Double Duct to Mucosa Pancreaticojejunostomy for Bifid Pancreatic Duct following Pylorus Preserving Pancreaticoduodenectomy: A Case Report

Abstract

Bifid pancreatic duct represents a relatively rare anatomical variation of the pancreatic ductal system, in which the main pancreatic duct is bifurcated along its length. This paper describes the challenging surgical management of a 68-year-old male patient, with presumptive diagnosis of periampullary malignancy who underwent a successful double duct to mucosa pancreaticojejunostomy for bifid pancreatic duct. Following pylorus preserving pancreaticoduodenectomy, careful intraoperative inspection of the cut surface of the residual dorsal pancreas identified the main in addition to the secondary pancreatic duct orifice. Bifid duct anatomy was confirmed via intraoperative probing and direct visualization of the ductal orifices. A decision was made for the performance of an end-to-site double duct to mucosa pancreaticojejunostomy. Postoperative outcome was favorable without any complications. Although bifid pancreatic duct is relatively rare, pancreatic surgeons should be aware of this anatomical variation and be familiar with the surgical techniques for its successful management. Lack of knowledge and surgical expertise for dealing with this anatomical variant may lead to serious, life threatening postoperative complications following pancreatic resections.

Figure 1

Linear EUS showing an inhomogeneous hypoechoic mass with irregular borders in the head of the pancreas. The echotexture of the pancreatic parenchyma appears heterogeneous with a coarse reticular pattern. A single pancreatic duct (PD) with a maximal diameter of 4 mm could be delineated in the head of the pancreas, appearing uniform with anechoic margins. A patent portal vein (PV) was also depicted bellow the PD with no evidence of tumor invasion.

Figure 2

Linear EUS showing a markedly inhomogeneous pancreatic body parenchyma. The ultrasound wave was unable to delineate anatomical structures corresponding to either the main or the secondary pancreatic duct.

Figure 3

Postoperative followup dynamic magnetic resonance T1-weighted imaging of the remnant pancreas depicting the main as well as the secondary pancreatic duct (arrow and arrowhead resp.) draining the remaining dorsal pancreas at the level of the double pancreaticojejunal anastomosis.

Scheme 1

This scheme demonstrates the adaptation of the cut edge of the jejunum to the surface of the dorsal pancreatic remnant at the time of completion of the posterior inner row of the two-layer, single-stich (with monofilament absorbable, PDS 5-0; Johnsosn & Johnsosn with atraumatic JRB-1 needle), double duct to mucosa adaptation. Special attention was given to accomplish a duct to mucosa adaptation between duct epithelium and jejunal mucosa as demonstrated in the scheme. A ductal stent or drainage has not been used. The anterior ductal sutures on both ducts, which have been placed previously as first step of the anastomosis, were integrated in order, and each suture was clipped with a mosquito clamp.