Francesco Giudici， Benedetta Pesi， Daniela Zambonin， Stefano Scaringi，Paolo Bechi and Giacomo BatignaniFlorence， Italy

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Safer intestinal invagination for a solid pancreatico-jejunal anastomosis in presence of a soft texture pancreatic remnant and non-dilated duct

Francesco Giudici， Benedetta Pesi， Daniela Zambonin， Stefano Scaringi，Paolo Bechi and Giacomo Batignani
Florence， Italy

ABSTRACT:Pancreatico-jejunal anastomosis after pancreatoduodenectomy still represents the Achilles’ heel of the procedure: the failure of this anastomosis is relatively common and it is the main cause of post-operative morbidity and mortality. Studies have described different reconstruction strategies for the control of the development of post-operative pancreatic fistula， but the strategy to obtain a safer pancreatico-jejunal anastomosis is still far from satisfaction. We report a novel variation of the invagination technique based on preliminary clinical experience in 8 patients who underwent pancreaticojejunal anastomosis after pancreatoduodenectomy in our hepatobiliopancreatic center from 2008 to 2014. The variation could obtain a safer intestinal invagination for a solid pancreatico-jejunal anastomosis even in the presence of soft pancreatic remnant.

（Hepatobiliary Pancreat Dis Int 2016；15:324-328）

KEY WORDS:pancreatico-jejunal anastomosis；anastomosis；pancreatoduodenectomy；invagination；novel variation

Author Affiliations: Unit of Surgery， Department of Surgery and Translational Medicine， University of Florence Medical School， Careggi University Hospital， Florence， Italy （Giudici F， Pesi B， Zambonin D， Scaringi S，Bechi P and Batignani G）

Published online October 21， 2015.

Introduction

Because of the severe complications of pancreatoduodenectomy （PD）， pancreatico-jejunal anastomosis is still the Achilles’ heel of the procedure.［1， 2］The failure of the pancreatico-jejunal anastomosis is a relatively common post-operative complication of PD as it is the main source of morbidity and mortality.

Related to patient characteristics， pancreatic disease and the procedure adopted， many factors influencing the pancreatico-jejunal anastomosis have been described.［3， 4］The factors as the nature and site of the pancreatic disease leading to surgery， the pancreatic duct size and gland texture are surely important， but the surgical technique，blood loss and operative time have to be considered. Taking into account the aspects of the surgical technique，many authors have described different reconstruction strategies for the decrease of the failure of post-operative pancreatico-jejunal anastomosis.［1， 5-7］

At present， the so called “invagination technique” and “duct-to-mucosa” anastomosis are the most widely adopted surgical methods.［8］Furthermore， numerous technical modifications of these methods have been proposed，［9， 10］but the perfect strategy to obtain a safe pancreaticojejunal anastomosis is not found. Therefore， we proposed a novel variation of the invagination technique based on our preliminary clinical experience.

Surgical technique

We evaluated the results of 8 consecutive patients undergoing PD in our hepatobiliopancreatic center from 2008 to 2014. These patients were operated upon by the same surgeon （BG）， using the novel variation of our invagination technique for pancreatico-jejunal anastomosis. Prospectively we collected patients’ medical and surgicalrecords from a computerized database. Surgery was indicated for pancreatic adenocarcinoma， ampullary and advanced colonic cancer. Surgical records included pancreatic texture （firm or soft）， pancreatic duct size， postoperative pathological diagnosis， values of pancreatic amylase from drainage during post-operative day 1， 3， 5 and 7， length of hospital stay， and anastomotic failure defined by the International Study Group on Pancreatic Fistula Study Group Consensus.［11］

Fig. 1. Intra-operative pictures of the initial steps of our anastomotic technique. A 3/0 prolene suture is passed through the pancreas from the anterior to the posterior surface 1 cm away from the transected margin， then the needle is used to catch the jejunal seromuscular layer and again passed through the pancreas in the same manner.

After the resection phase is finished and the specimen taken， a jejunal loop is brought up， in a trans-mesocolic fashion， to the transected neck of the pancreas， where two hemostatic prolene 3/0 （Ethicon?） sutures have been previously placed cranially and caudally within the pancreatic parenchyma before its transection （hemostatic sutures）. A 3/0 double armed prolene with large needles is passed through the pancreas: one needle from the anterior to the posterior surface 1 cm away from the transected margin （Fig. 1）， then the needle is used to catch the jejunal seromuscular layer 1.5 cm from the stapled edge and again passes through the pancreas in the same manner， few millimeters from where it enters. This invaginating suture is then suspended with a Kelly clamp. Another invaginating stitch is placed caudally to the duct adopting the same technique. Attention should be paid not to catch or to include the Wirsung duct in the suture， and it is helpful to use a small urethral catheter positioning into the duct. At this moment， the two previously placed hemostatic sutures are passed in the jejunal seromuscular layers cranially and caudally and tied. The stapled jejunal edge is opened， while removing the metallic suture. An internal layer is performed using a 3/0 polydioxanone （Ethicon?） interrupted stitches between the pancreatic capsule and the seromuscular layer of the transected jejunal loop. Once the internal inverting layer has been completed， the 2 suspended invaginating prolene sutures are passed on the anterior jejunal seromuscular layer （about 1.5 cm away from the anastomosis） and tied with a single knot: this will automatically invaginate the jejunum over the pancreas and the shear force will be applied only on the posterior or the anterior wall of the jejunum （Fig. 2）. This results in a compression of the pancreas， and for this reason， it is advisable to loose the previously performed single knot， using a metallic hook， after the jejunum is invaginated， tying it again in a more delicate manner thereafter （with multiple knots as usual）. It is to underline as in our technique，placing each double-armed suture needle through thepancreas and tying the sutures on the anterior aspect of the bowel. In our patients， we obtained a redirection of the shear forces from the pancreatic tissue to the jejunal wall （Fig. 3）. To avoid a compression of the Wirsung duct during the post-operative course， we used to leave inside it the previously positioned urethral catheter. All the patients had an epigastric drainage close to the pancreaticojejunal anastomosis.

