Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures?

doi:10.1016/0002-9610(91)90359-L

The American Journal of Surgery

Volume 161, Issue 1, January 1991, Pages 45-50

https://doi.org/10.1016/0002-9610(91)90359-L Get rights and content

Abstract

The patency of anastomoses joining the pancreas to either a Roux-Y loop of jejunum or the stomach was evaluated in 26 dogs. At a preliminary operation, the head and uncinate process of the pancreas were resected while carefully preserving the duodenal blood supply. The remaining body and tail of the pancreas were totally obstructed. After obstruction for a mean of 22 (range: 6 to 42) days, one of three anastomoses was performed: (1) inversion pancreatogastrostomy with two layers of sutures; (2) a similar inversion pancreatojejunostomy to the side of a Roux-Y jejunal loop; or (3) pancreatojejunostomy in which the major duct was joined to the jejunal mucosa with interrupted sutures. Six animals were kept for controls. Anastomotic patency was assessed after 8 to 12 weeks by pancreatography, with minimal pressures to achieve anastomotic flow recorded. Weight trends were consistent with anastomotic status. The eight dogs with ductto-mucosa sutures clearly achieved superior anastomotic patency.

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Cited by (78)

Pancreatic fistula following pancreatoduodenectomy. Evaluation of different surgical approaches in the management of pancreatic stump. Literature review
2015, International Journal of Surgery
Citation Excerpt :
PJ is most commonly used method of pacreato-enteric anastomosis after PD. Many Authors found that PJ duct to mucosa anastomosis is the safest option, particularly in case of wide pancreatic ducts, usually associated with firm or hard pancreatic tissue [58,59]. Marcus et al. identified low and high risk patients considering the patient related risk factors such as age (>70 years), gender (male), jaundice, malnutrition, and pancreas anatomic and functional related factors such as pancreatic disease, pancreatic softness, pancreatic duct caliber.
Pancreatoduodenectomy is the gold standard operation for malignant and benign diseases of the pancreas and periampullary region. Even if improvements in intensive care management and surgical technique have dramatically reduced postoperative mortality after pancreatic surgery, morbidity remains high (30–50%), also in specialized pancreatic units. In order to reduce postoperative complications, particularly pancreatic fistula, different surgical techniques and their modifications have been proposed. In order to determine the better management of the pancreatic stump after pancreatoduodenectomy, the Authors analysed and compared derivative – pancreaticojejunal, pancreaticogastrostomy – vs no-derivative technique – pancreatic stump closure (duct ligation or mechanical suture, duct occlusion by fibrin glue or cyanoacrylate). A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, analysing the risk factors and the incidence of short-medium term postoperative complications. Up to now, even if derivative procedures are preferred as gold standard the best method to deal a pancreatic stump is still controversial and remains matter of research. Pancreatic surgeons must have more than one technique for managing the pancreatic remnant.
Pancreaticojejunostomy with double-layer continuous suturing is associated with a lower risk of pancreatic fistula after pancreaticoduodenectomy: A comparative study
2015, International Journal of Surgery
Citation Excerpt :
A recent review estimated the incidence of this complication to be 10–28.5% [5]. To reduce the incidence of POPF, a number of methods, including pancreaticogastrostomy, duct-to-mucosa anastomosis, pancreatic duct occlusion, the use of biologic adhesive, intraoperative transanastomotic stents, and PD with or without external pancreatic duct drainage, have been proposed and tested [6–15]. Various reconstruction methods were also developed to diminish pancreatic leakage, such as end-to-end pancreaticojejunostomy, end-to-side pancreaticojejunostomy and their modifications.
