Two Layered End-to-side Duct to Mucosa Pancreaticojejunostomy

"There are a variety of ways to perform a pancreaticojejunostomy during the reconstruction phase of a Whipple procedure. Our preference is to perform a duct-to-mucosa anastomosis when the size of the duct and the texture of the gland allow. We have performed this type of anastomosis for ducts as small as 3-4 mm in diameter. We begin the reconstruction by delivering a retro-colic limb of the proximal jejunum through an opening in the transverse mesocolon created to the right of the middle colic vessels. The anastomosis is performed as an end-to-side pancreaticojejunostomy. The transected end of the pancreas is mobilized off the splenic vein for approximately 1-2 cm. Superior and inferior branches of the pancreatic arterial arcade are ligated with fine 5-0 absorbable suture ligatures to prevent bleeding from the cut edge of the pancreas and to avoid ischemic necrosis or a crush injury at the cut edge of the pancreas by taking larger sutures with a great deal of pancreas tissue. Once the pancreas is mobilized, we place our first outer row of the posterior layer using interrupted 3-0 silk sutures. The sutures are placed posteriorly on the capsule of the pancreas about 5-10 mm from the divided end of the pancreas and then brought through a thick seromuscular bite about 5-8 mm from the anti-mesenteric edge on what will become the posterior layer of the jejunal side of the anastomosis. All of the knots are placed in an upward position as simple sutures with no attempt to bury or invert the knots. Before the silk sutures are tied, we place the posterior row of the pancreatic duct sutures. We use a 4-0 PDS type suture with a first stitch placed in the 6 o¢clock position. The duct is then dilated, and 2 sutures are placed superior to that 6 o¢clock suture and 2 sutures are placed inferior to that for a usual total of 5 sutures in the posterior layer of the pancreatic duct. Again, all the sutures are placed with simple knots in an upward position. The next layer of sutures is on the anterior pancreatic duct with care taken to assure a good bite of pancreatic capsule and bringing out the sutures from the 9 o'clock through 3 o¢clock location with 5 interrupted sutures. Once the pancreatic duct sutures are in place, the sutures are retracted anteriorly and superiorly, and the silk sutures between the posterior gland and the posterior bowel wall are tied sequentially. The sutures are then divided, and with the bowel having then been positioned in a side-to-end fashion with the cut edge of the pancreas, we perform a small enterotomy at the anti-mesenteric border of the intestine. The enterotomy usually measures approximately 4-6 mm in length. We then place four 5-0 PDS sutures in a horizontal mattress fashion circumferentially around the enterotomy to anchor the intestinal mucosa to the submucosa and bowel wall. This creates a helpful outward protrusion of the intestinal mucosa when placing the small sutures from the pancreatic duct. We then place the 5 posterior duct sutures into the posterior wall of the small bowel enterotomy. These are full-thickness stitches with care taken to place the sutures at approximately the same distance as they were placed in the pancreatic duct. These sutures are then tied and divided. The anterior duct sutures are then placed from inside the bowel to outside the bowel wall, again using full-thickness bites with the knots in a simple upward location. This layer is tied, and then the anastomosis is finished by completing the outer layer of the anterior row using another layer of interrupted 3-0 silk sutures from the capsule of the gland to the seromuscular surface of the anterior bowel wall. No pancreatic stents are usually used. Two drains are usually placed anterior and posterior to the anastomosis and removed on post-operative days 3-5 if the amylase levels are < 1.5 x the serum levels." -Mark S. Talamonti, MD

The procedure shown was indicated for a resectable, biopsy proven pancreatic adenocarcinoma localized to the head of the pancreas.

Distant metastatic disease; Locally advanced pancreatic adenocarcinoma; vascular invasion precluding resection and reconstruction.

N/A

The patient is positioned supine on the operating room table with arms out at the side, secured safely on bilateral arm boards. The attending surgeon stands on the patient¢s left and assisting resident/fellow on the right. (See diagram in video)

The patient underwent a standard workup for obstructive jaundice. Typically, patients will have undergone a RUQ ultrasound or standard CT of the abdomen and pelvis prior to being seen by a surgical oncologist. These studies may be helpful in determining the etiology of the obstructive jaundice. A tissue diagnosis of pancreatic adenocarcinoma can be obtained by FNA biopsy performed during an EUS/ERCP. Although a tissue diagnosis is not required to be considered a candidate for curative resection, all patients with suspected pancreatic adenocarcinoma undergo a triple phase intravenous contrast CT with ultra-thin sections and 3-dimensional reconstructions (pancreas protocol) for further staging and operative planning. This high resolution, contrast enhanced modality provides dedicated imaging of the mesenteric vasculature and anatomic information regarding the feasibility of resection. Further staging includes a CT of the chest to rule out distant metastatic disease that would also preclude resection. Labs drawn include: CBC, BMP, Liver panel, coagulation panel and the biomarker CA 19-9.

