Ann Hepatobiliary Pancreat Surg.  2017 Feb;21(1):39-47. 10.14701/ahbps.2017.21.1.39.

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

• Kim M
• Shin WY
• Lee KY
• Ahn SI

• KMID: 2371566
• DOI: http://doi.org/10.14701/ahbps.2017.21.1.39

Abstract

Pancreaticoenteric anastomosis is the origin of postoperative pancreatic fistula (POPF). Although a variety of methods have been proposed to decrease the POPF rate, randomized controlled trials performed so far have failed to demonstrate superiority of any particular method to the others. Cattell-Warren duct-to-mucosa pancreaticojejunostomy (PJ) is a widely practiced procedure. Their method is challenging, especially when the pancreatic duct is small. We assumed that the difficulty resides in the pancreatic duct becoming difficult to access when the posterior row is tied before suturing the anterior row. We have modified the duct-to-mucosa PJ so that the entire circumference of the inner layer can be sutured and tied in one-step by anchoring and retracting the anterior row. The jejunal roux-limb and pancreatic stump are positioned spatially apart, allowing enough space for free needle work. During a 13-year period, 151 patients underwent pancreaticoduodenectomy with this method, and the cumulative POPF and mortality rates were 37.1% and 4.6%, respectively. These rates were stable throughout the study period, implicating a relative independence from surgeons' experience. We believe that our method is intuitive, easy to grasp, and can be readily adopted even by surgeons not accustomed to pancreaticoduodenectomy.

Keyword

Pancreaticojejunostomy; Pancreaticoduodenectomy; Surgical anastomosis

MeSH Terms

Anastomosis, Surgical
Hand Strength
Humans
Methods*
Mortality
Needles
Pancreatic Ducts
Pancreatic Fistula
Pancreaticoduodenectomy*
Pancreaticojejunostomy*
Surgeons
Sutures*

Figure

• 

  Fig. 1 Starting duct-to-mucosa pancreaticojejunostomy. The jejunum (J) and the pancreatic stump (P) are located apart, providing a clear visual field for the cut surface of the pancreas (A). Schematic drawing with jejunal opening and pancreatic duct orifice accentuated. Two absorbable sutures are placed in the inferior (3 o'clock) and superior (9 o'clock) directions. The needle work is performed in an out-in-in-out manner starting from the jejunal side. Also note that two stay sutures (arrow) are placed at either ends of the pancreatic stump (B).

• 

  Fig. 2 Suturing the posterior row of the inner layer. Operative photograph showing sufficient space for free needle work. Note that an assist right-angled clamp is retracting the already-sutured thread away from the working needle (A). Schematic diagram showing in-out-out-in needle work starting from the pancreatic duct side. Newly placed sutures are presented in red (B).

• 

  Fig. 3 Suturing the anterior row of the inner layer. Operative photograph showing an anterior (12 o'clock) suture including a short plastic stent. The needle work was performed in an out-in-stent-in-out manner from the jejunal side (A). Schematic diagram showing all anterior row sutures retracted caudad using anchoring threads (purple). Newly placed sutures are shown in red (B).

• 

  Fig. 4 Completing the inner layer of duct-to-mucosa anastomosis. (A) Tying the posterior row with an approximation of the jejunal limb and the pancreatic stump. Knot making is easily completed because anterior row sutures are anchored and retracted out of the working space. (B) Tying the anterior row. Note that the blunt-end of the stent causes bulging of the jejunal wall (arrow).

• 

  Fig. 5 Suturing the posterior row of the outer layer. (A) The posteroinferior aspect of the anastomosis can be approached from the caudal side of the patient. Note that the needle holder is freely positioned so that the needle can enter the pancreas perpendicular to its surface. (B) The posterosuperior aspect can be exposed by gently lifting the anastomosis anteriorly with the operator standing cephalad.

• 

  Fig. 6 (A) Operative photograph showing completed pancreaticojejunostomy (PJ) and hepaticojejunostomy (HJ), leaving the seromuscular layer of duodenojejunostomy (DJ). (B) Photograph of the resected specimen from a patient who suffered a local recurrence 50 months after pylorus-preserving pancreaticoduodenectomy. The tip of the hemostatic clamp indicates patent duct-to-mucosa anastomosis. Note that the sides of the anastomosis was waisted in a herringbone manner (arrow).

• 

  Fig. 7 Postoperative pancreatic fistula (POPF) rate, as calculated by using the International Study Group (ISGPF) definition. POPF rates were not different between the same-sized groups treated during consecutive periods.

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