An intuitive method of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: use of one-step circumferential interrupted sutures

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.

Contemporary Surgical, Oncological, and Survival Outcomes of Pancreaticoduodenectomy for Periampullary Tumours: a 5-Year Experience from Tertiary Cancer Center

With advances in surgical management of pancreaticoduodenectomy (PD), mortality rate for PD has been reported to be less than 5%. Postoperative pancreatic fistula (POPF) remains a major complication and morbidity after PD with incidence of up to 40%. This is a retrospective analysis of patients who underwent PD in a tertiary cancer referral center in southern India. Data was collected for the patients operated during the period from Jan 2014 to Dec 2018. Surgicopathological, oncological, and survival outcomes were described. Of 76 patients presumed as operable, 16 were excluded and data analyzed for 60 patients. Forty-four percent underwent classical Whipple's PD and 56% pylorus-preserving PD. The most common postoperative complications were wound infection (25%); pneumonia (20%); clinically relevant POPF (13%); and delayed gastric emptying (19%). Thirty-day in-hospital mortality was 5%, 90-day mortality was 8.3%, and fistula-related mortality was 1.6%. Ampullary cancer was the most common histology. Three-year survival rate was 23.3% with a mean overall survival of 33.2 months with significantly better survival in the node negative than positive group (41.3 vs 20.5 months, P = 0.003) and significantly lower survival in pancreatic head cancer than other tumor histologies (16.6 vs 37.3 months, P = 0.002). Multivariate analysis has shown pancreatic head histology (HR = 2.38, 95% CI (1.08-5.26), P = 0.033) and nodal positivity (HR = 2.38, 95% CI (1.27-4.44), P = 0.007) as poor prognostic factors. Pancreaticoduodenectomy is a safe operation in experienced hands. Adhering to a meticulous adaptable reproducible anastomotic technique with standard perioperative management strategies significantly decreases the operative morbidity and mortality.

Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.

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.

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.

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.