Anastomosis technique for pancreatojejunostomy and early removal of drainage tubes may reduce postoperative pancreatic fistula

Abstract

Background: Postoperative pancreatic fistula (POPF) is one of the most serious complications after pancreaticoduodenectomy (PD). Various factors have been reported as POPF risks, but the most serious of these is soft pancreas. To reduce POPF occurrences, many changes to the PD process have been proposed. This study evaluates short-term results of anastomosis technique for PD.

Methods: In total, 123 patients with soft pancreases who had undergone PD at Yamanashi University between January 2012 and August 2020 were retrospectively analyzed. We divided these patients into two groups depending on the time PD was performed: a conventional group (n = 67) and a modified group (n = 56).

Results: The rate of clinically relevant POPF was significantly lower in the modified group than that in the conventional group (5.4% vs 22.4%, p value < 0.001), with there being only one case of POPF in the modified group. There were no cases of POPF-related hemorrhaging in the modified group. On the third day after the operation, the amylase levels in the drainage fluid for the modified group became less than half (1696 vs 650 U/L). Multivariate analysis showed that the modified method was the independent predictors to prevent clinical POPF (p value = 0.002).

Conclusions: Our novel anastomosis technique for pancreatojejunostomy reduced POPF in PD, especially in cases where the patient had a soft pancreas.

Fig. 1

Schemes of PJ. a The duct-to-mucosa anastomosis was performed in an end-to-side fashion with eight absorbable interrupted sutures using 5–0 PDS-II with an external stent from the main pancreatic duct. b Before the sutures of the duct-to-mucosa were tied, the needle of the 4-0 Vascufil penetrated through the pancreatic parenchyma from the cut surface of the pancreas to the posterior wall. The serous muscle layer of the jejunum was then penetrated in three small steps (so as not to penetrate through all the layers of the wall) from the outside toward the insertion portion of the stent tube. The anastomosis of the posterior wall was performed at three places in total (arrows in b). The anastomosis of both the upper and lower edges was performed. The needle of the double-armed 4-0 Vascufil penetrated through the pancreatic parenchyma from the wall of the pancreas to the cut surface near the duct-to-mucosa anastomosis. The serous muscle layer of the jejunum was then penetrated in three steps from near the insertion portion of the stent tube toward the outside (arrows). c The anastomosis of the anterior pancreatic wall was performed similarly for both edges. These were performed at three places in total. d In the anterior wall and both the upper and lower edges, the needle at the pancreatic side of the double-armed 4-0 Vascufil was sutured at a point 5–8 mm from the lateral side of the previous suture, which penetrated the jejunal seromuscular wall like a triangular mattress suite (arrows). e All five sutures were tied gently to prevent tearing of the pancreatic parenchyma. This procedure completely covered the needle holes of the pancreatic wall by the jejunal serosa (arrows)