Modified Technique for Wirsung-Pancreatogastric Anastomosis after Pancreatoduodenectomy: A Single Center Experience and Systematic Review of the Literature

Abstract

Background: The mortality rate following pancreaticoduodenectomy (PD) has been decreasing over the past few years; nonetheless, the morbidity rate remains elevated. The most common complications after PD are post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) syndrome. The issue as to which is the best reconstruction method for the treatment of the pancreatic remnant after PD is still a matter of debate. The aim of this study was to retrospectively analyze the morbidity rate in 100 consecutive PD reconstructed with Wirsung-Pancreato-Gastro-Anastomosis (WPGA), performed by a single surgeon applying a personal modification of the pancreatic reconstruction technique. Methods: During an 8-year period (May 2012 to March 2020), 100 consecutive patients underwent PD reconstructed with WPGA. The series included 57 males and 43 females (M/F 1.32), with a mean age of 68 (range 41–86) years. The 90-day morbidity and mortality were retrospectively analyzed. Additionally, a systematic review was conducted, comparing our technique with the existing literature on the topic. Results: We observed eight cases of clinically relevant POPF (8%), three cases of “primary” DGE (3%) and four patients suffering “secondary” DGE. The surgical morbidity and mortality rate were 26% and 6%, respectively. The median hospital stay was 13.6 days. The systematic review of the literature confirmed the originality of our modified technique for Wirsung-Pancreato-Gastro-Anastomosis. Conclusions: Our modified double-layer WPGA is associated with a very low incidence of POPF and DGE. Also, the technique avoids the risk of acute hemorrhage of the pancreatic parenchyma.

Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score

“…Therefore, in this context, the question "pancreaticogastrostomy or pancreaticojejunostomy? ", first presented by Kausch and Whipple, still remains open today [8,30]. In this regard, a few reported meta-analyses and randomized trials have found that pancreaticogastrostomy might be better as it was associated with a smaller rate of pancreatic fistulas in the conducted studies.…”

“…Multiple advantages and disadvantages for both the pancreaticogastrostomy and pancreaticojejunostomy procedures have been communicated so far. A pancreaticogastrostomy is considered to be easier to perform (less technically demanding) than a pancreaticojejunostomy and its advantages include the following: the anatomic proximity, rich gastric vascularization, the gastric low pH preventing the activation of the pancreatic enzymes or inactivating them, absence of the enterokinase, and better postoperative control (endoscopy) with the possibility of gastric decompression and a putative lower risk of pancreatic fistula [2,8,30]. However, there are also disadvantages associated with such an anastomosis: difficult hemostasis of the gastric submucosa, a more difficult mobilization of the pancreas, increased risk of hemorrhage, postoperative delayed gastric emptying (due to gastroparesis and possible tensions on the anastomosis), and risk of pancreatic enzymes inactivation.…”

Updates on the Treatment of Pancreatic Diseases: Focus on Surgery, Electrochemotherapy and Rituximab

“…The overall rates of post-operative pancreatic fistula and delayed gastric emptying syndrome were low in this study [ 5 ]. They highlighted their results by comparing them with the available literature on wirsung-pancreato-gastro-anastomosis [ 5 ]. Furthermore, to reduce exocrine and endocrine complications, parenchymal-sparing pancreatic and duodenal resections have been considered for various benign or borderline malignant pancreatic tumors.…”

“…For patients with a localized pancreatic tumor involving the periampullary region, pancreatoduodenectomy (PD) is the recommended surgery, although there is still no standard regarding the surgical reconstruction method. In the present Special Issue, Bizzoca et al found surgical morbidity and mortality rates of 26% and 6%, respectively, in a retrospective series of 100 patients treated with PD and reconstructed with wirsung-pancreato-gastro-anastomosis [ 5 ]. The overall rates of post-operative pancreatic fistula and delayed gastric emptying syndrome were low in this study [ 5 ].…”

“…In the present Special Issue, Bizzoca et al found surgical morbidity and mortality rates of 26% and 6%, respectively, in a retrospective series of 100 patients treated with PD and reconstructed with wirsung-pancreato-gastro-anastomosis [ 5 ]. The overall rates of post-operative pancreatic fistula and delayed gastric emptying syndrome were low in this study [ 5 ]. They highlighted their results by comparing them with the available literature on wirsung-pancreato-gastro-anastomosis [ 5 ].…”