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Pancreaticojejunostomy-securing technique: duct-to-mucosa anastomosis by continuous running suture and parachuting using monofilament absorbable thread
Pancreaticojejunostomy-Securing Technique: Duct-to-Mucosa Anastomosis by Continuous Running Suture and Parachuting Using Monofilament Absorbable Thread Susumu Ohwada, MI), Shigeru Iwazaki, MD, Seiji Nakamura, MD, Tetsushi Ogawa, MD, Yoshihumi Tanahashi, MD, Toshiro Ikeya, MI), Yuichi Iino, MD, and Yasuo Morishita, MD Despite r e d u c e d operative mortality and intraabdominal complications after pancreaticoduodenectomy, pancreatic fistula is a leading cause of morbidity and mortality (1-5). A n u m b e r of methods have been described to deal with the pancreatic remnant, including nonanastomotic options, insertion into the j e j u n u m by a variety of techniques, and pancreaticogastrostomy (1, 6, 7). No matter which m e t h o d is used, however, pancreatic fistula is most likely to occur when anastomosis involves a normal pancreas (1, 2, 8, 9). Duct-tomucosa anastomosis is important in preventing anastomotic leakage and preserving anastomotic patency and pancreatic function (2). We refined a duct-to-mucosa anastomosis that is easier, safer, and less prone to fistula formation. In this report, we describe the technique and its results. Me~o~
Patients. From April 1992 to March 1995, 56 patients underwent pancreaticoduodenctomy at our institution and an affiliate hospital. Forty-six of the total 56 patients underwent a Billroth-I-like reconstruction and refined new duct-mucosa anastomosis, and they were the subject of this study. Ten patients (seven with modified Child reconstruction, two with Roux-Y method, and one with~ pancreaticogastrostomy) were excluded from the study because of e x t e n d e d pancreatectomy in six, hepaticopancreaticoduodenectomyin two, and reresection following carcinoma recurrence after pancreaticoduodenectomy in two. Diagnosis was Received December 2, 1997; Revised March 31, 1997; Accepted April 1, 1997. From the Second Department of Surgery, Gunma University School of Medicine, Showa-Machi, Maebashi, and the Maebashi Red Cross Hospital; Asahi-cho, Maebashi, Gunma, Japan. Correspondence address: Susumu Ohwada, MD, Second Department of Surgery, Gunma University School of Medicine, 3-39-15 ShowaMachi, Maebashi 371, Japan. © 1997 by the American College of Surgeons Published by Elsevier Science Inc.
190
pancreatic duct carcinoma in 13 patients, bile duct carcinoma in 11, and carcinoma of the papilla of Vater in 6. Gallbladder, gastric, and duodenal cancer were f o u n d in two patients each, and ascending colon cancer in one. Chronic pancreatitis was present in 6 patients and benign tumor in 3. Disease was malignant in 37 patients and benign in 9. Thirty patients w e r e male (80%) and 16 female (20%). The m e a n age was 63 years (range: 2 4 82). Extended dissection of the regional and paraaortic lymph node and surrounding connective and nerve tissues was p e r f o r m e d for patients with malignant disease. Evaluations. The diameter of the pancreatic duct was measured using films of endoscopic retrograde cholangiopancreatography or abdominal ultrasounds. Pancreatic anastomotic leakage was defined as fluid draining from the peripancreatic region with an amylase content three times greater than normal more than 7 days after surgery, or leakage demonstrated in x-rays. Surgicalprocedure. Pancreaticoduodenal resection was conducted as pancreas h e a d resection with either limited distal gastrectomy (PD) or pyloruspreserving modification (PPPD). The caudal side of the pancreas was clamped using intestinal forceps. The pancreatic transection was conducted carefully using a knife to identify the main pancreatic duct and its small branches. Small branches at the transecting surface were sutured using an absorbable monofilament suture (6-0 polydioxanone, PDSII; Ethicon, Inc, Somerville, NJ, USA). The pancreatic stump was not sutured, but hemostasis was secured by suture ligatures with 6-0 PDSII stitches or electrocautery. Truncal or selective vagotomy was not conducted in any patient. We reconstructed a Billroth-I type, similar to that after distal gastrectomy, which was a normal anatomic arrangement, entailed gastrojejunostomy in PD or d u o d e n o d u o d e n o s t o m y in PPPD followed ISSN 1072-7515/97/$17.00 PII S1072-7515(97)00037-9
Ohwada et al
PANCREATICOJEJUNOSTOMY-SECURINGTECHNIQUE 191
Polyglyconate continuous suture
te
/; stay
FIG 1. Posterior row of continuous r u n n i n g sutures with 5-0 or 6-0 monofilament absorbable stitch (polydioxanone; PDSII) between the pancreatic duct with the shallow parenchyma and jejunal mucosal layer. The tube tip is not inserted into the pancreatic duct.
