An easy and secure pancreaticogastrostomy after pancreaticoduodenectomy: transpancreatic suture with a buttress method through an anterior gastrotomy

Pancreatic anastomotic failure is the most important determinant for morbidity and mortality following pancreatoduodenectomy (PD). Many reconstruction techniques have been extensively studied in the last two decades in an attempt to reduce the incidence of pancreatic fistula [1-12].

Pancreaticogastrostomy (PG) has recently been reappraised as a more secure procedure over pancreaticojejunostomy (PJ) and many reports support the lower rates of pancreatic anastomotic failure with PG than with PJ [13-16]. Several different methods of anastomosing the pancreas to the stomach have also been introduced with greatly improved results [5, 12, 15, 17, 18].

In the present report, we describe our reconstructive technique of PG after PD: transpancreatic suture with a buttress method through an anterior gastrotomy, and this can provide an easy, secure pancreatoenteric anastomosis. We also discuss this procedure's effectiveness for reducing the incidence of postoperative complications.

The patients consisted of 17 men and 4 women, with an average age of 55.1 years (range, 35 to 69 years) and their average body mass index was 23.9 kg/m² (range, 20.8 to 27.8 kg/m²). The standard Whipple procedure was performed in only 1 case and the other 20 patients underwent a pylorus-preserving modification. Concomitant mesentericoportal vein resection was performed in 2 patients with pancreatic adenocarcinomas in this series. Nine patients underwent laparoscopy-assisted pylorus preserving PD and they had 4 intraductal papillary mucinous adenomas, 3 ampullary adenocarcinomas and 2 pancreatic endocrine tumors. The other 12 patients had various indications for PD (Table 1). Of the 21 patients, 11 (52.3%) patients had a soft pancreatic texture and the remaining 10 (47.6%) had a firm pancreatic texture. The median estimated pancreatic duct size was 4 mm (range, 2 to 14 mm). The mean operating time was 378 minutes (range, 290 to 410 minutes) in the open PD cases and 418 minutes (range, 310 to 450 minutes) in the laparoscopy-assisted PD cases. The mean blood loss was 1,640 mL (range, 1,300 to 1,800 mL) in the open PD cases and 300 mL (range, 100 to 800 mL) in the laparoscopy-assisted PD cases. The mean duration of postoperative hospitalization was 18.2 days (range, 9 to 28 days) in the open PD cases and 14.3 days (range, 8 to 16 days) in the laparoscopy-assisted PD cases.

Table 1
Pathological diagnosis in 21 patients

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There were no operative or hospital deaths. Five complications (23.8%) occurred in 4 patients (Table 2). A pancreatic fistula occurred in 1 patient (4.7%; grade B). He subsequently developed peripancreatic abscess, which was controlled by ultrasound-guided percutaneous drainage beside the operatively-placed drains, and delayed gastric emptying. Two patients experienced hemorrhage from the cross-section of the pancreatic stump and they were successfully treated by endoscopy. One patient developed wound infection and this resolved with conservative treatment.

Table 2
Operative complications in 21 patients

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Pancreatoenteric anastomsis is quite different from the anastomosis between hollow viscera such as gastrojejunostomy, jejunojejunostomy or colocolostomy. First of all, the nature of the two organs in pancreatoenteric anastomosis is disparate. One is solid and the other is tubular with a lumen. So, there is no landmark for the adequate thickness of the suture 'bites' between the two organs. Secondly, this solid organ has numerous accessory pancreatic ducts as well as a main pancreatic duct on the ross-section planes, and these ducts secrete pancreatic juice and this might account for breaking down of the anastomosis if left undrained. Also, if these ducts are occluded while performing anastomosis, then postoperative pancreatitis in the pancreatic remnant might occur, and this can contribute to the anastomotic failure. Third, the normal pancreas is so soft and fragile that pancreatic laceration is inevitable during suturing with a needle or during tightening of the suture thread. This is more evident when a suture made with a curved needle traps only a small amount of pancreatic parenchyma. Fourth, among the two organs in the pancreatoenteric anastomosis, one is fixed and the other is relatively movable. So, the pancreatoenteric anastomosis could be more vulnerable to disruption than others between hollow viscera.

