Ann Hepatobiliary Pancreat Surg.  2021 Aug;25(3):371-375. 10.14701/ahbps.2021.25.3.371.

Anterior pancreatic duct split prior to duct-to-mucosa pancreatico-jejunal anastomosis in pancreaticoduodenectomy

• Gadiyaram S
• Nachiappan M

• KMID: 2519294
• DOI: http://doi.org/10.14701/ahbps.2021.25.3.371

Abstract

A secure pancreatic-enteric anastomosis is widely accepted as the ‘Achilles heel’ in reconstruction following a pancreaticoduodenectomy. Most morbidity following the procedure is related to the failure of this anastomosis, resulting in intra-abdominal collections, secondary haemorrhage, delayed gastric emptying, need for radiological interventions and re-operation for some patients. Of several techniques available, the ‘duct-to-mucosa’ technique is widely employed for pancreaticojejunal anastomosis. Among several refinements to facilitate this anastomosis, viz; mobilization of pancreatic stump, magnification with loupes and modifications made on the jejunal side to enable a tension free anastomosis, none seems to address the pancreatic duct in particular. The operative technique of anterior pancreatic duct split described by us enables a wider, well visualized pancreatic duct for a secure duct to mucosa pancreaticojejunal anastomosis.

Keyword

Pancreas; Pancreaticoduodenectomy; Pancreaticojejunostomy; Duct-to-mucosa anastomosis; Anterior pancreatic duct split

Figure

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  Fig. 1 (A) Illustrations depicting the anterior pancreatic ductal split (APDS). (B) Operative photograph showing the pancreatic duct. (C) Initial APDS. (D) Completed APDS.

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  Fig. 2 Illustrations showing the entire circumference of the pancreatic duct (PD) prior to anterior pancreatic duct split (APDS) forming the posterior layer (bold line) of the duct for anastomosis and the entire transected surface of the pancreas prior to the split forming the posterior wall of the anastomosis (shaded area). Extra length of the duct available for the anastomosis post APDS is represented by dashed lines. ‘A’ point, where the duct is split; ‘A1’ and ‘A2’ points correspond to point ‘A’ after the split.

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  Fig. 3 (A) Illustration depicting pre-placed sutures on the posterior layer of the pancreatic duct. Note that this involves the entire circumference of the duct and the cut surface of the pancreas prior to the split. (B) Anchoring sutures on the jejunum.

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  Fig. 4 (A) Illustration showing the posterior layer pre-placed sutures being tied. (B) Operative photograph of completed posterior layer of duct-to-mucosa anastomosis.

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  Fig. 5 (A) Illustration showing sutures of the anterior layer of the anastomosis pre-placed. (B) The completed duct-to-mucosa anastomosis. (C) Operative photograph of pre-placed sutures of the anterior layer of the duct-to-mucosa anastomosis. (D) Completed anterior layer of the duct-to-mucosa anastomosis.

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