by pancreaticojejunostomy a n d biliary anastomosis. Pancreaticojejunostomy was c o n d u c t e d in endto-side anastomosis using two layers including duct-to-mucosa and the pancreatic p a r e n c h y m a a n d the jejunal seromuscular layer. A short elliptical incision in the series of the j e j u n u m approximately 7 cm from the jejunal stump was m a d e to aid rapid fusion between the pancreas and jejun u m and to prevent j e j u n u m narrowing. The center of the d e n u d e d area of the j e j u n u m was pierced with the sharp tip of a polyvlnyl chloride tube (Sumitomo Bakelite, Tokyo, Japan), b r o u g h t o u t t h r o u g h the biliary anastomosis and liver. A 4 Fr. (1.31 m m external diameter) tube, a diameter smaller than the pancreatic duct, was used, so as n o t to deliver all pancreatic juice to the outside. T h e tube tip was n o t inserted into the pancreatic duct to avoid impairing the access and visibility of the posterior row. First, a posterior row of continuous r u n n i n g sutures using 5-0 or 6-0 PDSII stitches was placed between the pancreatic duct a n d jejunal mucosal layer. T h e pancreatic duct sutures were placed at the pancreatic p a r e n c h y m a from the edge of the duct when the d u c t was fragile. Suturing began at the farthest point on the cranial side of the pancreatic duct a n d works toward the caudal side but was n o t tightened (parachuting) (Fig. 1). The tip of the tube was intro-
FIG 2. The posterior suture line is completed, then the tube tip is inserted into the pancreatic duct. Thereafter, the anterior row is similarly sutured.
d u c e d into the pancreatic duct following completion of the posterior suture line and sutured in place with 6-0 PDSII stitches. Thereafter, the anterior row was also sutured by parachuting (Fig. 2). Four (pancreatic duct less than 2 m m in diameter) to six (more than 5 m m ) sutures were used for both anterior and posterior rows. Parachuting sutures were pulled and secured serially with a right-angle h o o k initially in the posterior row, followed by the anterior row (Fig. 3). The sutures were t h e n tightened and tied with multiple throws. Second, the anastomosis was c o m p l e t e d by a layer of i n t e r r u p t e d 3-0 or 4-0 polybutester (Novafil; Davis and Geck ACC., St. Louis, MO) suture between the pancreatic p a r e n c h y m a and jejunal seromuscular layer from anterior to posterior walls. Fibrin glue (Beriplast; Behring Inst, GumbH, Marburg, Germany) was sprayed between the pancreas and jejunal seromuscular layer to protect against leakage of pancreatic juice from the cut e n d and to reinforce the anastomosis (Fig. 4). Finally, knots were tied and the pancreaticojejunostomy was completed. Reconstruction was completed after end-to-side biliary anastomosis with one layer i n t e r r u p t e d suture using 4-0 PDSII stitches and end-to-end gastrojejunostomy in PD with Gambee's m e t h o d using 4-0 PDSI! stitches or end-to-side d u o d e n o d u o d e n o s t o m y in PPPD using stapling devices. We used a stent tube in biliary anastomosis. T u b e gastrostomy o r j e j u n o s t o m y for feeding was c o n d u c t e d in some patients who had u n d e r g o n e pylorus-preserving pancreaticoduode-
192 J AM COLL SURG AUGUST1997 e x t e r n a l tube
t
VOLUME185:190--194
t
FIG 3. Preplaced sutures are secured serially with the right-angle hook initially at the posterior row, followed by the anterior row. The suture line is tightened.
nectomy. The anasomotic area of pancreaticojejunostomy a n d biliary anastomosis were drained separately with o p e n drains. Octreotide was n o t used prophylactically. Results
Twenty-eight patients u n d e r w e n t PD a n d 18 patients u n d e r w e n t PPPD (Table 1). T h e pancreatic duct was smaller than 2.0 m m in diameter in 13 patients, 2.0-5.0 m m in 21 patients, and m o r e than 5 m m in 12 patients (Table 2). T h e pancreatic duct was smaller than 3.0 m m in diameter in 23 patients, who h a d soft pancreas. T h e pancreatic duct tube was used in 39 patients, a short tube for internal drainage of the pancreatic juice was used as an anastomotic stent in 5 patients, a n d n o tube was used in two. Pancreatic anastomotic leakage occurred in only 1 patient with a d e n o m a of the papilla of Vater, who u n d e r w e n t pyloruspreserving pancreaticoduodenectomy, 2.2% overall. An incidence of 4.3% in patients with soft and n o r m a l pancreas and 7.7% in 13 patients with a n o r m a l (~ 2 m m ) pancreatic duct. No pancreatic anastomotic leakage or fistula occurred in patients with malignant disease and obstructive pancreatitis. No pancreatic anastomotic leakage occurred in patients using the lost tube or no tube. Minor biliary anastomotic leakage occurred in 3 patients (6.5%) and healed spontaneously without reoperation. No intra-abdominal abscess or gastrointestinal bleeding
"~',
external tube
FIG 4. Suturing between the pancreatic parenchyma and jejunal seromuscular layer from anterior to posterior walls with 3-0 monofilament suture (polybutester, Novafil) from anterior to posterior walls. Knots are n o t tied until after being sprayed with fibrin glue (Beriplast).
