Pancreaticojejunostomy for Pancreatico-enteric Anastomosis after Pancreaticoduodenectomy: one procedure with multiple techniques

[Robotic Pancreatoduodenectomy: Variations of Modified Blumgarts Pancreatojejunostomy]

Die wichtigste Komplikation nach Pankreatoduodenektomie ist die klinisch relevante Pankreasfistel. Um die Rate an Komplikationen zu senken, ist eine routinierte und standardisierte Operationstechnik zur Anlage der Pankreatojejunostomie notwendig.

Die Pankreatoduodenektomie ist im multimodalen Setting der Goldstandard zur Behandlung des lokal begrenzten Pankreaskopfkarzinoms und weiterer Pathologien. Das robotische Verfahren bietet als innovatives minimalinvasives Verfahren Vorteile bez. Morbidität und Ergonomie.

Nach der Resektionsphase folgt die Rekonstruktion beginnend mit der Pankreatojejunostomie. Die aktuell meistverbreitete robotische Technik ist die Anastomose nach Blumgart: Dabei wird eine äußere Naht transpankreatisch zwischen Jejunalwand und dem gesamten Pankreasparenchym in ventrodorsaler Ausrichtung angelegt, die Spannungs- und Scherkräfte verteilt. Die innere Naht wird durch eine Duct-to-Mucosa-Naht des Pankreasganges mit einer kleinen Jejujunostomie erreicht. In diesem Manuskript werden verschiedene Varianten dieser Rekonstruktion in robotischer Technik gezeigt.

Hinsichtlich der wissenschaftlichen Evidenz zeigt keine Anastomosenvariante einen Vorteil. Das Outcome ist abhängig von der Expertise des Operateurs, entsprechend sollte diejenige Anastomosentechnik angewendet werden, für die am meisten Erfahrung verfügbar ist. Die in diesem Beitrag gezeigten Variationen sollen für Anwender den Fokus auf wichtige Details legen sowie Tipps und Tricks zur Durchführung geben.

Surgical treatment of pancreaticojejunal stenosis after pancreaticoduodenectomy: case report

Pancreaticoduodenectomy is established as the procedure of choice for malignant tumor pathologies of the head of the pancreas or ampulla, where the patient's life prognosis is low. Complications after pancreaticoduodenectomy (e.g. pancreatic fistulas, hemorrhages, or intra-abdominal collection) are well described in the literature and are generally acute. However, there is still a small risk for late complications (e.g. pancreatitis, pancreatic insufficiency), and due to its low incidence, there has not been a consensus on the treatment. We present the case of an 18-year-old female with recurrent bouts of acute pancreatitis as a late complication of a pancreaticoduodenectomy plus pancreatojejunal anastomosis due to a pseudopapillary tumor of the pancreas. The complication was managed though surgical revision consisting of dilation and stent placement in the stenosis. The patient had an adequate postoperative evolution without further complications. Despite the advances in the surgical field, pancreaticoduodenectomy represents a highly complex surgery with high morbidity and mortality rates. The late complications of this surgery are under continuous study due to its low incidence associated with low patient survival.

Intussusception of Gastrojejunostomy After Pancreatoduodenectomy With Billroth II Reconstruction

Gastrojejunal anastomosis or gastrojejunostomy (GJ) is a surgical procedure used for allowing gastric emptying, especially in cases where complex reconstructions are needed. One of the less common complications but one of the most relevant in morbidity is the intussusception of the GJ. It requires a high index of suspicion, preoperative optimization of the patient, diagnostic corroboration, and identification of associated complications with the use of contrasted imaging. It was described for the first time by Bozzi in 1914; currently, multiple cases have been described in the literature, being more frequent in bariatric surgeries and reconstructions after distal gastrectomy. In hepatopancreaticobiliary surgery, it is an even uncommon complication. We present the case of a 60-year-old man with intussusception of the efferent loop of the GJ after a pylorus-preserving pancreatoduodenectomy with a Billroth II reconstruction in the setting of malignancy of the extrahepatic bile duct along with our emergency surgical treatment.

Which Suture to Choose in Hepato-Pancreatic-Biliary Surgery? Assessment of the Influence of Pancreatic Juice and Bile on the Resistance of Suturing Materials—In Vitro Research

(1) Background: The choice of appropriate surgical suture during operation is of great significance. Currently, there are no objective studies regarding the resistance of commonly used sutures in biliary tract surgery. (2) Methods: This fact leads one to conduct research concerning the resistance of the sutures (Polydioxanone, Poliglecaprone, Poliglactin 910, and their analogues coated with antibacterial triclosan) in the environment of sterile and contaminated bile and pancreatic juice. Tensile strength was tested at days 0, 7, 14, 21, and 28 of research. The study was performed in in vitro conditions for 28 days. (3) Results: Pancreatic juice and bile has a significant influence on the tensile strength of each suture. (4) Conclusions: The study indicated that sutures made of polydioxanone had the best qualities during the entire experiment.