Technique of Pancreaticojejunostomy

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1. Malignant or pre-malignant neoplasm in pancreatic head (including adenocarcinoma, neuroendocrine tumor). 2.Cholangiocarcinoma in peri-ampullar region. 3. Ampullary carcinoma.

The contraindications for pancreaticoduodenectomy include: 1. Superior mesenteric, celiac, or hepatic artery tumor involvement (note: not an absolute contraindication if vascular reconstruction is possible) 2. Metastatic disease

The patient lies supine on the operating table with arms tucked at the sides. The abdomen is prepped up to the subcostal margin and Ioban film is applied over the operative field. A right subcostal incision extending across the midline is performed and a self-retaining Bookwalter retractor is placed to aid in exposure. The basic steps of the pancreaticojejunostomy are as follows: 1) Following completion of the resection portion of the pancreaticoduodenectomy the jejunum is passed under the superior mesenteric vessels into the right upper quadrant of the abdomen, near the cut surface of the pancreas. 2) The pancreas had been previously divided with a vascular load of a TA stapler, the staple line is removed with Metzenbaum scissors until pancreatic secretions are noted from the pancreatic duct. 3) Any bleeding from the pancreatic parenchyma is controlled with the electrosurgical pencil, as the pancreaticoduodenal vessels are already controlled with the stapler. 4) The pancreatic duct is probed to ensure patency. 5) eight to ten stiches are placed around the circumference of the pancreatic duct (in a manner similar to a clock face) using 5-0 Maxon sutures which are then shodded. 6) A towel is placed over the anterior sutures and the posterior sutures are draped over these to maintain the orientation. 7) the posterior pancreatic parenchyma is sutured to the jejunal limb posterior to the location of the future anastomosis to anchor it using 3-0 silk sutures. 8) The electrosurgical pencil is used to make an opening in the jejunum to match the luminal size of the pancreatic duct. 9) The sutures of the posterior wall of the anastomosis are sutured to the posterior wall of the jejunotomy. 10) Care is maintained when passing these sutures off to the scrub tech to ensure constant safety around the needles. 11) Should a pancreatic duct stent be desired due to a small duct, a 5 French pediatric feeding tube is cut to the appropriate length and used as a pancreatic duct stent. 12) The anterior wall sutures are placed in the same fashion as the posterior wall sutures. 13) 3-0 silk sutures are placed on the sides and anterior portion of the pancreatic parenchyma to secure it to the jejunum. 14) The jejunal limb is secured to the retroperitoneal fat near the place it passes under the mesenteric vessels to prevent tension on the anastomosis or internal hernia. 15) Upon completion of the pancreaticojejunostomy, the hepaticojejunostomy is performed, followed by duodenojejunostomy.

In the setting of a neoplasm, pancreatic protocol CT scan of the abdomen should be obtained to determine respectability, and endoscopic ultrasound (EUS) with transluminal fine needle aspiration (FNA) is used to assess cytology. Tumor markers (CA 19-9, CEA) are obtained. Diagnostic laparoscopy can be used immediately pre-operatively to assess feasibility of the operation and avoid nontherapeutic laparotomy.

In cases of a very small pancreatic duct where duct to mucosa anastomosis cannot be performed, or when the pancreatic duct cannot be localized, a large jejunotomy can be performed and the whole neck of the pancreas invaginated into the jejunum.

The advantage of performing duct to mucosa anastomosis in this fashion is a decreased leak rate compared to invagination of the pancreas into the jejunum. A pediatric feeding tube may be used as a pancreatic duct stent if the pancreatic duct is small.

Intra-operative complications include damage to the pancreas, pancreatic duct, jejunum or mesenteric vessels. The most common post-operative complication related to the pancreaticojejunostomy is pancreatic fistula formation, occurring in 10-15% of patients. Post-operative complications seen in a pancreaticoduodenectomy but not specific to the pancreaticojejunostomy include delayed gastric emptying, bleeding, pancreatic insufficiency, and impaired glucose tolerance.

Intra-operative complications include damage to the pancreas, pancreatic duct, jejunum or mesenteric vessels. The most common post-operative complication related to the pancreaticojejunostomy is pancreatic fistula formation, occurring in 10-15% of patients. Post-operative complications seen in a pancreaticoduodenectomy but not specific to the pancreaticojejunostomy include delayed gastric emptying, bleeding, pancreatic insufficiency, and impaired glucose tolerance.

Tom Laws, BIDMC Media Services, who assisted in filming and editing this video

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