occurred, and no patients died. No pancreatic anastomotic leakage occurred in the 10 patients excluded from the study with different reconstructions (7 with end-to-side pancreaticojejunostomy, 2 with intussuscepting end-to-end pancreaticojejunostomy, and 1 with gastropancreaticostomy). Discussion
N u m e r o u s surgical techniques have been described to avoid leakage from the pancreatic remnant. Pancreaticojejunostomy or pancreaticogastrostomy is c o m m o n l y used as a pancreatic-enteric anastomosis after pancreaticoduodenectomy. Many factors could influence leakage at the pancreaticojejunal anastomosis, such as the individual T a b l e 1. I n d i c a t i o n s f o r P a n c r e a t i c o d u o d e n e c t o m y No, o f patients
PD
PPPD
Pancreas cancer Biliary d u c t cancer Chronic pancreatitis Papilla Vater cancer GaUbladder cancer D u o d e n a l cancer Gastric cancer Colon cancer Benign t u m o r
13 1l 6 6 2 2 2 1 3
10 8 2* 2 2 1 2 1
3 3 4 4
Total
46
28
18
1
3
*Postgastrectomy patient. PD, limited distal gastrectomy; PPPD, pylorus-preserving modiScation.
Ohwada et al Table
2. P a n c r e a t i c
Pancreatic
Anastomotic
Leakage
and Diameter
of
Duct Diameter of pancreatic duct (mm)
Pancreas cancer Biliary duct cancer Chronic pancreatitis Papilla Vater cancer Gallbladder cancer Duodenal cancer Gastric cancer Colon cancer Benign tumor Total patients with leakage
No. of patients
-< 2
2.1~t.9
>-- 5
13 11 6 6 2 2 2 1 1/3 1 / 4 6 (2.2%)
1 6 --1 -2 1 1/2 1/13 (7.7%)
8 4 2 3 1 2 --1 0/21
4 1 4 3 -----0/12
surgeon, the reconstruction m e t h o d , the anastomotic technique, the quality of the pancreatic r e m n a n t , and the use of a ductal tube or surgical drains. Leaks were strongly correlated with the factors affecting quality of the pancreatic remnant, including duct dilatation, pancreatic fibrosis, or a preoperative raised serum amylase level, or both (8, 9). In multivariate analysis, lower surgical volu m e and ampullary or d u o d e n a l disease Were strongly associated with pancreatic fistula (1, 2, 8, 9). The most i m p o r t a n t factor in the prevention of pancreatic fistula is technical precision and gentleness in construction of the pancreatic anastomosis. Duct-to-mucosa anastomosis in pancreaticojejunostomy is r e p o r t e d to be i m p o r t a n t to prevent leakage (2). It has been considered technically difficult to create a duct-to-mucosa pancreaticojejunostomy anastomosis when the pancreatic r e m n a n t was soft and the pancreatic duct small a n d thin (2, 10). T h e soft pancreatic p a r e n c h y m a a n d n o r m a l duct are susceptible to laceration by suturing or tying procedures. Pancreatic laceration occurs particularly often in the narrow space of the pancreatic-enteric anastomosis. Many surgeons adopt alternative procedures for anastomosis of the normal pancreas, including invagination with a d e f u n c t i o n e d jejunal loop or complete external drainage of pancreatic juice using a pancreatic tube t h r o u g h pancreaticojejunostomy (1, 6, 11). C o n t i n u o u s r u n n i n g suture and parachuting using a pliable traumatic m o n o f i l a m e n t stitch are techniques used in small vascular anastomoses such as coronary artery bypass grafting. We applied this technique to duct-to-mucosa anastomosis in pancreaticojejunostomy because the pancreatic duct diameter is over 2 m m , similar in size to a small vessel. This technique is m o r e applicable in patients with a soft pancreas and a small n o r m a l
PANCREATICOJEJUNOSTOMY-SECURINGTECHNIQUE 193 duct because polydioxanone is so pliable that we approximate the suture line easily, and both continuous r u n n i n g suture and parachuting eliminate the necessity of tying individual knots with four or five throws, which may injure both the parenchyma and the duct of the soft pancreas. This pancreaticoduodenectomy ~pancreaticojejunostomy series was performed by surgeons who all were 8 years postgraduate. Although the anastomosis was conducted under the naked eye even if the pancreatic duct diameter was less than 2 mm, a magnifying loupe, if available, is useful. When suturing the pancreatic duct, we took the pancreatic parenchyma from the edge of the duct when the duct was fragile. The m a n a g e m e n t of the pancreatic r e m n a n t also has been shown to be an i m p o r t a n t factor influencing the d e v e l o p m e n t of pancreatic fistula (1, 2, 8). The existence of small branches that communicate with the main pancreatic duct is noticed at the cut surface of the pancreatic remn a n t following distal pancreatectomy (12). Pancreatic juice can leak from the main pancreatic duct or from small branches, or both. We carefully sutured the small branches at the transecting surface of the r e m n a n t pancreas and used fibrin glue to seal these small ducts a n d did n o t close the pancreatic remnant. Fibrin glue m a d e with highly concentrated h u m a n fibrinogen and clotting factors is reported to prevent fistula formation after pancreatic surgery. There are some differences concerning how to use fibrin glue. Although fibrin glue was sprayed