Which is your preference about surgical treatment of the pancreatic stump after pancreaticoduodenectomy for cancer ? Pancreatic jeunostomy (end to side anastomosis)? Pancreatic jejunostomy (end to end anastomosis)? Occlusion of the duct of Wirsung ? Duct to mucosa pancreatic jejunostomy ?
Recent review paper has shown that pancreatogastrostomy results in reduction of pancreatic fistulas however with higher incidence of bleeding .I personally don't have any experience with this technique. We have been used for many years double loop technique that we described many years ago with reduction in fistula grade and reduction in mortality ,however the number of pancreatic fistulas did not decreased with this technique .Recent paper presented in ACS Congress in San Francisco showed a decreased fistula rate by using anti-tryptolytic drug octreotide and antibiotic .Long acting octreotide may also be beneficial however randomized studies are needed to confirm these data.
Soft pancreases with small ducts are more likely to leak. I think the severity of the leak and not the incidence maybe higher in Panc-jej as the leak would be a combination of pancreatic juice, enteric juice and possibly bile depending on the reconstruction used. however I do agree with my Dear Friend Marcel that other complications maybe higher in panc- gastro. I used both for few years and I now use panc-jej double layers with ducto mucosa. At parity of pancreatic parenchyma consistency and duct size , good surgical technique, carful tissue handling and less trauma to the pancreas during reconstruction are key factors to reduce leaks. Post operatively careful management of the drains and avoidance of introducing infection to the anastomosis is important.
I do prefer duct-mucosa pancreaticojejunostomy. However i think the most important factor is a good anastomosis technique. Not all pancreas are candidates for duct-mucosa anastomosis, so there are cases where pancreaticojejunostomy (end-to-side or end-to-end) or pancreaticogastrostomy are necessary. Pancreaticogastrostomy has more bleeding complications, and it looks difficult to perform during a classical Whipple procedure due to gastric reduction, that is why I only consider it during a Longmire procedure.
I always use a TachoSil sponge to cover anastomosis, which seems to reduce pancreatic fistula. This is a key-point for a good outcome, i think.
Thank you dear colleagues and fellow researchers for your comments. I agree with your experience and when possible i think is better to perform a duct-mucosa anastomosis.
Do you place a stent in Wirsung duct ?
To place a stent into pancreatric duct after pancreaticoduodenectomy is the same as to make a controlled pancreatic fistula .In soft pâncreas with tine ducts I prefer to place external stents however in larger ducts and harder paqncreas stents are not needed
I prefer to perform cobra mouth like end to end pancreaticojejunostomy., first row of stiches are placed 1.5cm away from the cut edge of the pancreas using the inverting seromuscular layer of the jejunum to pancreatic capsula., and the secon row, a few stiches are put deep through the whole layer of the jejunum and the capsula of the cut edge of the pancreas., nothing is done on the pancreatic duct.,
I creat whole-thickness matress PJ suture (twoor three layers) of end to side PJ anastomosis to prevent pancreatic parencyma injury (laceration) during making the secure tie when pancreatic texture is soft, and to spare duct anastomosis when duct is small.
please see the attached figures.
2-layer duct to mucosa pancreatioc-jejunostomy with a stent the for "soft pancreas and small duct combination". Using an isoloated Roux-limb to the pancreas avoids biliary activation of pancreatic enzymes and may further reduce the probability of subclinical leaks progressing.
I agree with Giuseppe In fact I have published the technique years ago
Machado MCC, Cunha JEM, Bacchella T, Bove P, Raia AA. A modified technique for the reconstruction of the alimentary tract after pancreatoduodenectomy. Surg Gyn Obst 1976;143-272.
Since then we have used this techniquiefor every patient with great success
I am Dezső Kelemen from Pécs University of Hungary. I have applied purse-string suture end-to-side pancreatojejunostomy, namely with one purse-string stitch (3/0 PDS) and two U-shaped transfixing mattress sutures (3/0 PDS big needle) for fixing the pancreatic remnant in the jejunum. So there is no stitch hole in the pancreas outside of the jejunal lumen. Till now I have 40 cases with 2 fistulas. In soft pancreas I use Wirsung stent for 2-3 weeks to prevent the occlusion of the duct by the purse-string suture. I am satisfied with the method, however these are only early results, More cases are needed to draw final conclusions. My data was published and cited in PUBMED, in Pancreatology and in Hungarian Journal of Surgery. I am interested in your comments! Kind regards!