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

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.

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

“…PJ was commonly used in reconstruction after PD, but the incidence of POPF remained high. PJ was further divided into two main categories, namely, duct-to-mucosa or invagination (dunking) 14 . In 2000, a novel method of PJ that combined the principle of duct-to-mucosa with the transpancreatic U suture technique was first proposed by Blumgart 15 .…”

Chen’s penetrating-suture technique for pancreaticojejunostomy following pancreaticoduodenectomy

“…Difficult procedures and surgical experience deficiency can also cause anastomotic failure. In order to prevent the failure of pancreaticojejunostomy failure, several techniques have been used and evaluated [ 4 , 15 , 24 – 26 ], including the anastomotic site (the pancreaticojejunostomy and pancreatogastrostomy), direction of anastomosis (end-to-end and end-to-side), anastomosis layer (one layer or two layer or three layer anastomosis); suture method (interrupted suture, continuous suture, mattress suture, purse string suture and binding, etc. ), suture material improvement (silk suture, Vicryl or non traumatic suture), and application of the pancreatic stent tube, etc.. All these improved methods cannot fundamentally prevent pancreaticojejunostomy failure.…”

Chen’s Penetrating-Suture Technique for Pancreaticojejunostomy Following Pancreaticoduodenectomy

“…Di cult procedures and surgical experience de ciency can also cause anastomotic failure. In order to prevent the failure of pancreaticojejunostomy failure, several techniques have been used and evaluated [4][16] [25][26][27] , including the anastomotic site (the pancreaticojejunostomy and pancreatogastrostomy), direction of anastomosis (end-to-end and end-toside), anastomosis layer (one layer or two layer or three layer anastomosis); suture method (interrupted suture, continuous suture, mattress suture, purse string suture and binding, etc. ), suture material improvement (silk suture, Vicryl or non traumatic suture), and application of the pancreatic stent tube, etc.. All these improved methods cannot fundamentally prevent pancreaticojejunostomy failure.…”