Pancreaticogastrostomy after Pancreaticoduodenectomy Using Twin Square Wrapping with Duct-to-Mucosa Anastomosis

Abstract

Background/Purpose: This study aimed to evaluate the feasibility and safety of a novel pancreaticogastrostomy technique for diminishing pancreatic fistulas after pancreaticoduodenectomy using gastric wrapping of the pancreatic stump with a twin square-shaped horizontal mattress and a suture fixing the main pancreatic duct to the gastric mucosa anastomosis [twin square wrapping (TSW) method]. Methods: Fifty-three patients undergoing pancreaticogastrostomy after pancreaticoduodenectomy were included in the study and chronologically divided into a conventional group (n = 32) and a TSW group (n = 21). The perioperative factors and the postoperative outcomes were retrospectively analyzed. Results: The operating time for the pancreatic anastomosis, the total operating time, and the blood loss volume in the TSW group were lower than in the conventional group, but without a statistically significant difference. The TSW group had a significantly lower postoperative white blood cell count and C-reactive protein level, with a reduced intra-abdominal fluid accumulation as assessed by computed tomography on postoperative day 7, had a lower incidence of postoperative complications and pancreatic fistulas, and achieved a shorter duration of drain placement and shorter postoperative hospital stays as compared to the conventional group. Conclusions: The TSW technique should be considered for reducing pancreatic fistulas by diminishing the postoperative inflammatory response and improving patient outcomes without increasing the operating time.

Modified “Blumgart-Type” Suture for Wirsung-Pancreaticogastrostomy: Technique and Results of a Pilot Study

“…These results are consistent with former retrospective studies featuring duct-to-mucosa anastomosis, pancreas-transfixing U-shaped sutures, and protection of the raw pancreatic cut surface provided by the gastric serosa wrapping the pancreatic remnant [9, 10]. Similarly to these designs, in B-WPGA the pancreaticogastric sutures are few and positioned in one layer, offering fewer occasions to fracture the pancreatic parenchyma; good visibility is also maintained during duct-to-mucosa anastomosis.…”

“…The results from this study improve on our previous POPF rate of 12% and compare well with fistula rates ranging from 0 to 30% in the literature [7, 9, 10, 18], although the fraction of cases with a soft pancreas in this series is smaller than in some of the previous studies on WPGA [9].…”

“…In the previous studies, however, pancreaticogastric sutures were knot-tied between the gastric serosa and the pancreatic capsule [9, 10]; in this respect, we envisaged potential risks of parenchymal fracture secondary to knot-tying or excessive manipulation of the pancreatic remnant, which have been indicated as the most important source of anastomosis-related morbidity that BA was designed to avoid [24]. B-WPGA differs from previous approaches in specific aspects:…”

“…The whole of the raw surface of the pancreas faces the gastric submucosa; the gastric submucosa provides cushioning and tamponades small accessory ducts; anastomosing to the gut submucosa has shown ability to provide quicker coalescence of anastomotic surfaces compared to serosa, with fewer necrotic areas and improved collagen deposition [22]; in the two previously published similar designs, the raw surface of the pancreas faces the submucosa near the opening of the Wirsung duct and the gastric serosa at the periphery [9, 10]…”

Is Invagination Anastomosis More Effective in Reducing Clinically Relevant Pancreatic Fistula for Soft Pancreas After Pancreaticoduodenectomy Under Novel Fistula Criteria: A Systematic Review and Meta-Analysis

“…After careful reading of these nine full-text articles, two studies were excluded because they did not include POPF outcomes. The remaining seven RCTs were included in the qualitative analysis and the final meta-analysis (10)(11)(12)(13)(14)(15)(16).…”