AIM: To present a new technique of end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and insertion of a silicone stent.

METHODS: We present an end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and the insertion of a silicone stent. This technique was performed in thirty-two consecutive patients who underwent a pancreaticoduodenectomy procedure by the same surgical team, from January 2005 to March 2011. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity.

RESULTS: There were 32 patients who underwent end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation. Thirteen of them were women and 19 were men. These data correspond to 40.6% and 59.4%, respectively. The mean age was 64.2 years, ranging from 55 to 82 years. The mean operative time was 310.2 ± 40.0 min, and was defined as the time period from the intubation up to the extubation of the patient. Also, the mean time needed to perform the pancreaticojejunostomy was 22.7 min, ranging from 18 to 25 min. Postoperatively, one patient developed a low output pancreatic fistula, three patients developed surgical site infection, and one patient developed pneumonia. The rate of overall morbidity was 15.6%. There was no 30-d postoperative mortality.

CONCLUSION: This modification appears to be a significantly safe approach to the pancreaticojejunostomy without adversely affecting operative time.

The first pancreaticoduodenectomy was performed by a German surgeon, Kausch, in 1909[1-3]. It has been considered the surgical procedure of choice for ampullary cancer, after Whipple et al[4] had described three cases in 1935. Nowadays, it has become the standard procedure in the management of pancreatic head and periampullary carcinoma[2]. In recent years, the mortality rate of pancreatico-duodenectomy has been decreased to below 5%[5-7]. However, the postoperative morbidity rate remains high, ranging from 30% to 50%[7-10]. Pancreatic fistula[11,12] is the most common complication and its reported incidence varies from 2% to 40%[8,11,13]. Several different anastomotic surgical techniques have been used, in order to minimize pancreatic fistula occurrence after pancreaticoduodenectomy, although it is still debated which of them has any clear advantage[2,9,10,14,15]. We present a modification for duct to mucosa end-to-side pancreaticojejunostomy, with a seromuscular jejunal flap, in order to increase the safety of the anastomosis.

During the period January 2005 to March 2011, 32 consecutive patients underwent pancreaticoduodenectomy by the same surgical team. There were 13 women and 19 men, with a mean age of 64.2 years (range 55-82 years). The underlying diseases of these patients are shown in Table 1. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity[11].

Technique

A scalpel is used to sharply transect the pancreas at the level of the portal vein. Hemostasis of the bleeding points of the pancreatic stump is achieved either with 4-0 non-absorbable suture and/or with electrocautery. After the pancreaticoduodenectomy specimen has been removed, the pancreatic remnant is dissected free of the underlying structures for a distance of approximately 2 cm. The transected jejunum is brought through the bed of the resected duodenum (i.e., posterior to the mesenteric vessels).

The jejunal seromuscular layer is incised starting about 2 cm distal to the jejunal stump, along the antimesenteric border. The length of this incision is just smaller than the cephalo-caudal diameter of the pancreatic stump. Using a scalpel the seromuscular layer of the jejunum is dissected free from the underlying submucosa, towards both sides of the aforementioned incision, in order to create two seromuscular flaps (i.e., one dorsal and one ventral flap), and to expose the underlying submucosa, which must remain intact (Figure 1). The extent of the dissection is determined by the antero-posterior diameter of the pancreatic stump, in order to fit the surface of the pancreatic cut edge on the surface area of the exposed mucosa.

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Figure 1 Preparation of the jejunal stump. A: Incision on the jejunum; B: Seromuscular flap formation; C: The seromuscular layers are dissected free from the submucosa. J: Jejunum; S: Submucosa; Arrow: Posterior seromuscular flap; Dotted arrow: Anterior seromuscular flap.

Following this, a segment of nelaton catheter is inserted into the main pancreatic duct, and is fixed with a 4-0 absorbable monofilament suture (polydioxanone, PDS II, Ethicon, Inc.). The tube girth is selected to exactly fit the diameter of the main pancreatic duct. On the intraductal part of the stent, several holes are created on different positions, at a distance of 1 cm from each other, in order to ensure uninhibited outflow of the pancreatic fluid. The extraductal part of the stent left is about 5 cm in length.

The next step is to create the first of all four suturing layers. The dorsal part of the jejunal seromuscular layer and the dorsal part of the capsular parenchyma of the pancreatic stump are sutured with 3-0 silk interrupted stitches of 0.5-1 cm distance from each other. This is the dorsal external suturing layer (Figure 2A).

