Pancreaticogastrostomy following Pancreaticoduodenectomy: Review of 102 Consecutive Cases

Abstract

Disruption of the pancreatic anastomosis with resultant sepsis is the cause of nearly 50% of deaths following pancreaticoduodenectomy (PD). Traditionally, the pancreatic remnant is anastomosed to the jejunum. Pancreaticogastrostomy (PG) was introduced as an alternative by Waugh and Clagett in 1946 and by Park, Mackie, and Rhoads in 1967. The purpose of this retrospective review was to assess the safety of PG at a single institution. Between 1986 and 1998 a total of 102 patients underwent PG following PD. The indications for PD were periampullary carcinoma (n = 89), pancreatitis (n = 7), and miscellaneous (n = 6). Altogether, 80 patients underwent the traditional Whipple procedure and 22 the pylorus-preserving Whipple (PPW) procedure. The PG was performed by a single-layer invagination technique to the posterior gastric wall using interrupted silk sutures. Leaks from the pancreatic anastomosis were detected by measuring amylase in fluid obtained from surgically placed drains. Operative mortality was 3.9% (4/102). The cause of death was uncontrolled upper gastrointestinal hemorrhage, sepsis, pulmonary embolus, and cardiac failure secondary to myocardial infarction. The mean operating time was 6.8 hours. Blood transfusion was given in 43 patients (42%), and the mean amount of the transfusion was 2.6 units. Nonfatal complications occurred in 35 patients (34%), and included leaks from the pancreatic anastomosis in 9 (8.8%), leaks from the biliary-enteric anastomosis in 4 (3.9%), and gastric paresis 7 (6.9%). Other complications included abscess, wound infection, colitis, delirium tremens, and hyperbilirubinemia. Discharge occurred 6 to 47 days (median 12 days) postoperatively and was prolonged in patients suffering from a complication. PD is associated with significant morbidity. PG is a safe alternative to pancreaticojejunostomy for managing the pancreatic remnant.

Results of Pancreaticogastrostomy after Pancreaticoduodenectomy in 159 Consecutive Cases

“…A higher incidence of delayed gastric emptying (DGE) or prolonged requirement of a nasogastric tube was observed in those patients with pylorus-preserving modification of the PD [9,20] . Highly acidic gastric juice can have a corrosive effect on the anastomosis and lead to anastomotic leakage [20] .…”

“…Bleeding following PG can occur from either the anastomotic site or the cut surface of the pancreas. Such bleeding occurs early during the postoperative period and almost always requires re-laparotomy [9] . During reoperation bleeding is always easy to control with stitches applied through an anterior gastrostomy.…”

“…PG was shown to be technically feasible in 1934. Clinical introduction of PG seems Whipple pancreatic ACA T2N0M0 1 2 C anastomosis fistula suture 7 died 64 M II Whipple ampullary ACA T1N0M0 1 2 C pancreatitis relaparotomy 85 home 45 M II Whipple duodenal ACA T3N0M0 2 1 C anastomosis fistula suture 47 home 75 M III Whipple ampullary ACA T1N0M0 1 1 C necrosis of pancreas resection 13 died 61 F II pylorus-preserving bile duct CA T3N0M0 4 to have originated with Waugh and Clagett [5] , as reported in 1946 [7,9] . PG has gained favor in recent years as a potential means of reducing the incidence of pancreatic fistula (PF).…”

“…In our material only 3% of POPF was observed. Some researchers reported that soft pancreatic texture, ampullary or duodenal lesions, longer operating time, greater intraoperative blood transfusion and lower surgical volume can increase the risk of PF formation significantly [6,9,10,12,15] . In our study, parameters such as operating time, blood loss, blood transfusions or ASA class did not influence the incidence of the PF formation.…”

“…Second, the excellent blood supply to the stomach wall is favorable for anastomotic healing, and the thickness of the stomach wall holds sutures well. Third, nasogastric suction provides continuous decompression of the stomach and therefore decreases tension on the anastomosis [3,6,[9][10][11] . Two multicenter studies [1,2] and a single-center randomized trial [10] presented no statistically significant differences in the rate of pancreatic fistulas after PG and PJ.…”