For these reasons, the management of a pancreatic remnant after PD has been of great concern to pancreatic surgeons and numerous techniques to reduce the pancreatic fistula have been described such as PJ or PG, end-to-end or end-to-side anastomosis, invagination or duct-to-mucosa anastomosis, the use of an isolated Roux-en-Y limb, binding PJ, the pancreatic duct stenting methods, application of topical adhesives and duct occlusion without pancreatoenteric anastomosis [1, 4-11, 19]. We started to adapt PG after PD in 2001 because of the superiority of PG over the PJ: the proximity of the stomach and the pancreas, the thick posterior wall and excellent blood supply of the stomach, a lack of enzyme activation in the stomach and finally less tension on the anastomosis through the nasogastric continuous decompression of the stomach.

We then revised the previous PG method based on the above mentioned analysis of the pancreatic anastomosis. In order to minimize the pancreatic laceration during suturing with a needle or tightening of the suture thread, we introduced transpancreatic suture with a straightened needle instead of the conventional circumferential suture with a curved needle around the stump of the pancreas. This maneuver can also prevent full disruption of the pancreas stump from the stomach by any possibility that there is a partial breakdown in the anastomosis. Moreover, in this improved PG method, only two sutures are applied on both edges of the pancreatic stump, which enabled further reducing the suture damage to the pancreatic parenchyma and shortening the overall time required for this anastomosis. Instead, this simplified PG method is compensated by including the stomach wall in both edges of the gastrotomy with buttresses during tightening of the suture thread, and this firmly anchors the gland to the stomach. Ohigashi et al. [12] also used straight sutures penetrating the pancreas in a U-like fashion and they reported a 0% pancreatic leakage rate with a shortened time required for the anastomotic procedure. They placed 4 to 8 pancreas-penetrating sutures (2 to 4 U-like loops) in accordance with the diameter of the pancreatic stumps. These sutures are not tied promptly, but instead they are left loose until all of the U-like loops have been performed and tied. So, it seems very embarrassing if an unexpected bleeding occurs while the needle is penetrating the pancreas before the completion of the U-like loops because the bleeding would stop when the sutures are firmly tied.

The approach via the gastrotomy in the anterior gastric wall provides an excellent field of vision and consequently much easier performance of the anastomosis. The direct vision of the surgical field and only two straight sutures for the completion of this anastomosis enabled us to more decrease the size of the laparotomy in the cases of laparoscopy-assisted PD. Further, the full-thickness suturing of the stomach wall from the inside spontaneously prevents the protrusion of gastric mucosa, which is very cumbersome in a conventional procedure, that is, the procedure that anastomoses the pancreatic stump to the posterior wall of the stomach from the outside.

As shown in Fig. 4, the pancreatic stump is sufficiently invaginated into the gastric lumen, and this guarantees adequate drainage of the pancreatic juice secreted from the accessory pancreatic ducts on the cross-section planes. The main pancreatic duct was incannulated using a short internal stent and then fixed with an absorbable suture. This is principally for facilitating identification of the Wirsung duct and avoiding inadvertently suturing it during the anastomosis.

With regard to the pancreatic fistula observed in the present study, it occurred in the early phase of our experience and in the case with a very soft pancreatic texture. Excessive traction to the stay sutures in order to insert the pancreatic stump into the gastric lumen damaged the soft pancreas and this resulted in partial amputation in the pancreatic stump. We estimated that this damaged portion of the pancreas slipped down out of the stomach and evoked leakage. This pancreatic fistula was resolved with conservative therapy and it was classified as grade B according to the ISGPF criteria. Afterward, this excessive traction was prevented by obtaining an adequate length of the posterior gastrotomy (3/4 the length of the pancreatic stump) and sufficient mobilization of the pancreatic stump (at least 4 cm) and pancreatic leakage never happened again after this.

In conclusion, this is a novel PG using two transpancreatic sutures with buttresses, and this procedure is performed through an anterior gastrotomy. We believe this technique is simple, secure and it possesses several advantages over the conventional PG: it is very easy to perform, it is less traumatic to the pancreatic stump, it can be performed through a mini-laparotomy due to the good vision and straight sutures and it is secure owing to anchoring the invaginated pancreatic stump to the stomach posterior wall with buttresses. However, to determine its superiority over the conventional procedures, this operative technique should be more comprehensively evaluated in a larger series.