosis. Unlike octreotide, ethanol provoked localized fibrosis that was maintained over time. It is expected that ethanol injection could eliminate POPF during pancreatic surgery.

Vascular resection in pancreaticoduodenectomy for periampullary cancers. A 10 year retrospective cohort study

BACKGROUND

Pancreaticoduodenectomy (PD) is the only chance of cure for periampullary cancers. This study aims to evaluate survival and complication rates for PD with additional vascular resection performed for local vascular involvement and compare to standard PD.

MATERIALS AND METHODS

A retrospective cohort analysis of a departmental hepato-pancreatobiliary database from 2004 to 2014 was performed. All patients (n = 92) who underwent PD without vascular resection (n = 72), with venous resection (n = 16), with both arterial and venous resection (n = 4) were included in the study. Patients who received palliative double bypass (n = 6) were also included for survival analysis. Survival and post-operative complications were assessed.

RESULTS

Median survival for standard PD and PD with venous resection was 21 months and 18 months respectively (P = 0.588). Patients who received PD with venous and arterial resection had a median survival of 7 months, significantly less than standard PD (P = 0.044). Median survival in the palliative bypass group was 4 months, comparable to PD with venous and arterial resection (P = 0.191). There was a significant survival advantage in patients who received an R0 resection (median survival 24 months) compared to those who received an R1 resection (median survival 18 months) (P < 0.02). Patients with a lymph node ratio <0.2 had a median survival of 25 months, which was significantly higher than that of patients who had a lymph node ratio ≥0.2 (9 months) (P < 0.005).

CONCLUSION

PD with venous resection has similar survival to standard PD with no increased risk of procedure specific post-operative complications. On the other hand, PD with venous resection and additional arterial resection has no survival benefit and may be a step too far in our experience.

One-layer versus two-layer duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: study protocol for a randomized controlled trial

Background

Although various pancreaticojejunal duct-to-mucosa anastomosis methods have been developed to reduce the postoperative risks of pancreaticoduodenectomy, pancreatic fistula remains the most serious complication with a high incident rate. The aim of this study is to compare the safety and effectiveness of one-layer and two-layer duct-to-mucosa pancreaticojejunostomy in patients undergoing pancreaticoduodenectomy.

Methods/design

In this study, adult patients who sign consent forms will be recruited and scheduled for elective pancreaticoduodenectomy. One hundred and fourteen patients will be included and randomized before pancreaticojejunal reconstruction and after resection of the lesion from the pancreatic or periampullary region. The primary efficacy endpoint is the incident rate of postoperative pancreatic fistula. Statistical analysis will be based on the intention-to-treat population. Patients will be followed up for 3 months by monitoring for complications and other adverse events.

Discussion

This prospective, single-center, randomized, single-blinded, two-group parallel trial is designed to compare one-layer with two-layer duct-to-mucosa anastomosis for pancreaticojejunal anastomosis during elective pancreaticoduodenectomy.

Trial registration

Clinical Trials.gov: NCT02511951. Registered on 29 July 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1517-8) contains supplementary material, which is available to authorized users.

Duct-to-Mucosa vs Invagination for Pancreaticojejunostomy after Pancreaticoduodenectomy: A Prospective, Randomized Controlled Trial from a Single Surgeon

BACKGROUND

Pancreatic fistula (PF) is the most common significant complication after pancreaticoduodenectomy. Invagination and duct-to-mucosa anastomoses are anastomotic techniques that are commonly performed after pancreaticoduodenectomy. There are conflicting data on invagination vs duct-to-mucosa anastomoses about which is superior for minimizing the risk of PF. In addition, all previous studies involved multiple operating surgeons and failed to control for variation in surgeon expertise.

STUDY DESIGN

This was a randomized controlled study comparing the outcomes of PD between patients who underwent invagination vs those who had duct-to-mucosa anastomoses. All 132 patients were operated on between October 2012 and March 2015 by a single surgeon experienced in both procedures. Pancreatic fistula was the main end point.

RESULTS

Overall and clinically relevant rates of PF rate were 29.5% and 10.6%, respectively. Overall PF rates in the patients treated with invagination vs duct-to-mucosa anastomoses were 30.9% vs 28.5% (p = 0.729), respectively and the corresponding clinically relevant PF rates were 17.6% vs 3.1%, respectively (p = 0.004). Although the overall complication rates were similar in the 2 groups, severe complications were significantly more frequent in the patients treated with invagination (p = 0.013). Duct-to-mucosa anastomosis was also associated with shorter postoperative hospital stay (13 vs 15 days; p = 0.021). There was one perioperative death. Independent variables for the risk of PF were the diameter of the pancreatic duct (greater risk with smaller diameter), the underlying pathology, and male sex.

CONCLUSIONS

Both methods yield similar overall rates for PF, but the rate of clinically relevant PF is lower in patients treated with duct-to-mucosa anastomosis. Additional single-surgeon studies or multi-institution randomized trials controlling for comparable expertise in both procedures should be conducted to confirm these results.