The length of the jejunal limb needed may vary based on the location of the remaining pancreas. In any case, the jejunum is mobilized enough to allow for a tension-free, well-approximated anastomosis between the pancreatic duct and the small bowel mucosa from an enterotomy made on the anti-mesenteric border of the jejunum.

See references for each below and further risk factors
Delayed gastric emptying
Pancreatic leak/fistula
Arterial stump breakdown (Pseudo-anuerysm of the gastroduodenal artery)

The authors have no disclosures

1. Berger AC, Howard TJ, Kennedy EP, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. Journal of the American College of Surgeons. May 2009;208(5):738-747; discussion 747-739.

ABSTRACT: BACKGROUND: Pancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy. There have been no large prospective randomized trials evaluating PF rates comparing invagination versus duct to mucosa pancreaticojejunostomy. We tested the hypothesis that a duct to mucosa pancreaticojejunostomy would reduce the PF rate. STUDY DESIGN: Between August 2006 and May 2008, 197 patients at two institutions underwent pancreaticoduodenectomy by a total of 8 experienced pancreatic surgeons as part of this prospective randomized trial (clinical trial no. NCT00359320). All patients were stratified by pancreatic texture and randomized to either an invagination or a duct to mucosa pancreaticojejunal anastomosis. Recorded variables included pancreatic duct diameter, operative time, blood loss, complications, and pathology. Primary end point was PF rate, as defined by the International Study Group on Pancreatic Fistula. Secondary end points included PF grade, postoperative length of hospital stay, other morbidities, and mortality. RESULTS: Rate of PF for the entire cohort was 17.8%. There were 23 fistulas (24%) in the duct to mucosa cohort and 12 fistulas (12%) in the invagination cohort (p < 0.05). The greatest risk factor for a PF was pancreas texture: PF developed in only 8 patients (8%) with hard glands, and in 27 patients (27%) with a soft gland. There were two perioperative deaths (both in the duct to mucosa group), with the proximate causes of death being PF, followed by bleeding and sepsis. CONCLUSIONS: This dual-institution prospective randomized trial reveals considerably fewer fistulas with invagination compared with duct to mucosa pancreaticojejunostomy after pancreaticoduodenectomy. Results confirm increased PF rates in soft as compared with hard glands. Additional studies are needed to define the optimal technique of pancreatic reconstruction after pancreaticoduodenectomy. 2. Warshaw AL, Thayer SP. Pancreaticoduodenectomy. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. Sep-Oct 2004;8(6):733-741. http://www.ncbi.nlm.nih.gov/pubmed/15358336 3. The Pancreas. In: Cameron JL. ed. Atlas of Surgery, Vol 1. 1st ed. Hamilton, Ontario: BC Decker, Inc;1990:409. 4. Liu QY, Zhang WZ, Xia HT, et al. Analysis of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy. World journal of gastroenterology. Dec 14 2014;20(46):17491-17497. ABSTRACT: AIM: To explore the morbidity and risk factors of postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy. METHODS: The data from 196 consecutive patients who underwent pancreaticoduodenectomy, performed by different surgeons, in the General Hospital of the People's Liberation Army between January 1(st), 2013 and December 31(st), 2013 were retrospectively collected for analysis. The diagnoses of POPF and clinically relevant (CR)-POPF following pancreaticoduodenectomy were judged strictly by the International Study Group on Pancreatic Fistula Definition. Univariate analysis was performed to analyze the following factors: patient age, sex, body mass index (BMI), hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pancreatic duct diameter, pylorus preserving pancreaticoduodenectomy, pancreatic drainage and pancreaticojejunostomy. Multivariate logistic regression analysis was used to determine the main independent risk factors for POPF. RESULTS: POPF occurred in 126 (64.3%) of the patients, and the incidence of CR-POPF was 32.7% (64/196). Patient characteristics of age, sex, BMI, hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pylorus preserving pancreaticoduodenectomy and pancreaticojejunostomy showed no statistical difference related to the morbidity of POPF or CR-POPF. Pancreatic duct diameter was found to be significantly correlated with POPF rates by univariate analysis and multivariate regression analysis, with a pancreatic duct diameter </= 3 mm being an independent risk factor for POPF (OR = 0.291; P = 0.000) and CR-POPF (OR = 0.399; P = 0.004). The CR-POPF rate was higher in patients without external pancreatic stenting, which was found to be an independent risk factor for CR-POPF (OR = 0.394; P = 0.012). Among the entire patient series, there were three postoperative deaths, giving a total mortality rate of 1.5% (3/196), and the mortality associated with pancreatic fistula was 2.4% (3/126). CONCLUSION: A pancreatic duct diameter </= 3 mm is an independent risk factor for POPF. External stent drainage of pancreatic secretion may reduce CR-POPF mortality and POPF severity. 