to seal the anastomosis in previous reports (13, 14), we used it at the transected surface of the r e m n a n t pancreas to prevent pancreatic leakage from small branches and to reinforce both the anastomosis of the duct-mucosa and of the pancreatic capsule and the jejunal seromuscular layer. Some advocate the use of a long tube t h r o u g h the anastomosis as a drain a n d complete external drainag e of pancreatic juice during healing (11, 15). We do n o t agree fully with this concept and maintain that complete external pancreatic juice drainage is not obligatory in duct-to-mucosa anastomosis. We applied a 4 Fr. (1.31 m m in external diameter) tube, a smaller diameter than the pancreatic duct, as a guarantee and a treatment measure for anastomotic leakage. A tube large e n o u g h to fill the duct disturbs the duct-to-mucosa anastomosis. No pancreatic anastomotic leakage occurred in patients using a lost tube or no tube. T h e incidence of pancreatic anastomotic leakage ranges from 5-25% in most series (1-5, 9, 10). In patients with n o r m a l pancreatic parenchyma, fistula occurred in 12-28%, c o m p a r e d with 5-9%
194 J AM COLL SURG AUGUST1997
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in those considered to have pancreatic fibrosis. Pancreatic anastomotic leakage developed significantly more frequently in patients with benign diseases other than chronic pancreatitis (16). The incidence of pancreatic leakage ranged from 1725% in our previous study of an end-to-side pancreaticojejunostomy or intussuscepting end-to-end pancreaticojejunostomy (17, 18). We performed 46 pancreaticojejunostomies using this technique with Billroth-I reconstruction. In our series, the incidence of pancreatic leakage was 2.2% overall, 4.3% in 23 patients with soft and normal pancreas, and 7.7% in 13 patients with a normal (-< 2 mm) pancreatic duct. No pancreatic fistula occurred in patients with obstructive pancreatitis. Pancreatic anastomotic leakage occurred in only one patient with adenoma of the ampulla of Vater, which was one of the high-risk factors for pancreatic fstula (1, 8, 16). Our series achieved a lower incidence of pancreatic leakage even in normal pancreatic parenchyma, compared with previous studies (1-5, 8, 9). We believe that simple continuous running suture and parachuting using a polydioxanone monofilament suture have theoretic and practical advantages for pancreaticojejunal anastomosis in cases with soft parenchyma and a small duct. We believe also that fibrin glue reinforces the pancreatic anastomosis by protecting against the leakage of pancreatic juice from the cut end of the pancreas remnant. This technique can also be applied to other types of pancreaticojejunostomy or pancreaticogastrostomy after pancreaticoduodenectomy. References 1. Marcus SG, Cohen H, and RansonJH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221:635-45. 2. Matsumoto Y, Fujii H, Miura K, et al. Successful pancreatoje-
junal anastomosis for pancreatoduodenectomy. Surg Gynecol Obstet 1992;175:555-62. 3. Cullen JJ, Sarr MG, and Ilstrup DM. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management. AmJ Surg 1994;168:295-8. 4. Cameron JL, Pitt HA, Yeo CJ, et al. One hundred and fortyfive consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993;217:430-5. 5. Baumel H, Huguier M, Manderscheid JC, et al. Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery. BrJ Surg 1994;81:102-7. 6. Hiraoka T, Kanemitsu K, Tsuji T, et al. A method of safe pancreaticojejunostomy. Am J Surg 1993;165:270-3. 7. Yeo cJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995;222:580-8. 8. Grace PA, Pitt HA, Tompkins RK, et al. Decreased morbidity and mortality after pancreaticoduodenectomy. Am J Surg 1986;151:141-9. 9. Bartoli FG, Armone GB, Ravera G, and Bachi V. Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical metaanalysis regarding 15 years of literature. Anticancer Res 1991;11: 1831-48. 10. Aston SJ, and Longmire WPJr. Management of the pancreas after pancreaticoduodenectomy. Ann Surg 1974;179:322-7. 11. Hamanaka Y, and Suzuki T. Total pancreatic duct drainage for leak proof pancreaticojejunostomy. Surgery 1994;115: 22-3. 12. Konishi T, Hiraishi M, Kubota K, et al. Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy. Ann Surg 1995;22: 165-70. 13. Tashiro S, Murata E, Hiraoka T, et al. New technique for pancreaticojejunostomyusing a biological adhesive. BrJ Surg 1987;74:392-4. 14. Kram HB, Clark SR, Ocampo HP, et al. Fibrin glue sealing of pancreatic injuries, resections, and anastomoses. Am J Surg 1994;161:479-81. 15. Smith R. Progress in the surgical treatment of pancreatic disease. Am J Surg 1973;125:143-53. 16. Barens SA, Lillemoe KD, Kaufman HS, et al. Pancreaticoduodenectomy for benign disease. Am J Surg 1996;171:131-4. 17. Miyamoto Y, Takeshita M, Makita F, et al. Pancreatic fistula after pancreaticoduodenectomy. Jpn J Gastroenterol Surg ,1988;21:2573-6. (In Japanese.) 18. Ohwada S, Nakamura S, Tanahashi Y, et al. Modified technique for pancreaticojejunostomyfollowing pancreaticoduodenectomy. Kitakanto Med J 1993;43:63-8. (In Japanese.)
