commonest problem after pancreatico-gastrectostomy. If you could elaborate your anastomotic techniques, some suggestions may be possible. What is the source of bleeding you identify in gastroscopy?

Adding two well illustrated papers. It will be your preference which method you would like to adopt. Controlling both transverse pancreatic vessels with fig-of-8 is a well proven precautionary step. My personal choice in your situation would have been to go through anterior gastrotomy and ensuring good hemostasis at gastric edges of the anastomosis, till the team develops a comfortable protocol. 

Sorry for the funny typo in my previous post.

Thank Dr. Borthakur. Your feedback is highly appreciated. All the bleedings seemed to arise from the pancreatic stump rather than the gasrto-pancreatic suture itself.  Our technique was that of double gastrotomies (Bassi & coll of your references).

figure of  8 corner sutures effectively prevents bleeding.Bipolar cautery in addition is

useful.

It is necessary to control the two pancreatic transverse arteries with non resorbable monofilament full thickness figure of eight sutures (like Prolene 2/0). Then every bleeder on the pancreatic stump is meticulously controlled with figure of eight non resorbable stitches, as the use of coagulation may be a bit risky. The patient is kept on PPI during the postoperative course.

Here is a link for a video at the website of the French Surgical Assosiation (AFC) of a pancreatogastrostomy performed by prof.Bachellier. I hope it helps.

http://www.chirurgie-viscerale.org/main/videotheque/chirurgie-viscerale-digestive/pancréas/article.phtml?id=rc%2forg%2fchirurgie-viscerale%2fhtm%2fArticle%2f2012%2f20120201-103725-675

In all cases in our experience pancreatico-jejunostomy, either end to side or end to end with invagination of the stump is largely preferable to pancreatico-gastrostomy. The incidence of fistulas is equally high, but bleedingis a rare occurrence.

To my opinion, Dr. Domenic Piccolboni`s idea of pancreatico-jejunostomy is more compatible to the physiologic circumstance than pancreato-gastrostomy firstly, there is risk of corrosive gastric acid reflux to basic pancreatic juice while jejunostomy permits reconstruction with Roux-en-Y procedure for anti-reflux, even though jejunum is nearly similarly basic.     

My question was how to prevent bleeding from gastrojejunistomy, not wich type of anastomosis should be performed.......of course we do perform a duct-to-mucosa (wirsung-jejuno) in most of the cases....

I agree that the spirit of the question is how to prevent bleeding and not what is the best type of pancreatic reconstruction after a duodenopancreatectomy. However i would like to cite two published RCT from Topal (2013) in Lancet Oncol. and Figueras (2013) in Br J Surg. They both conclude that a pancreaticogastrostomy reduces the incidence of pancreatic fistula compared to a pancreaticojejunostomy.

http://www.ncbi.nlm.nih.gov/pubmed/23643139

http://www.ncbi.nlm.nih.gov/pubmed/24264781

I know that some researchers don't agree with these results but to my knowledge there is no RCT showing a superiority for a pancreaticojejunostomy.

With my excuses, here is the link for the pancreaticogastrostomy video by Prof Bachellier that is missing from my previous answer.

http://www.chirurgie-viscerale.org/main/videotheque/chirurgie-viscerale-digestive/pancréas/article.phtml?id=rc%2forg%2fchirurgie-viscerale%2fhtm%2fArticle%2f2012%2f20120201-103725-675

I agree that no RCT had demonstrated the superiority of a reconstruction over another. However, every surgeon should be trained to choose the best option according to the patient characteristics, consistency of the glad, diameter of the duct. Lastly, in very selected case a total pancreatectomy is always an option.....

Thorough hemostasis of the pancreatic stump at surgery and the most important  - high doses of PPI