5. Dong Z, Xu J, Wang Z, Petrov MS. Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy. The Cochrane database of systematic reviews. 2013;6:CD008914. ABSTRACT: BACKGROUND: Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date, there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting is preferable. OBJECTIVES: To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy. SEARCH METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ISI Web of Science and four major Chinese biomedical databases were searched up to February 2011. We also searched four major trials registers. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents following pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS: Two authors extracted the data independently. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. The results were shown as relative risk (RR) with 95% confidence interval (CI). MAIN RESULTS: A total of 656 patients were included in the systematic review. Overall, the use of stents (both external and internal) was not associated with a statistically significant change in any of the studied outcomes. In a subgroup analysis, it was found that the use of external, but not internal, stents is associated with a significant reduction in the incidence of pancreatic fistulae (RR 0.33; 95% CI 0.11 to 0.98, P = 0.04), the incidence of complications (RR 0.48; 95% CI 0.25 to 0.92, P = 0.03) and length of hospital stay (RR -0.57; 95% CI -0.94 to -0.21, P = 0.002). In RCTs on the use of internal versus external stents, no statistically significant difference was found in terms of any of the studied outcomes. AUTHORS' CONCLUSIONS: This systematic review suggests that the use of external stents following pancreaticoduodenectomy may be beneficial. However, only a limited number of RCTs with rather small sample sizes were available. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted. 6. Ven Fong Z, Correa-Gallego C, Ferrone CR, et al. Early Drain Removal--The Middle Ground Between the Drain Versus No Drain Debate in Patients Undergoing Pancreaticoduodenectomy: A Prospective Validation Study. Annals of surgery. Aug 2015;262(2):378-383. ABSTRACT: OBJECTIVE: To perform an unbiased assessment of first postoperative day (POD 1) drain amylase level and pancreatic fistula (PF) after pancreaticoduodenectomy (PD). BACKGROUND: Recent evidence demonstrated that drain abandonment in PD is unsafe. Early drain amylase levels have been proposed as predictors of PF after PD, allowing for selection of patients for early drain removal. METHODS: Daily drain amylase levels were correlated with the development of PF in 2 independent cohorts of patients undergoing PD: training cohort (n = 126; year 2008) and validation cohort (n = 369; years 2009-2012). RESULTS: POD 1 drain amylase level had the highest predictive ability (concordance index: 0.911) for PF in the training cohort. An amylase level of 612 U/L or higher showed the best accuracy (86%), sensitivity (93%), and specificity (79%). Thus, a cutoff value of 600 U/L was utilized. In the validation cohort, 229 (62.1%) patients had a POD 1 drain amylase level of lower than 600 U/L, and PF developed in only 2 (0.9%) cases; whereas in patients with POD 1 drain amylase level of 600 U/L or higher (n = 140) the PF rate was 31.4% (odds ratio [OR] = 52, P < 0.0001). On multivariate analysis, POD 1 drain amylase level of lower than 600 U/L (OR = 0.0192, P < 0.0001) was a stronger predictor of the absence of PF than pancreatic gland texture (OR = 0.193, P = 0.002) and duct diameter (OR = 0.861, P = 0.835). CONCLUSIONS: After PD, the risk of PF is less than 1% if POD 1 drain amylase level is lower than 600 U/L. We propose that in this group, which comprise more than 60% of patients, drains should be removed on POD 1. 