Stented pancreaticojejunostomy (with video)

Abstract

Background/purpose Using a standardized technique for pancreaticojejunostomy that we term ''pair-watch suturing technique'', we prospectively analyzed the effects of a pancreatic stent tube for preventing pancreatic fistula and furthermore evaluated which perioperative factors had an influence on the development of pancreatic fistula. Operative procedure Before anastomosis, we imagine the faces of a pair of wristwatches on the jejunal hole and pancreatic duct. The first stitch was put between 9 o'clock on the pancreatic side and 3 o'clock on the jejunal side, and a total of 7 stitches were put in the posterior wall, followed by 5 stitches in the anterior wall. Using this technique, twelve stitches can be sutured in the first layer anastomosis regardless of the caliber of the pancreatic duct. Patients and methods From March 2007 to April 2009, 55 consecutive patients who underwent the pair-watch suturing technique were divided into two groups: stent (n = 28) and no-stent (n = 27). The incidence rate of pancreatic fistula was statistically analyzed. From March 2007 to March 2011, 102 consecutive patients were retrospectively divided into two groups according to the International Study Group on Pancreatic Fistula criteria: postoperative pancreatic fistula (POPF) and non-POPF. Results Perioperative factors were almost the same between the stent and no-stent groups, and the incidence of pancreatic fistula was very similar: 10.7% in the stent group and 14.8% in the no-stent group. Additionally, all patients who developed pancreatic fistula belonged to grade A. Among 102 patients, 15 (14.7%) were identified as having pancreatic fistula: 9 (8.8%) in grade A, 5 (4.9%) in grade B, and 1 (0.9%) in grade C. Comparing the POPF and non-POPF groups, we could not detect any significant risk factors for the development of pancreatic fistula. Conclusion We consider that the pair-watch suturing technique is less susceptible to any factors, providing reliable anastomosis for any size of pancreatic duct and any texture of remnant pancreas.

A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy

“…Moreover, pancreatic anastomosis techniques are generally described in single-surgeon or singleinstitution studies often reporting low POPF rates of their preferred pancreatic anastomosis. 11,61,62 This is supported by the current data, showing a higher pooled incidence of POPF in multicenter and two-center trials compared to single-center trials. In the ISGPS position statement, it is stated that experienced surgeons at high-volume centers can decrease the incidence of POPF by performing a variety of techniques in diverse intraoperative situations.…”

“True” Duct-to-Mucosa Pancreaticojejunostomy, with Secure Eversion of the Enteric Mucosa, in Whipple Operation

“…8,30,31 However, these results are not consistent in the literature, and, in agreement with other studies, no predictors of POPF were identified in the present study. 13,32 It should be kept in mind that there are several key steps in creating a safe pancreaticoenteric anastomosis, which include the following: (1) the exact approximation of the enteral mucosa and the duct epithelium; (2) preservation of adequate blood flow at the pancreatic stump, requiring low-tension tying of the sutures; (3) identification and ligation of minor ductules on the cut surface of the pancreas; (4) elimination of dead space between the cut surface of the pancreas and the enteric serosa, where the autolytic pancreatic juice could accumulate and lead to anastomotic breakdown; (5) facilitation of pancreatic juice flow into the enteric lumen, especially during the first postoperative days when tissue edema is present, and, even more so, in the case of a soft pancreas with a normal amount of pancreatic secretions. Successful pancreatic surgery requires meticulous and standardized preoperative diagnostic workup (high-quality imaging and operative risk assessment) and the provision of highly specialized peri-and postoperative care and medication protocols.…”

Pancreas-visceral fat CT value ratio and serrated pancreatic contour are strong predictors of postoperative pancreatic fistula after pancreaticojejunostomy

“…For pancreaticojejunostomy, the first-layer anastomosis, which was a duct-to-mucosa anastomosis, was performed using PWST with 6-0 PDS II (Ethicon, Inc. Somerville, NJ, USA). This technique was conducted using 12 interrupted sutures oriented in a clock formation regardless of the MPD diameter [18][19][20]. This can be imagined as the faces of a pair of wristwatches, with the jejunal hole corresponding to the left-hand watch and the pancreatic duct hole to the right-hand one.…”

“…The procedures of pancreatoenteral anastomosis have not been standardized, and each institution performs their own preferred procedure, such as pancreaticogastrostomy, pancreaticojejunostomy, external tube drainage, the lost stent method and invagination; this diversity of procedures makes it difficult to evaluate the frequency of POPF [15][16][17]. Our institution reported the method of 12 interrupted-stitched duct-to-mucosa pancreaticojejunostomy, named the "pair-watch suturing technique (PWST)", which allowed us to standardize the method of pancreaticojejunostomy [18][19][20]. However, even though the anastomotic technique has progressed, POPF still has yet to be thoroughly prevented after PD, and the incidence of POPF in patients with soft pancreas has been reported to be particularly high; thus, the prevention of POPF in patients with soft pancreas is still under discussion [21][22][23].…”