Imanaga’s First Method for Reconstruction with Preservation of Mesojejunal Autonomic Nerves During Pylorus-Preserving Pancreatoduodenectomy

Abstract

Case seriesPatient: —Final Diagnosis: Pancreatic diseasesSymptoms: Postoperative physiologic functionMedication: —Clinical Procedure: Imanaga’s first methodSpecialty: SurgeryObjective:Unusual or unexpected effect of treatmentBackground:Pancreatic surgeries have undergone substantial development. Pancreaticoduodenectomy and pylorus-preserving pancreatoduodenectomy inherently require reconstruction. In 1960, Professor Imanaga introduced a reconstructive technique performed in the order of the gastric remnant, pancreatic duct, and biliary tree from the viewpoint of physiologic function after pancreaticoduodenectomy. We herein report our experience with Imanaga’s first method during pylorus-preserving pancreatoduodenectomy and retrospectively evaluate the short- and long-term outcomes. Technicalities and pitfalls are also discussed.Case Report:Eight patients were evaluated (mean follow-up period, 16.7±1.0 years). Mesojejunal autonomic nerves were preserved without tension to the greatest extent possible for reconstruction. Intentional dissection of regional lymph nodes and nerves was performed in five and two patients, respectively. During the short-term postoperative period, one patient developed pancreatic leakage resulting in an intraperitoneal abscess, and endoscopic transgastric drainage was required. Two patients developed delayed gastric emptying. In three patients, passage from the duodenojejunostomy to pancreaticojejunostomy was mechanically disturbed, and endoscopic dilations with a balloon bougie were repeated. Repeated cholangitis was observed in three patients. During the long-term postoperative period, neither cachexia nor sarcopenia was observed, although two patients had diabetes. Two patients were free from all medications. Three patients who did not undergo intentional dissection of lymph nodes and nerves showed acceptable short- and long-term outcomes, although one each developed repeated cholangitis and adhesive ileus during the short-term period.ConclusionsImanaga’s first reconstruction may have potential benefits, especially for diseases that do not require intentional dissection. Adequate mobilization of the pancreatic remnant is important for successful reconstruction.

Inferior Pancreaticoduodenal Artery Aneurysm Related with Groove Pancreatitis Persistently Repeated Hemosuccus Pancreaticus Even After Coil Embolization

“…A simple question has arisen: Is a PD for pancreatic aneurysm and HP risky business? The risk of PD has fallen to 5% to 10% [25,27], though PD easily causes postoperative complications (e.g., delayed gastric emptying, gastrointestinal ulcer, postoperative cholangitis, anastomotic leakage, intraperitoneal abscess, intractable pancreatic fistula, pseudoaneurysm, and massive bleeding). Actual findings of typical complications after advanced SSpPDs with extended resections of vessels and surrounding organs and/or intentional dissections of nerve plexuses and lymph nodes were summarized in Figure 6.…”

Aggressive Graphic/Surgical R0 Resection and Jejunal Interposition with Preservation of Mesojejunal Autonomic Nerves in Patients with Stage IV Esophagogastric Junction Adenocarcinoma: A Report of 3 Cases

“…The clinical profiles of our 3 patients are summarized in Table 1; note that all patients received adjuvant chemotherapy from the early postoperative period (POD 10 or 11). Sufficient oral intake is important for excellent postoperative course [13,14,44,45]. Adequate intakes in each case were accomplished at each POD of start of meal intake, if adequate intake was defined as a dietary intake of more than half of meal [13,14,45].…”

“…Sufficient oral intake is important for excellent postoperative course [13,14,44,45]. Adequate intakes in each case were accomplished at each POD of start of meal intake, if adequate intake was defined as a dietary intake of more than half of meal [13,14,45]. Systemic chemotherapy is a key in the treatment of stage IV EGJC [20,46].…”

“…The importance of preservation of mesojejunal autonomic nerves has been documented in the field of digestive surgery [15,16]. The interposing jejunum was harvested at a suitable point from the ligament of Treitz (Approximately 40 cm from the Treitz), and our surgical techniques for preservation of the mesojejunal autonomic nerves of the lifted jejunum are described in detailed elsewhere [13,14]. To preserve the physiological function of the autonomic nerves in the distal mesojejunum, the jejunum was sacrificed as close to the jejunal wall as possible (Figure 1A).…”

“…In our institution, we employed jejunal interposition for digestive reconstruction, in which end-to-end jejunojejunostomy was performed with a biofragmentable anastomosis ring [13]. Moreover, the mesojejunal autonomic nerves of the lifted jejunum were preserved [13,14]. We managed 3 patients with stage IV EGJC (adenocarcinoma) who underwent extended treatments for graphic/surgical R0 resection and adjuvant chemotherapy from the early postoperative period.…”