Selection of Pancreaticojejunostomy Techniques According to Pancreatic Texture and Duct Size

Abstract

Selection of proper pancreaticojejunostomy techniques according to pancreatic texture and the main duct size reduces the pancreatic fistula rate.Design and Patients: Data from 50 consecutive patients undergoing pancreatoduodenectomy with 3 different anastomotic techniques prospectively used according to pancreatic texture and the main duct size were analyzed. Duct-invagination anastomosis was selected for pancreata with a small duct (n=34 [29 with a soft texture and 5 with a hard texture]). Stitches between the stump parenchyma and the jejunal seromuscular layer were added to this anastomosis procedure only for the hard pancreata. Pancreata with a large duct were reconstructed with a conventional duct-to-mucosa anastomosis (n=16).Setting: A university hospital department of digestive surgery. Results:The morbidity was 40% (20 of 50 patients) in this series. Four patients (8%) with a soft pancreas and a small duct developed a pancreatic stump leak after ductinvagination anastomosis, but all of them were removed without sequelae. No pancreatic anastomotic leak was seen in this series, which resulted in no mortality, no remnant pancreatectomy, and only 1 relaparotomy in the consecutive 50 patients. Conclusion:The proper selection of pancreatic reconstruction techniques according to our criteria may reduce the pancreatic fistula rate, eliminate risky pancreatic anastomotic leaks, and result in excellent outcomes for those undergoing pancreatoduodenectomy.

Risk factors affecting pancreatic fistulas after pancreaticoduodenectomy

“…Patients in whom the pancreatic texture has a hard consistency have been reported to be at lower risk for pancreatic leakage than those patients who have a pancreatic parenchyma with a soft or intermediate consistency [22,23] . The texture of the pancreatic parenchyma has been reported to be correlated with the pancreatic duct diameter [24] , in considering the ease in performing a pancreatic duct-to-jejunum mucosa anastomosis, such a simple comparison requires more consideration. The pancreatic duct diameter has been correlated with pancreatic leakage [5] , and our study showed that 136 (79.1%) patients had evidence of pancreatic duct dilatation by histopathologic reports, confirming the correlation between pancreatic duct size and pancreatic fistula development (P = 0.001).…”

Pancreatoduodenectomy - Preventing Complications

“…The rates of fistula are significantly lower in patients undergoing duct to mucosa anastomosis when compared to invagination [44,[52][53][54][55]. Bassi et al in a prospective study showed no difference in the technique used [56].…”

“…Amongst all, texture of the gland remains the most important predictive factor. The soft and fatty texture of the pancreas [38][39][40][41][42][43][44][45][46] with a non dilated duct (duct size < 3 mm) [45,46] has a higher incidence of fistula when compared to fibrotic/atrophic pancreas with a dilated duct. Increased secretion of pancreatic juice is seen in patients with soft or normal pancreatic remnant and is associated with increased rates of POPF [41].…”

Improvement of Surgery of Pancreatic Head Masses

“…Pancreatic stump tissue condition and pancreatic duct diameter are considered to be the most significant risk factors of PDA dehiscence [16][17][18]. To reduce PDA dehiscence rate, the authors [6, [19][20][21] suggest an individual approach to anastomosis, which is determined, primarily, by the pancreatic condition and pancreatic duct diameter. Currently, there is no lifetime morphometric assessment of pancreatic parenchyma.…”

“…In literature one can find just a few reports on the criteria to estimate the pancreatic condition. So, Suzuki et al [21] have determined the pancreatic parenchyma condition (dense or soft) based on the difficulty or easiness in pancreatic tissue dissection by an ultrasound scalpel. We have suggested a criterion of "ligature incision of tissue".…”