Pancreatic anastomosis during Whipple or Longmire procedures is crucial to obtain good outcomes. Pancreatic fistula, which can lead to sepsis or haemorrhage, is feared by all surgeons and every efforts to reduce it are welcome. There are several risk factors for postoperative pancreatic fistula (POPF):
soft pancreas
main pancreatic duct < 3mm
tension anastomosis
emergency operation
re-operation
jaundice
mal nutrition
coronary disease
Additionally, diseases that do not create obstruction of the Wirsung with subsequent chronic pancreatitis, will have greater incidence of POPF.
There are several options to deal with pancreatic stump: duct-mucosa anastomosis, invagination pancreaticojejunostomy, pancreaticogastrostomy.
A main factor to decide which technique is best suitable for the patient we are operating, is the main pancreatic duct's diameter. In cases of a diameter <3 mm a pancreaticogastric anastomosis might be indicated, but a wide mobilization of the remaining pancreas should be obtained for 3-4 cm. This is a major disadvantage. Invagination pancreaticojejunostomy is another option in that setting. For a wider Wirsung a duct-mucosa anastomosis is a viable good option. From the studies published worldwide comparing the several techniques, no valid conclusion or consensus were achieved to decide which technique has better results. According to worldwide reports, the POPF rates were 4%– 18% in duct-to-mucosa anastomosis, 3%–15% in invagination, 8%– 25% in pancreaticogastrostomy and 11%–34% in pancreatojejunostomy.
While debate is still going on, a new simplified invagination pancreaticojejunostomy has been tested by a group of japanese surgeons. The results of this pilot study were recently published in the "International Journal of Surgery & Surgical Procedures", for which I am an editor.
Kazuaki Shibuya et al. from the Hokkaido University, studied 22 consecutive pancreatoduodenectomies in which a simplified invagination pancreaticojejunostomy was performed. Diagnosis were pancreatic ductal carcinoma, duodenal carcinoma, bile duct carcinoma, and serous cyst adenoma. In nine patients a soft pancreas was found, and in the remaining 13 there was an hard pancreas. Eighteen patients were operated by a skilled surgeon, and 4 patients by an training surgeon.
The technique is describe by the authors. It involves two-layers of interrupted sutures. Posterior outer sutures are placed through pancreas serosa and jejunal seromuscular layer. Posterior inner sutures are then place through pancreas parenchyma and jejunal mucosa layer. Main pancreatic
duct is not sutured. A stent is introduced in the Wirsung to mantain patency, getting out through the small bowel 30 cm distal to the anastomosis. Anterior inner and outer layers are placed like the posterior ones. Two drains are left near the pancreticojejunostomy.
Main operative time was 496 min. Kazuaki Shibuya et al. report a POPF of 13,5%, two Grade A and one Grade B. This results are similar to other techniques data, but they reported less Grade B POPF than other techniques.
According to the authors some advantages exist. First, "the pancreatic juice from the main pancreatic duct and also its branches or parenchyma runs through the jejunum" which can decrease POPF; secondly, "no matter how narrow the pancreatic duct is", anastomosis can be performed because Wirsung is not sutured; third, there is no need for extra mobilization of pancreatic stump like in pancreaticogastric anastomosis. On the other hand, because the main duct is not sutured, a risk of low long term latency rate exists with invagination technique. However, there were no cases of anastomosis occlusion at 12 months in Kazuaki Shibuya's pilot study.
Additionally the authors report that the results were similar comparing skilled surgeons and trainees. Because of this Kazuaki Shibuya et al. believe this technique is simpler and can be a good option to teach younger surgeons.
Althought this is a pilot study with a small number of patients, it got my attention because it brings another possible option to deal with the pancreatic stump after pancreaticoduodenectomy. I will wait for more data.
Do not forget... If there are several valid techniques, its because none is ideal!
Questions to the reader:
Which is your preferred technique to deal with pancreatic stump?
What to you think about drainage after pancreaticoduodenectomy?
What is your opinion about this new simplified invagination technique?
Exchanging ideas makes you stronger! Please comment below...
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Dr. Carlos Eduardo Costa Almeida
General Surgeon