Patients. From April 1992 to March 1995, 56 patients underwent pancreaticoduodenctomy at our institution and an affiliate hospital. Forty-six of the total 56 patients underwent a Billroth-I-like reconstruction and refined new duct-mucosa anastomosis, and they were the subject of this study. Ten patients (seven with modified Child reconstruction, two with Roux-Y method, and one with~ pancreaticogastrostomy) were excluded from the study because of e x t e n d e d pancreatectomy in six, hepaticopancreaticoduodenectomyin two, and reresection following carcinoma recurrence after pancreaticoduodenectomy in two. Diagnosis was Received December 2, 1997; Revised March 31, 1997; Accepted April 1, 1997. From the Second Department of Surgery, Gunma University School of Medicine, Showa-Machi, Maebashi, and the Maebashi Red Cross Hospital; Asahi-cho, Maebashi, Gunma, Japan. Correspondence address: Susumu Ohwada, MD, Second Department of Surgery, Gunma University School of Medicine, 3-39-15 ShowaMachi, Maebashi 371, Japan. © 1997 by the American College of Surgeons Published by Elsevier Science Inc.
190
pancreatic duct carcinoma in 13 patients, bile duct carcinoma in 11, and carcinoma of the papilla of Vater in 6. Gallbladder, gastric, and duodenal cancer were f o u n d in two patients each, and ascending colon cancer in one. Chronic pancreatitis was present in 6 patients and benign tumor in 3. Disease was malignant in 37 patients and benign in 9. Thirty patients w e r e male (80%) and 16 female (20%). The m e a n age was 63 years (range: 2 4 82). Extended dissection of the regional and paraaortic lymph node and surrounding connective and nerve tissues was p e r f o r m e d for patients with malignant disease. Evaluations. The diameter of the pancreatic duct was measured using films of endoscopic retrograde cholangiopancreatography or abdominal ultrasounds. Pancreatic anastomotic leakage was defined as fluid draining from the peripancreatic region with an amylase content three times greater than normal more than 7 days after surgery, or leakage demonstrated in x-rays. Surgicalprocedure. Pancreaticoduodenal resection was conducted as pancreas h e a d resection with either limited distal gastrectomy (PD) or pyloruspreserving modification (PPPD). The caudal side of the pancreas was clamped using intestinal forceps. The pancreatic transection was conducted carefully using a knife to identify the main pancreatic duct and its small branches. Small branches at the transecting surface were sutured using an absorbable monofilament suture (6-0 polydioxanone, PDSII; Ethicon, Inc, Somerville, NJ, USA). The pancreatic stump was not sutured, but hemostasis was secured by suture ligatures with 6-0 PDSII stitches or electrocautery. Truncal or selective vagotomy was not conducted in any patient. We reconstructed a Billroth-I type, similar to that after distal gastrectomy, which was a normal anatomic arrangement, entailed gastrojejunostomy in PD or d u o d e n o d u o d e n o s t o m y in PPPD followed ISSN 1072-7515/97/$17.00 PII S1072-7515(97)00037-9
Ohwada et al
PANCREATICOJEJUNOSTOMY-SECURINGTECHNIQUE 191
Polyglyconate continuous suture
te
/; stay
FIG 1. Posterior row of continuous r u n n i n g sutures with 5-0 or 6-0 monofilament absorbable stitch (polydioxanone; PDSII) between the pancreatic duct with the shallow parenchyma and jejunal mucosal layer. The tube tip is not inserted into the pancreatic duct.
by pancreaticojejunostomy a n d biliary anastomosis. Pancreaticojejunostomy was c o n d u c t e d in endto-side anastomosis using two layers including duct-to-mucosa and the pancreatic p a r e n c h y m a a n d the jejunal seromuscular layer. A short elliptical incision in the series of the j e j u n u m approximately 7 cm from the jejunal stump was m a d e to aid rapid fusion between the pancreas and jejun u m and to prevent j e j u n u m narrowing. The center of the d e n u d e d area of the j e j u n u m was pierced with the sharp tip of a polyvlnyl chloride tube (Sumitomo Bakelite, Tokyo, Japan), b r o u g h t o u t t h r o u g h the biliary anastomosis and liver. A 4 Fr. (1.31 m m external diameter) tube, a diameter smaller than the pancreatic duct, was used, so as n o t to deliver all pancreatic juice to the outside. T h e tube tip was n o t inserted into the pancreatic duct to avoid impairing the access and visibility of the posterior row. First, a posterior row of continuous r u n n i n g sutures using 5-0 or 6-0 PDSII stitches was placed between the pancreatic duct a n d jejunal mucosal layer. T h e pancreatic duct sutures were placed at the pancreatic p a r e n c h y m a from the edge of the duct when the d u c t was fragile. Suturing began at the farthest point on the cranial side of the pancreatic duct a n d works toward the caudal side but was n o t tightened (parachuting) (Fig. 1). The tip of the tube was intro-
FIG 2. The posterior suture line is completed, then the tube tip is inserted into the pancreatic duct. Thereafter, the anterior row is similarly sutured.
