A novel anastomosis technique facilitates pancreaticojejunostomy in total laparoscopic pancreaticoduodenectomy (with video)

Abstract

Background While the best technique for pancreatic anastomosis during Whipple's procedure remains controversial, laparoscopic pancreaticoduodenectomy (LPD) has been rapidly increasing in popularity. Because of their feasibility and reliability, new pancreatic anastomosis techniques may have vital roles when adapted for LPD. Here, we describe a new pancreaticojejunostomy (PJ) technique using three sutures (termed the "three sutures" PJ technique), which facilitates pancreatic anastomosis during total LPD. Methods A total of 149 patients who underwent LPD using the "three sutures" PJ technique at three hospitals were included in this study (81 patients at Guangdong Provincial People's Hospital [GDPH], 60 patients at Sun Yat-Sen Memorial Hospital [SMH], and 8 patients at Affiliated Hospital of Guangdong Medical University [AHGMU]). Data on the demographic characteristics, operative outcomes, and postoperative results (pancreatic fistula rate, mortality rate, and length of hospital stay) of these patients were collected and analyzed. Results A surgical video showing the details of the "three sutures" PJ method was included. The mean operation times at GDPH, SMH, and AHGMU were 4.08 ± 0.99 h, 4.65 ± 1.53 h, and 4.67 ± 0.64 h, respectively, and the average PJ times were 17.96 ± 3.49 min, 18.19 ± 2.63 min, and 22.5 ± 3.96 min, respectively. The numbers of grade B pancreatic fistulas were 9 (11.11%), 2 (3.33%), and 1 (12.50%), respectively, and two patients had grade C fistulas, one each at GDPH and SMH. The numbers of clinically relevant postoperative pancreatic fistula (CR-POPF) were 10 (12.35%), 3 (5.00%), and 1 (12.50%) in each center, respectively. The overall rate of CR-POPF was 9.40% (14/149) among patients of all three centers. The perioperative mortality rate was 0%. Conclusions The "three sutures" PJ technique for total LPD is a safe and reliable method, with a low risk of pancreatic fistula, short anastomosis time, and steep learning curve.

Pancreaticojejunostomy Conducive to Biological Healing in Minimally Invasive Pancreaticoduodenectomy

“…In 2021, Zhou et al reported the “three sutures” PJ, which also applies purse-string suture in the anastomosis. 11 First, a U-shaped suture penetrating the pancreas is placed around the MPD, and the needles are preserved for further use after knotting (Fig. 7a ).…”

“…Further, it should be confirmed that the tube is tightly fixed within the MPD in case of displacement. The tightening of the purse-string sutures should also be performed properly; otherwise, pancreatic juice may seep from the gap 11 Zhou et al The whole anastomosis: 4–0 polypropylene 17 mm 1/2c (Prolene) sutures The combined use of the pancreatic stent and the purse-string sutures helps to ensure the patency of the pancreatic juice outflow and promote the healing of pancreaticointestinal epidermis along the tube Double-layer DTM interrupted PJ (modified Blumgart PJ) 38 Fujii et al U-suture: 4–0 double-needles polypropylene 17 mm 1/2c (Prolene) sutures Double-arm “mattress sutures” facilitate the wrapping of the anastomotic stoma by the jejunum and provide evenly distributed shear force The procedures are still relatively complex for MIPD, and there is a risk of lateral injury of the MPD when placing the transpancreatic U-sutures 15 Kobayashi et al DTM anastomosis: 5–0 absorbable sutures; U-suture: 4–0 double-needles non-absorbable sutures Reduced U-sutures are placed to minimize the risk of lateral injury 39 Li et al U-suture and fixation of the pancreatic stent: 3–0 double-needles polypropylene 17 mm 1/2c (Prolene) sutures DTM anastomosis is omitted by pancreatic stenting and posterior walls of the anastomotic stoma are superimposed on each other to eliminate the dead cavity 40 Kojima et al U-suture: 4–0 double-needles polypropylene 17 mm 1/2c (Prolene) sutures Peritoneal lavage is performed to clean the abdominal cavity and closed drains with dressing materials are placed to prevent retrograde infection 16 Menonna et al U-suture: 3–0 double-needles polypropylene 17 mm 1/2c (Prolene) sutures The number of the U-sutures are reduced to 2, and 2 half purse-string sutures are placed at both corners of the pancreas to strengthen the fixation 41 Poves et al U-suture: 2–0 double-needles polypropylene 36 mm 1/2 c (Prolene) sutures; DTM anastomosis: 5–0 polyglactin 910 13 mm 1/2c (Vicryl) sutures The distance and angle between the pancreas and the jejunum can be adjusted by external traction of the transpancreatic sutures out of the trocars; thus, suturing under a laparoscope is conveniently possible Modified invaginated PJ <...…”

“… 10 – 13 Regarding innovation, this theory emphasizes that excessive sutures are not conducive to the coalescence of anastomotic stoma and may even increase the risk of POPF. For example, if the needle distance is too near, the blood supply of the pancreatic remnant will be destroyed 10 , 11 , 14 ; if there are too many sutures of the MPD, pancreatic juice seeping out of the pinholes may corrode the vascular stumps resulting in secondary hemorrhage. 11 , 15 , 16 Furthermore, if the sutures are overtightened, the shear force of strings may lead to pancreatic edema and necrosis.…”

“…For example, if the needle distance is too near, the blood supply of the pancreatic remnant will be destroyed 10 , 11 , 14 ; if there are too many sutures of the MPD, pancreatic juice seeping out of the pinholes may corrode the vascular stumps resulting in secondary hemorrhage. 11 , 15 , 16 Furthermore, if the sutures are overtightened, the shear force of strings may lead to pancreatic edema and necrosis. 10 , 11 , 17 Therefore, instead of pursuing mechanical tightness alone, we should consider factors such as the blood supply of the tissues, tension of the anastomotic stoma, healing of the pancreatic stump, and recovery of digestive function.…”

“… 11 , 15 , 16 Furthermore, if the sutures are overtightened, the shear force of strings may lead to pancreatic edema and necrosis. 10 , 11 , 17 Therefore, instead of pursuing mechanical tightness alone, we should consider factors such as the blood supply of the tissues, tension of the anastomotic stoma, healing of the pancreatic stump, and recovery of digestive function. “Wide, loose, and sparse” anastomosis has been recommended as a new goal for PJ.…”