Yonsei Med J.  2018 Sep;59(7):872-878. 10.3349/ymj.2018.59.7.872.

Fish-Mouth Closure of the Pancreatic Stump and Parachuting of the Pancreatic End with Double U Trans-Pancreatic Sutures for Pancreatico-Jejunostomy

• Lee WJ

• KMID: 2428914
• DOI: http://doi.org/10.3349/ymj.2018.59.7.872

Abstract

PURPOSE
Leakage of pancreatico-jejunal anastomosis (PJ) remains the primary cause of morbidity and mortality after Whipple's operation. To reduce the occurrence thereof, the present author recently began to apply a modification of the Blumgart method of anastomosis after Whipple's operation (hereinafter referred to as Lee's method), with very good results.
MATERIALS AND METHODS
The modified method and technique utilizes fish-mouth closure of a beveled pancreatic stump and parachuting of the pancreatic end with double U trans-pancreatic sutures (symmetric horizontal mattress-type sutures between the full thickness of the pancreas and the jejunal limb) after duct-to-mucosa pancreatico-jejunostomy.
RESULTS
Eleven cases of pylorus preserving Whipple's operation have been performed without a clinically significant postoperative pancreatic fistula.
CONCLUSION
This new method (Lee's method) may dramatically reduce the occurrence of postoperative pancreatic fistula after Whipple's operation.

Keyword

Pancreatico-jejunostomy; Blumgart anastomosis; fish-mouth closure of pancreatic stump; post-operative pancreatic fistula (POPF); Whipple's operation

MeSH Terms

Aviation*
Methods
Mortality
Pancreas
Pancreatic Fistula
Pylorus
Sutures*

Figure

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  Fig. 1 Fish-mouth closure of the pancreatic stump. (A) Pancreatic stump with raw cut surface after cutting at the neck. (B) Fish-mouth wedge shaped by carving with a loop electrode. (C) The beveled edge of the pancreatic stump is closed with interrupted 4-0 Prolene vertical mattress sutures (fish-mouth approximation), except for the area around the main pancreatic duct.

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  Fig. 2 Valleylab tungsten loop electrode and a loop electrode on an electrosurgical pencil.

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  Fig. 3 Image of a beveled pancreatic stump carved with a loop electrode before fish-mouth closure.

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  Fig. 4 Image of a pancreatic stump that has been closed in a fish-mouth fashion with a short silicone tube stent prior starting pancreatico-jejunal duct-to-mucosa anastomosis.

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  Fig. 5 Depiction of the mucosa squeeze-out technique.

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  Fig. 6 Images of the mucosa squeeze-out technique.

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  Fig. 7 Starting the pancreatico-jejunostomy using U sutures (posterior trans-pancreatic U suture) with 3-0 Prolene.

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  Fig. 8 Anterior U suture after duct-to-mucosa pancreatico-jejunostomy.

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  Fig. 9 Pancreatico-jejunostomy after the double U sutures are tightened at a final step to approximate the gland and the jejunum by parachuting (horse saddle shape) with tension evenly distributed across four suture sites.

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  Fig. 10 Image showing that only the pancreatic duct is connected to the jejunum and that the stump of the pancreas has not adhered to the serosa of the jejunum.

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  Fig. 11 Difference between the Blumgart and Lee's method of pancreatico-jejunostomy after U suture. Minor pancreatic ducts are exposed and covered by a jejunal serosal patch with BA. With Lee's method, the minor ducts are closed with a fish-mouth closure and covered by a jejunal serosal patch.

Reference

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