Ann Hepatobiliary Pancreat Surg.  2021 May;25(2):251-258. 10.14701/ahbps.2021.25.2.251.

Clinical outcomes and technical description of unstented end to side pancreaticogastrostomy by small posterior gastrotomy

• Bhoriwal SK
• Kumar S
• Deo S
• Sharma J
• Mishra A
• Kumar N
• Saikia J
• Dhall K

• KMID: 2516246
• DOI: http://doi.org/10.14701/ahbps.2021.25.2.251

Abstract

Backgrounds/Aims
Morbidity following Whipple’s surgery largely depends upon the pancreatic stump anastomosis leak. Pancreaticogastrostomy is one of the techniques of pancreatic stump reconstruction and is described variously in the literature. Duct to mucosa pancreaticogastrostomy is described either by a large 3-4 cm posterior gastrotomy or by small gastrotomy of 2-3 mm with the use of internal stents along with. We describe clinical outcomes and technique of 2 layer end to side pancreatico-gastrostomy by a small posterior gastrotomy without the use of internal stents.
Methods
Hospital records of 35 patients where the technique of, small posterior gastrotomy end to side duct to mucosa pancreatico-gastrostomy without internal stents, was used for pancreatic stump reconstruction were studied retrospectively. The data were analyzed for demographic details, stage of the disease, and short term outcomes related to surgical procedure.
Results
The mean duration of surgery was 7.4 hours. Grade A, B, and C POPF were observed in 10 (28.5%), 3 (8.5%), and 1 (2.8%) of patients respectively. The mean time to remove pancreatic drain was 9 days, and the mean time to start oral feeds was 8.9 days. The mean hospital stay was 12.9 days (07-26). Thirty days mortality was 2.8%.
Conclusions
Unstented duct to mucosa end to side pancreatico-gastrostomy technique is comparable with other pancreatico-gastrostomy techniques in outcomes in terms of POPF, morbidity, mortality, and hospital stay. However, to establish the superiority or inferiority of this technique, a larger study is recommended.

Keyword

Pancreatic cancer; Pancreaticoduodenectomy; Pancreatic fistula

Figure

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  Fig. 1 Diagrammatic representation of the surgical technique. (A) Shows preparation of pancreatic stump. Approximately 2–3 cm of the body of the pancreas is cleared off soft tissue and veins draining to splenic veins are tied. (B) (Anterior first layer). Passing of the first layer of sutures from the anterior serosal surface of the pancreas through the cut surface of the pancreas. These are numbered and held aligned by hemostats. (C) (Anterior second layer). Passing of the second layer of sutures from the cut surface of the pancreas through the anterior wall of the pancreatic duct. These are numbered and held aligned by hemostats. (D) (Posterior second layer) passing of posterior second layer of sutures from the posterior wall of the duct through the cut surface of the pancreas. These are numbered and held aligned by hemostats. (E) (Posterior first layer) Passing of posterior first layer of sutures from the cut surface of the pancreas through the posterior serosal surface of the pancreas. These are numbered and held aligned by hemostats. (F) The greater curvature of the stomach is flipped anteriorly and superiorly. Appropriate site of approximation of the pancreas to the posterior surface of the stomach is identified and posterior first layer sutures are passed through the posterior layer of the stomach in the sero-muscular plane and tied. This completes the posterior first layer. (G) A small gastrotomy of the size of the duct is made in the posterior wall of the stomach. Sutures of the posterior second layer are now passed from the serosal surface of the stomach full thickness into the lumen and taken out from the lumen of the gastrotomy site and tied. This completes the posterior second layer. (H) Sutures of anterior second layers are now passed through the gastrotomy from the mucosal surface of the stomach full thickness and taken out from the serosal side and tied. This completes the anterior second layer. (I) Demonstrates the completed duct to mucosa anastomosis and now the sutures from the anterior first layer are passed in the sero-muscular plane of the stomach and tied. This completes the anterior first layer. (J) Shows the completed anastomosis where the only duct to mucosa anastomosis is visible in the posterior wall of the stomach.

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