d u c e d into the pancreatic duct following completion of the posterior suture line and sutured in place with 6-0 PDSII stitches. Thereafter, the anterior row was also sutured by parachuting (Fig. 2). Four (pancreatic duct less than 2 m m in diameter) to six (more than 5 m m ) sutures were used for both anterior and posterior rows. Parachuting sutures were pulled and secured serially with a right-angle h o o k initially in the posterior row, followed by the anterior row (Fig. 3). The sutures were t h e n tightened and tied with multiple throws. Second, the anastomosis was c o m p l e t e d by a layer of i n t e r r u p t e d 3-0 or 4-0 polybutester (Novafil; Davis and Geck ACC., St. Louis, MO) suture between the pancreatic p a r e n c h y m a and jejunal seromuscular layer from anterior to posterior walls. Fibrin glue (Beriplast; Behring Inst, GumbH, Marburg, Germany) was sprayed between the pancreas and jejunal seromuscular layer to protect against leakage of pancreatic juice from the cut e n d and to reinforce the anastomosis (Fig. 4). Finally, knots were tied and the pancreaticojejunostomy was completed. Reconstruction was completed after end-to-side biliary anastomosis with one layer i n t e r r u p t e d suture using 4-0 PDSII stitches and end-to-end gastrojejunostomy in PD with Gambee's m e t h o d using 4-0 PDSI! stitches or end-to-side d u o d e n o d u o d e n o s t o m y in PPPD using stapling devices. We used a stent tube in biliary anastomosis. T u b e gastrostomy o r j e j u n o s t o m y for feeding was c o n d u c t e d in some patients who had u n d e r g o n e pylorus-preserving pancreaticoduode-
192 J AM COLL SURG AUGUST1997 e x t e r n a l tube
t
VOLUME185:190--194
t
FIG 3. Preplaced sutures are secured serially with the right-angle hook initially at the posterior row, followed by the anterior row. The suture line is tightened.
nectomy. The anasomotic area of pancreaticojejunostomy a n d biliary anastomosis were drained separately with o p e n drains. Octreotide was n o t used prophylactically. Results
Twenty-eight patients u n d e r w e n t PD a n d 18 patients u n d e r w e n t PPPD (Table 1). T h e pancreatic duct was smaller than 2.0 m m in diameter in 13 patients, 2.0-5.0 m m in 21 patients, and m o r e than 5 m m in 12 patients (Table 2). T h e pancreatic duct was smaller than 3.0 m m in diameter in 23 patients, who h a d soft pancreas. T h e pancreatic duct tube was used in 39 patients, a short tube for internal drainage of the pancreatic juice was used as an anastomotic stent in 5 patients, a n d n o tube was used in two. Pancreatic anastomotic leakage occurred in only 1 patient with a d e n o m a of the papilla of Vater, who u n d e r w e n t pyloruspreserving pancreaticoduodenectomy, 2.2% overall. An incidence of 4.3% in patients with soft and n o r m a l pancreas and 7.7% in 13 patients with a n o r m a l (~ 2 m m ) pancreatic duct. No pancreatic anastomotic leakage or fistula occurred in patients with malignant disease and obstructive pancreatitis. No pancreatic anastomotic leakage occurred in patients using the lost tube or no tube. Minor biliary anastomotic leakage occurred in 3 patients (6.5%) and healed spontaneously without reoperation. No intra-abdominal abscess or gastrointestinal bleeding
"~',
external tube
FIG 4. Suturing between the pancreatic parenchyma and jejunal seromuscular layer from anterior to posterior walls with 3-0 monofilament suture (polybutester, Novafil) from anterior to posterior walls. Knots are n o t tied until after being sprayed with fibrin glue (Beriplast).
occurred, and no patients died. No pancreatic anastomotic leakage occurred in the 10 patients excluded from the study with different reconstructions (7 with end-to-side pancreaticojejunostomy, 2 with intussuscepting end-to-end pancreaticojejunostomy, and 1 with gastropancreaticostomy). Discussion
N u m e r o u s surgical techniques have been described to avoid leakage from the pancreatic remnant. Pancreaticojejunostomy or pancreaticogastrostomy is c o m m o n l y used as a pancreatic-enteric anastomosis after pancreaticoduodenectomy. Many factors could influence leakage at the pancreaticojejunal anastomosis, such as the individual T a b l e 1. I n d i c a t i o n s f o r P a n c r e a t i c o d u o d e n e c t o m y No, o f patients
PD
PPPD
Pancreas cancer Biliary d u c t cancer Chronic pancreatitis Papilla Vater cancer GaUbladder cancer D u o d e n a l cancer Gastric cancer Colon cancer Benign t u m o r
13 1l 6 6 2 2 2 1 3
10 8 2* 2 2 1 2 1
3 3 4 4
Total
46
28
18
1
3
*Postgastrectomy patient. PD, limited distal gastrectomy; PPPD, pylorus-preserving modiScation.
