Modified Heidelberg Technique for Pancreatic Anastomosis

Abstract

Background : Pancreatic fistula is a major cause of morbidity and mortality after pancreatoduodenectomy. To prevent this complication, many technical procedures have been described. Aim: To present a novel technique based on slight modifications of the original Heidelberg technique, as new pancreatojejunostomy technique for reconstruction of pancreatic stump after pancreatoduodenectomy and present initial results. Method: The technique was used for patients with soft or hard pancreas and with duct size smaller or larger than 3 mm. The stitches are performed with 5-0 double needle prolene at the 2 o’clock, 4 o’clock, 6 o’clock, 8 o’clock, 10 o’clock, and 12 o’clock, positions, full thickness of the parenchyma. A running suture is performed with 4-0 single needle prolene on the posterior and anterior aspect the pancreatic parenchyma with the jejunal seromuscular layer. A plastic stent, 20 cm long, is inserted into the pancreatic duct and extended into the jejunal lumen. Two previously placed hemostatic sutures on the superior and inferior edges of the remnant pancreatic stump are passed in the jejunal seromuscular layer and tied. Results : Seventeen patients underwent pancreatojejunostomy after pancreatoduodenectomy for different causes. None developed grade B or C pancreatic fistula. Biochemical leak according to the new definition (International Study Group on Pancreatic Surgery) was observed in four patients (23.5%). No mortality was observed. Conclusion : Early results of this technique confirm that it is simple, reliable, easy to perform, and easy to learn. This technique is useful to reduce the incidence of pancreatic fistula after pancreatoduodenectomy.

Combined Bile Duct and Pancreatic Duct Injuries during Distal Gastrectomy for Obstructing Peptic Ulcer Disease

“…Soft pancreas with narrow ducts is better dunked into the stomach due to the technical ease. However, at expert hands with the aid of intraoperative loupe, duct-to-mucosa pancreatojejunostomy (modified Heidelberg technique) is an alternative with excellent outcome as was performed in the present case [ 8 ]. The nondilated bile duct (for hepaticojejunostomy) is better dealt with by wide spatulation or by using a Miller's cuff at the level of cystic duct insertion for narrowing free anastomosis to the jejunum.…”

Modified Heidelberg technique of pancreatic anastomosis postpancreaticoduodenectomy – 10 years of experience

“…Torres et al in 2017 modified the original Heidelberg technique of pancreaticojejunostomy described by the Heidelberg group and later by Shrikhande et al and published their data of 17 patients. [2][3][4] We have been using a similar technique although with minor technical differences since 2008 in consecutive 208 patients.…”

“…Pancreatic fistulas have always been a dreaded complication after PA with current literature showing incidence somewhere between 3% and 45% probably because multiple techniques of pancreatic reconstruction have been described, and few authors have candidly reported their anastomotic dehiscence rates. [2] The consideration of multiple techniques of anastomosis, however, only points to the supposition that no one technique is irrevocably better than the other. Nevertheless, the detailed duct-to-mucosa anastomosis pioneered by the Heidelberg group in 2002 and later described by Shrikhande et al in 2007 continued to be one of the most commonly used techniques against which many other techniques were compared during the past decade.…”

“…[3,4] Of late, we read an adept article by Torres et al describing a modified Heidelberg technique (MHT) in 17 patients. [2] We were buoyant to read this article as it describes a technique that we have been using since 2008. In the past 10 years (2008-2018), we have used this technique sans publication in 208 patients post-PD for a sundry of pancreatic head lesions.…”

Pancreaticojejunostomy—a review of modern techniques

“…4c, d). Additionally, the intestine is fixed with two hemostatic stitches, previously placed in the pancreas (before the removal of the pancreatic head) [35].…”