Background: Postoperative pancreatic fistula (POPF) remains a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). Thus, a number of technical modifications regarding the pancreatoenteric anastomosis after PD have been proposed to reduce POPF rate. In this article we focused on evaluating whether the double layer continuous suture technique was better than the double layer interrupted suture technique in pancreatic–enteric anastomosis after PD. Material and methods: From 2012 to 2013, 114 patients (67 men and 47 women) underwent a pancreatic–enteric anastomosis after PD were analysed. There were 79 patients using the double layer continuous suture technique and 35 patients were using the double layer interrupted suture technique. The operation time, intraoperative blood loss, initial postoperative day of oral feeding, postoperative hospital stay and the presence of main early complications (pancreatic fistulas) were evaluated by chi-square test or unpaired t-test in this study. Results: Pancreatic fistulas occurred in patients with double layer continuous suture was 17.14%(6/35), and in those with interrupted suture was 39.24%(31/79) (p < 0.05). Grade A of POPF was found in 4 patients (4/35, 11.43%) of the double layer continuous suture group and in 5 patients (5/79, 6.33%) of the double layer interrupted suture group. Grade B of POPF was identified only in 1 patients (1/35, 2.83%) of the double layer continuous suture group and in 23 patients (23/79, 29.11%) of the double layer interrupted suture group. The presence of Grade C pancreatic fistulas was only documented in one patient in the double layer continuous suture group and 3 patients in the interrupted suture group. No operative or in-hospital deaths occurred. Conclusions: The double-layer continuous suturing after PD is safe, reliable, rapid, favorable and associated with a lower risk of pancreatic fistula than the double layer interrupted suture.
Triple-layer duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa decreased pancreatic fistula after pancreaticoduodenectomy
2014, Journal of Surgical Research
Citation Excerpt :
However, two recent studies revealed that binding PJ after PD could not decrease the PF rate, one of which also found higher incidence of hemorrhage in the patients with binding PJ when compared with duct-to-mucosa PJ [28,29]. Duct-to-mucosa PJ is commonly used by many surgeons and usually described as being safer and having a significantly lower leakage rate [30,31]. So we decided to search for technical improvements of duct-to-mucosa PJ to reduce the PF rate.
Pancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy (PD). We described a new method of pancreaticojejunostomy (PJ) developed by combining triple-layer duct-to-mucosa PJ with resection of jejunal serosa, which was named as modified layer-to-layer PJ (MLLPJ). The aim of the present study was to observe whether the new technique would effectively reduce the PF rate in comparison with two-layer duct-to-mucosa PJ (TLPJ).
Data on 184 consecutive patients who underwent the two methods of PJ after standard PD between January 1, 2010 and January 31, 2013 were collected retrospectively from a prospective database. The primary endpoint was the PF rate. The risk factors of PF were investigated by using univariate and multivariate analyses.
A total of 88 patients received TLPJ and 96 underwent MLLPJ. Rate of PF for the entire cohort was 8.2%. There were 11 fistulas (12.5%) in the TLPJ group and four fistulas (4.2%) in the MLLPJ group (P = 0.039). Body mass index, pancreatic texture, pancreatic duct diameter, and methods of PJ anastomosis had significant effects on the formation of PF on univariate analysis. Multivariate analysis showed that pancreatic duct diameter ≤3 mm and TLPJ were the significant risk factors of PF.
MLLPJ effectively reduces the PF rate after PD in comparison with TLPJ. Results confirm increased PF rates in patients with pancreatic duct diameter ≤3 mm compared with pancreatic duct diameter >3 mm.
Pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy: Critical analysis of prospective randomised trials
2011, Cirugia Espanola