Ohwada et al Table
2. P a n c r e a t i c
Pancreatic
Anastomotic
Leakage
and Diameter
of
Duct Diameter of pancreatic duct (mm)
Pancreas cancer Biliary duct cancer Chronic pancreatitis Papilla Vater cancer Gallbladder cancer Duodenal cancer Gastric cancer Colon cancer Benign tumor Total patients with leakage
No. of patients
-< 2
2.1~t.9
>-- 5
13 11 6 6 2 2 2 1 1/3 1 / 4 6 (2.2%)
1 6 --1 -2 1 1/2 1/13 (7.7%)
8 4 2 3 1 2 --1 0/21
4 1 4 3 -----0/12
surgeon, the reconstruction m e t h o d , the anastomotic technique, the quality of the pancreatic r e m n a n t , and the use of a ductal tube or surgical drains. Leaks were strongly correlated with the factors affecting quality of the pancreatic remnant, including duct dilatation, pancreatic fibrosis, or a preoperative raised serum amylase level, or both (8, 9). In multivariate analysis, lower surgical volu m e and ampullary or d u o d e n a l disease Were strongly associated with pancreatic fistula (1, 2, 8, 9). The most i m p o r t a n t factor in the prevention of pancreatic fistula is technical precision and gentleness in construction of the pancreatic anastomosis. Duct-to-mucosa anastomosis in pancreaticojejunostomy is r e p o r t e d to be i m p o r t a n t to prevent leakage (2). It has been considered technically difficult to create a duct-to-mucosa pancreaticojejunostomy anastomosis when the pancreatic r e m n a n t was soft and the pancreatic duct small a n d thin (2, 10). T h e soft pancreatic p a r e n c h y m a a n d n o r m a l duct are susceptible to laceration by suturing or tying procedures. Pancreatic laceration occurs particularly often in the narrow space of the pancreatic-enteric anastomosis. Many surgeons adopt alternative procedures for anastomosis of the normal pancreas, including invagination with a d e f u n c t i o n e d jejunal loop or complete external drainage of pancreatic juice using a pancreatic tube t h r o u g h pancreaticojejunostomy (1, 6, 11). C o n t i n u o u s r u n n i n g suture and parachuting using a pliable traumatic m o n o f i l a m e n t stitch are techniques used in small vascular anastomoses such as coronary artery bypass grafting. We applied this technique to duct-to-mucosa anastomosis in pancreaticojejunostomy because the pancreatic duct diameter is over 2 m m , similar in size to a small vessel. This technique is m o r e applicable in patients with a soft pancreas and a small n o r m a l
PANCREATICOJEJUNOSTOMY-SECURINGTECHNIQUE 193 duct because polydioxanone is so pliable that we approximate the suture line easily, and both continuous r u n n i n g suture and parachuting eliminate the necessity of tying individual knots with four or five throws, which may injure both the parenchyma and the duct of the soft pancreas. This pancreaticoduodenectomy ~pancreaticojejunostomy series was performed by surgeons who all were 8 years postgraduate. Although the anastomosis was conducted under the naked eye even if the pancreatic duct diameter was less than 2 mm, a magnifying loupe, if available, is useful. When suturing the pancreatic duct, we took the pancreatic parenchyma from the edge of the duct when the duct was fragile. The m a n a g e m e n t of the pancreatic r e m n a n t also has been shown to be an i m p o r t a n t factor influencing the d e v e l o p m e n t of pancreatic fistula (1, 2, 8). The existence of small branches that communicate with the main pancreatic duct is noticed at the cut surface of the pancreatic remn a n t following distal pancreatectomy (12). Pancreatic juice can leak from the main pancreatic duct or from small branches, or both. We carefully sutured the small branches at the transecting surface of the r e m n a n t pancreas and used fibrin glue to seal these small ducts a n d did n o t close the pancreatic remnant. Fibrin glue m a d e with highly concentrated h u m a n fibrinogen and clotting factors is reported to prevent fistula formation after pancreatic surgery. There are some differences concerning how to use fibrin glue. Although fibrin glue was sprayed to seal the anastomosis in previous reports (13, 14), we used it at the transected surface of the r e m n a n t pancreas to prevent pancreatic leakage from small branches and to reinforce both the anastomosis of the duct-mucosa and of the pancreatic capsule and the jejunal seromuscular layer. Some advocate the use of a long tube t h r o u g h the anastomosis as a drain a n d complete external drainag e of pancreatic juice during healing (11, 15). We do n o t agree fully with this concept and maintain that complete external pancreatic juice drainage is not obligatory in duct-to-mucosa anastomosis. We applied a 4 Fr. (1.31 m m in external diameter) tube, a smaller diameter than the pancreatic duct, as a guarantee and a treatment measure for anastomotic leakage. A tube large e n o u g h to fill the duct disturbs the duct-to-mucosa anastomosis. No pancreatic anastomotic leakage occurred in patients using a lost tube or no tube. T h e incidence of pancreatic anastomotic leakage ranges from 5-25% in most series (1-5, 9, 10). In patients with n o r m a l pancreatic parenchyma, fistula occurred in 12-28%, c o m p a r e d with 5-9%