Fig. 2. Intra-operative pictures of the final steps of our anastomotic technique. After the internal layer has been completed， the 2 suspended prolene sutures are passed on the anterior jejunal seromuscular layer and tied， thus invaginating the jejunum over the pancreas.

Among the 8 patients receiving PD with our new technique， 3 were males and 5 females， with a mean age of 68 years （range 62-70）. Pancreatic texture was soft in 7 patients， and the mean pancreatic duct size was 8 mm （range 6-10）. Pancreatic adenocarcinoma was indicated for surgery in 5 patients， ampullary cancer in 2， and a colonic cancer invading the pancreatic head in 1. The mean length of post-operative hospital stay was 15 days （range 7-28）. There was no in-hospital peri-operative death. Increased amylase in serum and epigastric drainage and decreased urinary output compatible with mild pancreatitis in 4 patients resolved spontaneously within 3 days. No dehiscence of pancreatico-jejunal anastomosis occurred， nor pancreatic fistula developed in our patients. One patient had post-operative bleeding from the transverse mesocolon， which required surgical treatment.

Fig. 3. Schematic view of the procedure. The shear force will be only on the posterior and anterior jejunal wall after tying the sutures on the anterior aspect of the jejunum. We create a shear force redirection from the pancreatic tissue to the jejunal wall.

Discussion

The post-operative mortality rate of patients after partial pancreatic resection has decreased in the last decade.［12， 13］Several factors are thought to be related to this change: advances in radiological imaging， strict oncological indi-cations for surgery and improvement of peri-operative and operative techniques.［11， 14， 15］However， the rate of complications after pancreatic surgery does not decrease accordingly with the mortality， even in large surgical centers.［16， 17］Many factors for the failure of pancreaticojejunal anastomosis have been described， and gland texture and duct size are recognized as the most statistically significant risk factors.［18-20］

The presence of a firm， fibrotic gland with a dilated duct is at lower risk for anastomotic dehiscence irrespective of the type of anastomosis. It is difficult to pass stitches on a normal pancreas without the risk of laceration when they are tied， especially invaginating those stitches placed on the capsule into the small bowel， and those are also unfaithful in anastomotic strength. Therefore， to avoid this life-threatening complication， the original technique described by Whipple［21］in 1935 had multiple variations［5-7， 22， 23］used to balance the shear and compressive forces that could cause cutting through and deformation of the fragile pancreatic parenchyma during suture placement and knot tying. In 2010， Grobmyer et al［22］developed a technique similar to ours but with the Wirsung-jejunal anastomosis performed end to side. They reported an incidence of anastomotic dehiscence of 6.9% in a large cohort of patients； however， others［24-26］reported experiences with pancreatico-jejunal anastomosis showing an incidence of dehiscence of about 15%. Thus， we looked for a more trustable placement of the stitches in order to invaginate properly the jejunum without lacerating the pancreas and perform a solid pancreatico-enterostomy with a lower risk of dehiscence. Theoretically， our technique could be useful in decreasing post-operative pancreatico-jejunal anastomotic leakage， while showing soft gland texture and nondilated duct. The outer row can significantly decrease shear stress in suture tying and redistribute the stress forces from the pancreas to the bowel. We “sandwiched”the pancreas between the two jejunum walls with a mild compression without negatively affecting the blood flow to the pancreatic stump. During surgery for the last 4 patients of our series， loosing the first knot was emphasized after the jejunum was invaginated. This resulted in a lower rate of post-operative pancreatitis than the first 4 patients of our series （0/4 vs 4/4）. It is quite clear that the limited number of patients we operated on with this new anastomotic technique is the limitation of our study. Thus， randomized clinical trials are needed to assess the real value of our method in decreasing the incidence of post-operative pancreatic fistula.

In conclusion， pancreatico-enteric anastomosis remains the major cause of morbidity after PD. Our modification of the original invagination technique is a safer intestinal invagination for solid pancreatic anastomosis even in the presence of soft pancreatic remnant. Therefore， although the number of patients is limited， this technique seems to be promising in lowering the incidence of dehiscence.

Contributors: GF， PB and BG conceived and designed the study. All authors collected and analyzed the data. GF and PB wrote the draft and BG revised this manuscript. All authors contributed to the design and interpretation of the study and to further draft. BG is the guarantor.

Funding: None.

Ethical approval: Not needed.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Received February 12， 2015

Accepted after revision July 14， 2015

Corresponding Author:Giacomo Batignani， MD， Department of Surgery and Translational Medicine， University of Florence， Largo Brambilla 3，F(xiàn)lorence 50139， Italy （Tel: +39-55-7946185； Email: g.batignani@unifi.it）? 2016， Hepatobiliary Pancreat Dis Int. All rights reserved.

doi:10.1016/S1499-3872（15）60027-3