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A Technique for Pancreaticogastrostomy
HOW I DO IT
A Technique for Pancreaticogastrostomy Gerard V. Aranha, MD, Maywood, Illinois
A technique for pancreaticogastrostomy is presented. The technique is a one-layer, invaginated anastomosis of the pancreatic remnant to the posterior gastric wall following a Whipple resection of the pancreatic head. Key steps to achieve a successful anastomosis are described. Using this technique, there have been no pancreatic anastomotic leaks in 29 consecutive patients. Am J Surg. 1998;175:328 –329. © 1998 by Excerpta Medica, Inc.
M
anagement of the pancreatic stump after a Whipple operation continues to be a source of controversy. Both pancreaticojejunostomy and pancreaticogastrostomy have supporters.1–3 Described here is a technique of a one-layer invaginating pancreaticogastric anastomosis following a Whipple procedure that has been successful in 29 consecutive patients.
TECHNIQUE After dissection of the superior mesenteric and portal vein from the under surface of the pancreas, figure-of-eight sutures of 3-0 silk are placed opposite each other at the inferior and superior borders of the pancreas. The pancreas is then severed over the superior mesenteric and portal vein using cautery (Figure 1). Care is taken not to extensively cauterize the cut main pancreatic duct. The pancreatic remnant is then mobilized for a distance of 4 cm (Figure 2). Single layer sutures of 3-0 silk are placed from the posterior superior wall of the stomach to the anterior wall of the pancreas (Figure 3). The sutures on the pancreas are placed at least 1 cm away from the cut edge. A gastrotomy of 3 cm in length is made (occasionally, because of the size of the cut pancreas, a larger gastrotomy is needed), and then 3-0 silk sutures are placed from the posterior inferior wall of the stomach to the posterior pancreas (Figure 4). When the sutures are tied, 1 cm of the pancreas is invaginated into the stomach (Figure 5).
Figure 1. Pancreas being transected between figure-of-eight sutures placed at superior and inferior borders.
RESULTS This technique has been used in 29 consecutive patients, and there have been no postoperative leaks from the pancreatic anastomosis. Evaluation of a leak of the pancreatic anastomosis was done by measuring amylase in the drain-
From the Section of Surgical Oncology, Department of Surgery, Loyola Stritch School of Medicine and Hines VA Hospital, Hines and Maywood, Illinois. Requests for reprints should be addressed to Gerard V. Aranha, MD, EMS 110-3236, 2160 S. First Avenue, Maywood, Illinois 60153. Manuscript submitted August 27, 1997 and accepted in revised form December 11, 1997.
328
© 1998 by Excerpta Medica, Inc. All rights reserved.
Figure 2. Pancreas remnant mobilized for a distance of 4 cm.
age fluid from the retrogastric drain 1 day after the patient was on a general diet. If the drainage was not amylase-rich, the drain was pulled, and the patient was discharged. Of the 29 patients, none returned with evidence of pancreati0002-9610/98/$19.00 PII S0002-9610(98)00005-1
TECHNIQUE FOR PANCREATICOGASTROSTOMY/ARANHA
Figure 5. Completed anastomoses after Whipple with pancreaticogastrostomy.
Figure 3. Sutures placed from posterior superior wall of stomach to anterior wall of pancreas.
was not performed, it is uncertain whether the bleeding occurred from the anastomotic line or from the cut surface of the invaginated pancreas, both of which have been implicated in bleeding following pancreaticogastrostomy.4 – 6
COMMENTS It is felt that the placement of the figure-of-eight sutures allows for the occlusion of the transverse pancreatic vessels, thus decreasing the chance for postoperative bleeding from the cut pancreatic edge. In addition, it is theorized that the figure-of-eight sutures occlude the minor branches of the pancreatic duct at or near the cut surface of the pancreas, thus forcing most of the pancreatic juice draining in that area into the main duct at the cut edge of the gland. The importance of mobilizing the pancreatic remnant for a distance of at least 4 cm so that one gets a good invagination into the stomach cannot be overemphasized. Sutures from the stomach to the pancreas are placed a distance of 3 to 4 mm apart. This allows for at least 6 to 8 sutures for each wall of the anastomosis, which is usually 3 cm long.
REFERENCES Figure 4. Gastrotomy and sutures placed from posterior inferior wall of stomach to posterior wall of pancreas.
tis, postoperative fluid collections or abscess, or peritonitis. One of the 29 patients developed upper gastrointestinal (GI) hemorrhage on the second postoperative day. It was noted that the nasogastric tube was not working and was kinked. After the nasogastric tube was unkinked, the upper gastrointestinal bleeding was controlled by conservative measures using iced saline lavage and H2 antagonists. Since the bleeding stopped spontaneously, an upper GI endoscopy was not performed. Because an upper GI endoscopy
1. Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticocuodenectomy. Ann Surg. 1995;222:580 –592. 2. Mason GR, Freeark RJ. Current experience with pancretigastrostomy. Am J Surg. 1995;169:217–219. 3. McHenry SB. Management of the pancreatic stump during the Whipple operation. Am J Surg. 1996;171:438. 4. Delcore R, Thomas JH, Pierce GE, Hermreck AS. Pancreaticogastrostomy: a safe drainage procedure after pancreatoduodenectomy. Surgery. 1990;108:641– 647. 5. Kapur BML. Pancreaticogastrostomy in pancreaticoduodenal resection for ampullary carcinoma: experience in thirty-one cases. Surgery. 1986;100:489 – 493. 6. Icard P, Dubois F. Pancreaticogastrostomy following pancreatoduodenectomy. Ann Surg. 1988;207:253–256.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 175 APRIL 1998
329
A Technique for Pancreaticogastrostomy Gerard V. Aranha, MD, Maywood, Illinois
A technique for pancreaticogastrostomy is presented. The technique is a one-layer, invaginated anastomosis of the pancreatic remnant to the posterior gastric wall following a Whipple resection of the pancreatic head. Key steps to achieve a successful anastomosis are described. Using this technique, there have been no pancreatic anastomotic leaks in 29 consecutive patients. Am J Surg. 1998;175:328 –329. © 1998 by Excerpta Medica, Inc.
