Both surgeons and patients fear the pancreatic fistula complicating pancreatoduodenectomy. This complication has been reported in 3-45% of procedures. In that setting several techniques have been described (invagination, duct-to-mucosa, Blumgart, Kakita) but none as prove better results over the others. Pancreatogastrostomy and pancreatojejunostomy are both valid options, with some papers reporting better results for the first but other concluding for the later one. Risk factors for pancreatic fistula include soft pancreas (fistula is common in this type of parenchyma) and a pancreatic duct smaller than 3 mm. The ideal technique must be suitable for hard and soft pancreas, suitable for pancreatic ducts smaller or larger than 3 mm, provide a good blood supply, a good pancreatic juice flow to gastrointestinal tract, easy to learn and to perform, and cause a low rate of pancreatic fistula.
The ideal technique must be suitable for soft and hard pancreas, and for ducts smaller or larger than 3 mm.
Prof. Dr. Orlando Torres et al. from Brazil published a modification of the Heidelberg technique which can be a good solution. The Heidelberg technique was first described 10 years ago in Germany, and simple modifications have been presented. Prof. Dr. Orlando Torres provided very good pictures of his technique, which I have the pleasure and honor to publish.
The modified technique includes:
Three sutures of 5-0 double needle Prolene are placed on the posterior wall of the pancreatic duct including the full thickness of the pancreas
Other three sutures of 5-0 double needle Prolene are placed on the anterior wall of the pancreatic duct passing through the entire thickness of the pancreas
Running suture between posterior pancreas and jejunum
Posterior inner layer is performed using a 0,5cm enterotomy (from outside to inside)
A plastic stent is placed and fixed with absorbable suture, and the anterior inner layer is performed (from inside to outside)
Running suture completes the outer layer
Stay sutures: the two hemostatic sutures previously placed on the superior and inferior edges, are passed through the jejunum
Two drains are placed near the pancreatojejunostomy
The authors performed this technique in 17 patients. Adenocarcinoma was the diagnosis in 9 patients, a soft pancreas was found in 6 patients, 8 patients had a pancreatic duct smaller than 3mm, and 5 patients had both a soft pancreas and a duct smaller than 3mm. This means that the authors included patients with major risk factors for postoperative pancreatic fistula. According to International Study Group on Pancreatic Surgery type A fistula is a biochemical leak. This type of complication was found in 4 patients and solved spontaneously in one week. None had type B or C fistula. No mortality occurred.
Modified Heidelberg technique has low rate of pancreatic fistula comparing to other modifications.
According to Prof. Dr. Torres et al. this modified Heidelberg technique has low rate of pancreatic fistula comparing to other published modifications. Plastic stent is not part of the original technique, but it secures a good drainage into the gastrointestinal lumen, decreases stricture formation and decreases pancreatic duct occlusion rate. The authors also state that the stay sutures reduce pressure on the anastomosis, which can be a factor to decrease fistula formation.
Comparing to the classical duct-to-mucosa technique, the modified Heidelberg anastomosis decreases the risk of duct tear and anastomosis rupture because it includes about 1cm of full thickness pancreatic parenchyma plus the duct wall while performing the inner layer. In the invagination technique the pancreatic surface is exposed to the gastrointestinal lumen, hemorrhagic complications can easily occur, and it is not suitable for large pancreatic stumps. The Heidelberg modified technique avoids all these drawbacks of the invagination technique. I believe the authors present a technique with potential advantages over the classical techniques worldwide used. Although it has an exceptionally good potential, this technique cannot be a standard until more patients are included in a future study. Till then, this technique must be taken into consideration by all surgeons. I know I will…
The authors conclude the Heidelberg modified technique for pancreas anastomosis is safe and easy to perform. It is suitable for both hard and soft pancreas and for a pancreatic duct of any size, which are important characteristics that all surgeons seek when choosing a preferable technique. The authors conclude that this new modification can reduce pancreatic fistula.
Drains are placed near the anastomosis. “I had never regret of placing a drain but had already regret of not placing one.”
In my opinion this is a modified technique that can be of good help. It gives the surgeon the feeling of extra safety because it includes the full thickness of the pancreas in the duct anastomosis. Although the stent placement is not in the original description, I have been using it in a systematic way for several years in CHUC-HG (Hospital dos Covões) in Coimbra, Portugal, without pancreatic fistula formation or anastomosis stricture. This was a teaching from one of the senior surgeons with whom I have been working for several years, Dr. Luis Carvalho. Drain placement is described and advised by the authors. While many guidelines for several techniques advise not to use drains, I believe a drain is never too much and can be particularly important to control a fistula. Remember an old-school surgeons’ idea: “I had never regret of placing a drain but had already regret of not placing one.” Pancreatojejunostomy with a duct-to-mucosa anastomosis is my preferred one and I will adopt this modified technique, that is for sure.
Thank you to Prof. Dr. Orlando Torres for providing the outstanding pictures.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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