Two-in-one method: Novel pancreaticojejunostomy technique for the bifid pancreas

Abstract

The bifid pancreas is a rare anatomical variation of the pancreatic duct in which double main pancreatic ducts in the body and tail of the pancreas join at the pancreas head and drain through the major papilla. When pancreaticoduodenectomies are carried out on bifid pancreases, close attention must be paid to the reconstruction because of the possibility that there may be two pancreatic ducts that need to be reconstructed. We present a case of pancreaticoduodenectomy for the bifid pancreas and a novel technique named the 'two-in-one' method for double pancreatic duct to jejunum anastomosis. Using the two-in-one method, we anastomosed one jejunal hole to a double pancreatic duct. Pancreatic texture was normal and postoperative volumes of pancreatic juice from the two external pancreatic duct stents were 250 mL and 100 mL/day, respectively. Postoperative recovery went well although the patient needed a slightly longer hospital stay as a result of surgical site infection. This novel anastomotic technique was as simple to carry out as a normal pancreaticojejunostomy and may be useful for reconstruction of the bifid pancreas.

Keywords: bifid pancreas; pancreaticoduodenectomy; pancreaticojejunostomy.

Figure 1

Preoperative computed tomography images. (A‐F) There is a low‐density mass including calcification around the inferior vena cava behind the liver and the head of the pancreas. Arrowheads in A‐F in figure 1 are pointing to a low density mass including calcification

Figure 2

Double pancreatic duct orifices were found on the cut surface of the residual pancreas. A, Blunt tip probe could be inserted deep into the cranial duct. B, Blunt tip probe could be inserted 3 cm into the caudal duct. C, Schema after transection of the pancreas. Double pancreatic ducts joined near the cut surface of the pancreas head. Distance between the two ducts on the cut surface was 3 mm. Pbt, body and tail of the pancreas; Ph, head of the pancreas; PV, portal vein

Figure 3

Preoperative multi‐detector computed tomography shows a bifurcated double main pancreatic duct. A, There were two pancreatic ducts in the pancreas body. B, Two ducts joined at the level of the portal vein. Arrowheads in part A shows double main pancreatic duct. Arrowhead in part B shows the main pancreatic duct on the left side of the confluence of double pancreatic duct

Figure 4

Two‐in‐one method for double pancreatic duct to jejunum anastomosis with transpancreatic jejunal sutures (modified Blumgart mattress suture technique). (A,B) We carried out posterior sutures of the double pancreatic duct‐to‐jejunum anastomosis using four threads for each duct, followed by a 4‐Fr external pancreatic duct stent insertion into each duct. C, After the anterior sutures, using three threads for each duct, we sutured through the seromuscular layer of the jejunal anterior wall using a modified Blumgart mattress suture technique tied at the ventral wall of the jejunum to completely cover the pancreatic stump with the jejunal serosa

Figure 5

Three types of pancreatic transections and reconstructions for the bifid pancreas based on the location. Type 1: Pancreatic transection on the proximal side of the confluence of the duplicated pancreatic ducts enables surgeons to carry out a normal pancreaticojejunostomy. Type 2: Pancreatic transection on the distal side of the confluence of the duplicated pancreatic ducts enables surgeons to carry out a pancreaticojejunostomy for the double pancreatic ducts. Type 3: Pancreatic transection on the distal side of the terminal of the shorter pancreatic duct enables surgeons to carry out a normal pancreaticojejunostomy. PV, portal vein