Este es un análisis crítico de los ensayos prospectivos aleatorizados que comparan las técnicas de reconstrucción pancreática con el estómago y con el intestino, después de pancreaticoduodenectomía. Se utilizó un cuestionario de preguntas del Centro de Medicina Basada en Evidencias de la Universidad de Oxford (análisis PICO), y se han seguido los criterios en la evaluación de estudios prospectivos aleatorizados para intervenciones quirúrgicas de la Universidad de McMaster de Ontario. Se encontró que los estudios difieren en aspectos metodológicos, el más importante la falta de una definición uniforme de fístula pancreática. Las técnicas de realización de la pancreaticogastrostomía y pancreaticoyeyunostomía no fueron homogéneas. No existen diferencias en el porcentaje de fístula pancreática en tres de estos estudios; uno que modifica la técnica de pancreticogastrostomía presentó resultados más favorables. Los nuevos estudios comparativos deberán utilizar las nuevas definiciones de las complicaciones de la pancreaticoduodenectomía y estandarizar la técnica de reconstrucción pancreática.
This is a critical analysis of prospective randomised trials that compare pancreatic reconstruction techniques with the stomach and the intestine, after pancreaticoduodenectomy. A questionnaire with questions from the Evidence Based Medicine Centre of Oxford University (PICO analysis) was used, following the criteria for the evaluation of randomised prospective studies for surgical interventions of the McMaster University in Ontario. It was found that the studies differed in methodological aspects, the most important being the lack of a uniform definition of a pancreatic fistula. The techniques for performing pancreaticogastrostomy and pancreaticojejunostomy were not homogeneous. There were no differences in the percentage of pancreatic fistula in three of these studies; one which modified the pancreaticogastrostomy technique had more favourable results. New comparative studies should use new definitions of the complications of pancreaticoduodenectomy and standardise the pancreatic reconstruction technique.
Options of restorative pancreaticoenteric anastomosis following pancreaticoduodenectomy: A review
2010, Surgical Oncology
Citation Excerpt :
Another study recently reported incidence of leak to be 5% in DM PJ compared to 22% in total external tube drainage [58]. DM PJ is difficult to secure in a small pancreatic duct, thus a microscopic technique has been advocated by Greene [68]. The microscopic technique is difficult to perform in a soft gland with small and thin pancreatic duct because of the difference in wall thickness between the two structures and fragility of the duct [69].
Pancreatic fistula (PF), haemorrhage and delayed gastric emptying are some of the common causes of morbidity and PF is the single most important cause of mortality following pancreaticoduodenectomy (PD). Authors, who claim to have reduced leak rates, recommend modifications of the standard technique of pancreaticojejunostomy (PJ) that are often complex and difficult to standardize for wider applications. Most individual studies, multicenter retrospective analysis and certain prospective studies report a lower leak rate with pancreaticogastrostomy (PG) when compared with PJ. However, the only three randomized controlled clinical trials (RCTs) to date have failed to demonstrate the superiority of either technique. Here we discuss the various aspects of pancreaticoenteric anastomosis following pylorus preserving pancreaticoduodenectomy (PPD) and the standard pancreaticoduodenectomy (PD).
Which one is better? Laparoscopic versus robotic reconstruction in the remnant soft pancreas with a small pancreatic duct following pancreaticoduodenectomy: a multicenter study with propensity score matching analysis
2023, Surgical Endoscopy

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^☆: Presented at the 31st Annual Meeting of the Society for Surgery of the Alimentary Tract, San Antonio, Texas, May 15–16, 1990.

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Scientific paperAre pancreatoenteric anastomoses improved by duct-to-mucosa sutures?☆

Abstract

Am J Surg

Surg Clin North Am

Techniques of pancreaticojejunostomy in pancreatoduodenectomy

Prob Gen Surg

Considerations that lower pancreatoduodenectomy mortality

Am J Surg

Pancreatico-duodenectomy: 41 consecutive Whipple resections without an operative mortality

Ann Surg

Digestive function after radical pancreaticoduodenectomy

Am J Surg

Ligation versus implantation of the pancreatic duct after pancreaticoduodenectomy

Surg Gynecol Obstet

Preservation of the pylorus in pancreaticoduodenectomy: a followup evaluation

Ann Surg

Chronic pancreatitis: results of Whipple's resection and total pancreatectomy

Arch Surg

Scientific paper
Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures?☆