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in those considered to have pancreatic fibrosis. Pancreatic anastomotic leakage developed significantly more frequently in patients with benign diseases other than chronic pancreatitis (16). The incidence of pancreatic leakage ranged from 1725% in our previous study of an end-to-side pancreaticojejunostomy or intussuscepting end-to-end pancreaticojejunostomy (17, 18). We performed 46 pancreaticojejunostomies using this technique with Billroth-I reconstruction. In our series, the incidence of pancreatic leakage was 2.2% overall, 4.3% in 23 patients with soft and normal pancreas, and 7.7% in 13 patients with a normal (-< 2 mm) pancreatic duct. No pancreatic fistula occurred in patients with obstructive pancreatitis. Pancreatic anastomotic leakage occurred in only one patient with adenoma of the ampulla of Vater, which was one of the high-risk factors for pancreatic fstula (1, 8, 16). Our series achieved a lower incidence of pancreatic leakage even in normal pancreatic parenchyma, compared with previous studies (1-5, 8, 9). We believe that simple continuous running suture and parachuting using a polydioxanone monofilament suture have theoretic and practical advantages for pancreaticojejunal anastomosis in cases with soft parenchyma and a small duct. We believe also that fibrin glue reinforces the pancreatic anastomosis by protecting against the leakage of pancreatic juice from the cut end of the pancreas remnant. This technique can also be applied to other types of pancreaticojejunostomy or pancreaticogastrostomy after pancreaticoduodenectomy. References 1. Marcus SG, Cohen H, and RansonJH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221:635-45. 2. Matsumoto Y, Fujii H, Miura K, et al. Successful pancreatoje-
junal anastomosis for pancreatoduodenectomy. Surg Gynecol Obstet 1992;175:555-62. 3. Cullen JJ, Sarr MG, and Ilstrup DM. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management. AmJ Surg 1994;168:295-8. 4. Cameron JL, Pitt HA, Yeo CJ, et al. One hundred and fortyfive consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993;217:430-5. 5. Baumel H, Huguier M, Manderscheid JC, et al. Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery. BrJ Surg 1994;81:102-7. 6. Hiraoka T, Kanemitsu K, Tsuji T, et al. A method of safe pancreaticojejunostomy. Am J Surg 1993;165:270-3. 7. Yeo cJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995;222:580-8. 8. Grace PA, Pitt HA, Tompkins RK, et al. Decreased morbidity and mortality after pancreaticoduodenectomy. Am J Surg 1986;151:141-9. 9. Bartoli FG, Armone GB, Ravera G, and Bachi V. Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical metaanalysis regarding 15 years of literature. Anticancer Res 1991;11: 1831-48. 10. Aston SJ, and Longmire WPJr. Management of the pancreas after pancreaticoduodenectomy. Ann Surg 1974;179:322-7. 11. Hamanaka Y, and Suzuki T. Total pancreatic duct drainage for leak proof pancreaticojejunostomy. Surgery 1994;115: 22-3. 12. Konishi T, Hiraishi M, Kubota K, et al. Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy. Ann Surg 1995;22: 165-70. 13. Tashiro S, Murata E, Hiraoka T, et al. New technique for pancreaticojejunostomyusing a biological adhesive. BrJ Surg 1987;74:392-4. 14. Kram HB, Clark SR, Ocampo HP, et al. Fibrin glue sealing of pancreatic injuries, resections, and anastomoses. Am J Surg 1994;161:479-81. 15. Smith R. Progress in the surgical treatment of pancreatic disease. Am J Surg 1973;125:143-53. 16. Barens SA, Lillemoe KD, Kaufman HS, et al. Pancreaticoduodenectomy for benign disease. Am J Surg 1996;171:131-4. 17. Miyamoto Y, Takeshita M, Makita F, et al. Pancreatic fistula after pancreaticoduodenectomy. Jpn J Gastroenterol Surg ,1988;21:2573-6. (In Japanese.) 18. Ohwada S, Nakamura S, Tanahashi Y, et al. Modified technique for pancreaticojejunostomyfollowing pancreaticoduodenectomy. Kitakanto Med J 1993;43:63-8. (In Japanese.)