MODIFIED HEIDELBERG TECHNIQUE FOR PANCREATIC ANASTOMOSIS

Abstract

Background: Pancreatic fistula is a major cause of morbidity and mortality after pancreatoduodenectomy. To prevent this complication, many technical procedures have been described.

Aim: To present a novel technique based on slight modifications of the original Heidelberg technique, as new pancreatojejunostomy technique for reconstruction of pancreatic stump after pancreatoduodenectomy and present initial results.

Method: The technique was used for patients with soft or hard pancreas and with duct size smaller or larger than 3 mm. The stitches are performed with 5-0 double needle prolene at the 2 o'clock, 4 o'clock, 6 o'clock, 8 o'clock, 10 o'clock, and 12 o'clock, positions, full thickness of the parenchyma. A running suture is performed with 4-0 single needle prolene on the posterior and anterior aspect the pancreatic parenchyma with the jejunal seromuscular layer. A plastic stent, 20 cm long, is inserted into the pancreatic duct and extended into the jejunal lumen. Two previously placed hemostatic sutures on the superior and inferior edges of the remnant pancreatic stump are passed in the jejunal seromuscular layer and tied.

Results: Seventeen patients underwent pancreatojejunostomy after pancreatoduodenectomy for different causes. None developed grade B or C pancreatic fistula. Biochemical leak according to the new definition (International Study Group on Pancreatic Surgery) was observed in four patients (23.5%). No mortality was observed.

Conclusion: Early results of this technique confirm that it is simple, reliable, easy to perform, and easy to learn. This technique is useful to reduce the incidence of pancreatic fistula after pancreatoduodenectomy.

FIGURE 1. A) Cut surface of the pancreas, stay sutures and pancreatic duct; B) three stitches full thickness posterior at 4 o’clock, 6 o’clock, and 8 o’clock positions; C) three stitches full thickness anterior at 10 o’clock, 12 o’clock, and 2 o’clock positions; D) running suture on the posterior aspect; E) sutures are passed in the positions 4 o’clock, 6 o’clock, and 8 o’clock; F) sutures are passed in the positions 10 o’clock, 12 o’clock, and 2 o’clock and one stent is put into the pancreatic duct; G) running anterior suture and stay stitches.