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Figure 2 The posterior, anterior external layer of sutures and stent in place. A: The posterior (dorsal) external layer of sutures; B: Stent in place. Arrow: The stent enters the jejunal small opening, which has been created in the middle of the dissected submucosal surface; C: The anterior (ventral) internal layer of sutures. Arrow: Anterior pancreatic cut edge border; Dotted arrow: Anterior seromuscular flap; D: The anterior (ventral) external layer of sutures. Arrow: Anterior pancreatic part of the capsular parenchyma; Dotted arrow: Anterior part of the jejunal seromuscular layer. J: Jejunum; S: Stent; P: Pancreatic stump cut surface.

Then, the dorsal cut edge border of the pancreatic stump is sutured to the edge of the dorsal jejunal seromuscular flap with 4-0 polydioxanone sutures (PDS) II interrupted stitches 0.5 to 1 cm apart. This is the dorsal internal layer.

A small hole in the jejunal mucosa is made, in accordance with the diameter of the main pancreatic duct. The free end of the stent tube is advanced through this hole into the jejunal lumen (Figure 2B). The mucosa at the site of the hole and the edge of the main pancreatic duct are sutured with two interrupted stitches of 4-0 PDS II.

The third layer is created by the approximation of the ventral cut edge border of the pancreatic stump and the edge of the ventral jejunal seromuscular flap with 4-0 PDS II interrupted stitches, 0.5-1 cm apart (Figure 2C). This is the ventral internal layer.

The final layer of sutures, the ventral external layer, is created by suturing the ventral part of the jejunal seromuscular layer and the ventral part of the capsular parenchyma of pancreatic stump, with 3-0 silk interrupted stitches (Figure 2D). Figure 3 shows a drawing of the jejunal and pancreatic sites of anastomosis.

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Figure 3 This is a schema that shows the dissected surface of the jejunum and the cut surface of the pancreas that are approximated. The red dotted line represents the ventral internal suturing layer (i.e., the 3^rd one). The blue dotted line represents the ventral external suturing layer (i.e., the 4^th one).

There were 32 consecutive patients that underwent pancreaticoduodenectomy with the above described pancreaticojejunostomy technique. There were 13 women and 19 men, with a mean age of 64.2 years (range 55-82 years). The underlying diseases of these patients are shown in Table 1. The mean operative time was 310.2 ± 40.0 min, and the mean time needed to perform the pancreaticojejunostomy was 22.7 min (range 18-25 min). One patient developed low output pancreatic fistula. Three patients developed surgical site infection and one patient developed pneumonia, postoperatively. The overall morbidity rate was 15.6%. There was no postoperative mortality.

Pancreaticojejunostomy represents one of the most challenging technical aspects of the Whipple procedure, because of its failure rates, as well as the resulting morbidity and mortality. Several technical variations have been proposed, in an effort to minimize postoperative pancreatic fistula rates[1,2,9,10,14-20]. The most important risk factors identified are technique, soft pancreatic texture and main pancreatic duct diameter of 3 mm or less[13,21-26]. The technique we describe is an end-to-side, duct-to-mucosa two-layer pancreaticojejunostomy. Each step of the procedure already described adheres to a rationale focused on the elimination of pancreatic leakage. First, the exposure of intact jejunal mucosa was thought to promote vascularization and enhance the healing process between the mucosa and the cut surface of the pancreatic stump[27]. Such an approach has been employed in the past with favorable results, but still carried a significant fistula occurrence.

With this in mind, we incorporated the dissection of the seromuscular flaps and their fixation to the border of the pancreatic stump aiming to offer a more reliable sealing of the anastomosis. In the same context, we proposed the internal layer of sutures, which was not previously employed, in order to keep the two traumatic surfaces firmly in contact to further favor the healing process between them. Finally, stenting the main pancreatic duct ensures duct patency, while eliminating undesired distention. In one of our cases, the stent was present in situ even on the six-year follow-up.

In conclusion, this technique appears to be safe and reliable. Because this is a preliminary report of a small series, it is of essential importance that it is evaluated via a prospective study in a larger series, before firm conclusions can be drawn.

Furthermore, while of sound reasoning, the assumption that healing is significantly augmented by exposing the intestinal submucosa is yet to be experimentally proved.