7. Kirihara Y, Takahashi N, Hashimoto Y, et al. Prediction of pancreatic anastomotic failure after pancreatoduodenectomy: the use of preoperative, quantitative computed tomography to measure remnant pancreatic volume and body composition. Annals of surgery. Mar 2013;257(3):512-519. ABSTRACT: OBJECTIVE: To determine whether remnant pancreatic volume (RPV), subcutaneous/visceral adipose tissue(SAT/VAT) area, and skeletal muscle (SM) area calculated from preoperative computed tomography (CT) can predict the occurrence of pancreatic anastomotic failure (PAF) after pancreatoduodenectomy (PD). BACKGROUND: Increased body mass index, small main pancreatic duct, and soft pancreatic texture are well-established predictors of PAF after PD. The impact on PAF of anthropomorphic measurements, such as RPV and body composition, is unknown. METHODS: In 173 patients undergoing PD from 2004 to 2009, cross sections of SAT/VAT/SM area were quantitated volumetrically, respectively, from preoperative CT. RPV was calculated from the CT as the sum of pancreatic tissue area to the left of the presumed pancreatic transection site. The predictive ability for multiple models using combinations of body mass index, RPV, SAT/VAT area, SM area, main pancreatic duct size, and pancreatic gland texture was described using a concordance index (c-index). RESULTS: Clinically relevant PAF occurred in 22 patients (13%). Multivariate logistic regression analysis identified RPV (P = 0.0012), VAT area (P = 0.0003), and SM area (P = 0.0006) as independent predictors of PAF. Using previously identified risk factors, the best 2-predictor model (body mass index and pancreatic duct size) resulted in a c-index of 0.748. Using anthropomorphic factors, however, the 2-predictor model using VAT and SM areas revealed a superior c-index of 0.959. CONCLUSIONS: Our 2-predictor model using VAT area and SM area based on volumetric quantification using preoperative CT may offer clinical benefit as an objective prognostic measure to predict clinically relevant PAF after PD 8. Eshuis WJ, van Eijck CH, Gerhards MF, et al. Antecolic versus retrocolic route of the gastroenteric anastomosis after pancreatoduodenectomy: a randomized controlled trial. Annals of surgery. Jan 2014;259(1):45-51. ABSTRACT: OBJECTIVE: To investigate the relationship between the route of gastroenteric (GE) reconstruction after pancreatoduodenectomy (PD) and the postoperative incidence of delayed gastric emptying (DGE). BACKGROUND: DGE is one of the most common complications after PD. Recent studies suggest that an antecolic route of the GE reconstruction leads to a lower incidence of DGE, compared to a retrocolic route. In a nonrandomized comparison within our trial center, we found no difference in DGE after antecolic or retrocolic GE reconstruction. METHODS: Ten middle- to high-volume centers participated in the patient inclusion. Patients scheduled for PD who gave written informed consent were included and randomized during surgery after resection. Standard operation was a pylorus-preserving PD. Primary endpoint was DGE. Secondary endpoints included other complications and length of hospital stay. RESULTS: There were 125 patients in the retrocolic group, and 121 patients in the antecolic group. Baseline and treatment characteristics did not differ between the study groups. In the retrocolic group, 45 patients (36%) developed clinically relevant DGE compared with 41 (34%) in the antecolic group (absolute risk difference: 2.1%; 95% confidence interval: -9.8% to 14.0%). There were no differences in need for postoperative (par)enteral nutritional support, other complications, hospital mortality, and median length of hospital stay. CONCLUSIONS: The route of GE reconstruction after PD does not influence the postoperative incidence of DGE or other complications. The etiology and treatment of DGE, which occurs frequently after both procedures, need further investigation. The GE reconstruction after PD should be routed according to the surgeon's preference. 9. Wolf AM, Lavu H. Pancreaticoduodenectomy and its variants. Cancer journal. Nov-Dec 2012;18(6):555-561. ABSTRACT: Pancreaticoduodenectomy (PD) is a complex surgical procedure involving resection of the duodenum, the pancreatic head and uncinate process, and the distal common bile duct. It is most commonly performed for periampullary malignancy but may also be indicated in select cases of chronic pancreatitis or benign periampullary tumors. When evaluating a patient for potential PD, the foremost question is determining the ability to perform an adequate (margin-negative) and safe resection. Herein, we present the surgical technique for performing a pylorus-preserving PD divided into the extirpative and reconstructive phases. There are a number of accepted alternatives to the pylorus-preserving PD as presented, and the commonly accepted alternatives will also be reviewed. The sequence of steps in the extirpative phase may vary depending on the tumor location (i.e., head, neck, and uncinate) and extent of disease, whereas reconstruction techniques may vary based on a given surgeon's training and preference. Multiple advancements in recent years, including those presented below, have helped to significantly reduce the operative mortality associated with PD.