M
anagement of the pancreatic stump after a Whipple operation continues to be a source of controversy. Both pancreaticojejunostomy and pancreaticogastrostomy have supporters.1–3 Described here is a technique of a one-layer invaginating pancreaticogastric anastomosis following a Whipple procedure that has been successful in 29 consecutive patients.
TECHNIQUE After dissection of the superior mesenteric and portal vein from the under surface of the pancreas, figure-of-eight sutures of 3-0 silk are placed opposite each other at the inferior and superior borders of the pancreas. The pancreas is then severed over the superior mesenteric and portal vein using cautery (Figure 1). Care is taken not to extensively cauterize the cut main pancreatic duct. The pancreatic remnant is then mobilized for a distance of 4 cm (Figure 2). Single layer sutures of 3-0 silk are placed from the posterior superior wall of the stomach to the anterior wall of the pancreas (Figure 3). The sutures on the pancreas are placed at least 1 cm away from the cut edge. A gastrotomy of 3 cm in length is made (occasionally, because of the size of the cut pancreas, a larger gastrotomy is needed), and then 3-0 silk sutures are placed from the posterior inferior wall of the stomach to the posterior pancreas (Figure 4). When the sutures are tied, 1 cm of the pancreas is invaginated into the stomach (Figure 5).
Figure 1. Pancreas being transected between figure-of-eight sutures placed at superior and inferior borders.
RESULTS This technique has been used in 29 consecutive patients, and there have been no postoperative leaks from the pancreatic anastomosis. Evaluation of a leak of the pancreatic anastomosis was done by measuring amylase in the drain-
From the Section of Surgical Oncology, Department of Surgery, Loyola Stritch School of Medicine and Hines VA Hospital, Hines and Maywood, Illinois. Requests for reprints should be addressed to Gerard V. Aranha, MD, EMS 110-3236, 2160 S. First Avenue, Maywood, Illinois 60153. Manuscript submitted August 27, 1997 and accepted in revised form December 11, 1997.
328
© 1998 by Excerpta Medica, Inc. All rights reserved.
Figure 2. Pancreas remnant mobilized for a distance of 4 cm.
age fluid from the retrogastric drain 1 day after the patient was on a general diet. If the drainage was not amylase-rich, the drain was pulled, and the patient was discharged. Of the 29 patients, none returned with evidence of pancreati0002-9610/98/$19.00 PII S0002-9610(98)00005-1
TECHNIQUE FOR PANCREATICOGASTROSTOMY/ARANHA
Figure 5. Completed anastomoses after Whipple with pancreaticogastrostomy.
Figure 3. Sutures placed from posterior superior wall of stomach to anterior wall of pancreas.
was not performed, it is uncertain whether the bleeding occurred from the anastomotic line or from the cut surface of the invaginated pancreas, both of which have been implicated in bleeding following pancreaticogastrostomy.4 – 6
COMMENTS It is felt that the placement of the figure-of-eight sutures allows for the occlusion of the transverse pancreatic vessels, thus decreasing the chance for postoperative bleeding from the cut pancreatic edge. In addition, it is theorized that the figure-of-eight sutures occlude the minor branches of the pancreatic duct at or near the cut surface of the pancreas, thus forcing most of the pancreatic juice draining in that area into the main duct at the cut edge of the gland. The importance of mobilizing the pancreatic remnant for a distance of at least 4 cm so that one gets a good invagination into the stomach cannot be overemphasized. Sutures from the stomach to the pancreas are placed a distance of 3 to 4 mm apart. This allows for at least 6 to 8 sutures for each wall of the anastomosis, which is usually 3 cm long.
REFERENCES Figure 4. Gastrotomy and sutures placed from posterior inferior wall of stomach to posterior wall of pancreas.
tis, postoperative fluid collections or abscess, or peritonitis. One of the 29 patients developed upper gastrointestinal (GI) hemorrhage on the second postoperative day. It was noted that the nasogastric tube was not working and was kinked. After the nasogastric tube was unkinked, the upper gastrointestinal bleeding was controlled by conservative measures using iced saline lavage and H2 antagonists. Since the bleeding stopped spontaneously, an upper GI endoscopy was not performed. Because an upper GI endoscopy
1. Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticocuodenectomy. Ann Surg. 1995;222:580 –592. 2. Mason GR, Freeark RJ. Current experience with pancretigastrostomy. Am J Surg. 1995;169:217–219. 3. McHenry SB. Management of the pancreatic stump during the Whipple operation. Am J Surg. 1996;171:438. 4. Delcore R, Thomas JH, Pierce GE, Hermreck AS. Pancreaticogastrostomy: a safe drainage procedure after pancreatoduodenectomy. Surgery. 1990;108:641– 647. 5. Kapur BML. Pancreaticogastrostomy in pancreaticoduodenal resection for ampullary carcinoma: experience in thirty-one cases. Surgery. 1986;100:489 – 493. 6. Icard P, Dubois F. Pancreaticogastrostomy following pancreatoduodenectomy. Ann Surg. 1988;207:253–256.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 175 APRIL 1998
329