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 ¤  Abstract
 ¤ Introduction
 ¤ Surgical Technique
 ¤ Results
 ¤ Discussion
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 Table of Contents     
HOW I DO IT DIFFERENTLY
Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 412-414
 

A different suturing method of the duct-to-mucosa pancreaticojejunostomy for the normal pancreatic duct in laparoscopic pancreaticoduodenectomy


Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China

Date of Submission22-Nov-2020
Date of Decision22-Dec-2020
Date of Acceptance05-Jan-2021
Date of Web Publication16-Apr-2021

Correspondence Address:
Prof. Nengwen Ke
Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_298_20

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 ¤ Abstract 

Although laparoscopic pancreaticoduodenectomy (LPD) is safe and widely used in clinical practice, pancreaticojejunostomy is still one of the most challenging parts of LPD surgery. We introduce a simpler method of pancreaticoenterostomy which reduces the technical complexity and produces acceptable results.


Keywords: laparoscopic, pancreaticoduodenectomy, pancreaticojejunostomy


How to cite this article:
Wang Z, Wang X, Ke N. A different suturing method of the duct-to-mucosa pancreaticojejunostomy for the normal pancreatic duct in laparoscopic pancreaticoduodenectomy. J Min Access Surg 2021;17:412-4

How to cite this URL:
Wang Z, Wang X, Ke N. A different suturing method of the duct-to-mucosa pancreaticojejunostomy for the normal pancreatic duct in laparoscopic pancreaticoduodenectomy. J Min Access Surg [serial online] 2021 [cited 2021 Jul 25];17:412-4. Available from: https://www.journalofmas.com/text.asp?2021/17/3/412/313936

Ziyao Wang, Xin Wang. Contribute equally to the article



 ¤ Introduction Top


Laparoscopic pancreaticoduodenectomy (LPD) has been safely used in clinical practice. Compared with traditional pancreaticoduodenectomy, LPD can reduce perioperative pain and the incidence of complications and hence decrease length of hospital stay and improve time to functional recovery.[1] At present, one of the reasons that limit the wider development of this operation is how to master the complicated technique of pancreaticoenterostomy.[2],[3] Now, although the traditional LPD (duct–mucosal anastomosis) is reliable and widely used,[4] it is difficult to perform to patients with soft pancreas and thin pancreatic ducts.[5] The authors developed and introduced a simpler way of pancreaticojejunostomy, which is especially suitable for patients with soft pancreas and thin pancreatic duct.


 ¤ Surgical Technique Top


From May 2019 to November 2020, a total of 35 patients from the Pancreatic Surgery Department of West China Hospital used this method during the LPD. The patients in this study did not include patients with pancreatic head cancer. The important thing is that the diameter of the pancreatic duct of the patients included in this study was normal range. Before the operation, the patient was informed of the operation method and risks in detail, and informed consent was obtained. The clinical data, intra-operative information and post-operative conditions of each patient were prospectively collected for retrospective analysis.

Before the operation, the patient was in a supine position with legs apart. The surgeon stands on the right side of the patient, and five trocars were symmetrically arranged. No-touch technique was used to resect the tumour in inferior–transverse colon area. After cutting off the pancreatic neck, the distal pancreas would be dissected about 1 cm for the pancreaticojejunostomy. The chief surgeon stands on the right side of the patient and uses two 12-mm Trocars on the right side of the patient's abdomen to perform pancreaticojejunostomy. The actual state of the key steps of pancreaticojejunostomy in the operation is shown in [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d.
Figure 1: Images of the key steps of pancreaticojejunostomy during surgery. (a) Fix the pancreatic duct support tube. (b) Anastomosis technique for posterior wall of the pancreas. (c) Purse-string anastomosis. (d) Anastomosis technique for anterior wall of the pancreas

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The key steps in the anastomosis are described in detail below. Frist, 4-0 coated vicryl plus antibacterial suture was used to fasten the support tube in the pancreatic duct [Figure 2]a. After cutting off the jejunum, drag the jejunum to the upper area of the transverse colon through the hole which we incised in the transverse colon–transverse mesocolon. This method included internal and external layer anastomosis. The external anastomosis includes the anastomosis between the anterior and posterior wall of the pancreas and the jejunum. Two or three transpancreatic U-shaped anastomoses was used to suture the posterior wall of the pancreas with the lateral wall of the jejunum using 4-0 prolene suture [Figure 2]b. The number of sutures depended on the area of the pancreatic neck section; sometimes, three or more U-shaped anastomosis sutures are required to fasten the jejunum wall to the posterior wall of pancreatic neck section without a gap. Then, we used the ultracision–harmonic scalpel to make a sizeable opening in the side wall of jejunum and insert the pancreatic duct support tube into enteric cavity. For the internal layer anastomosis, pancreatic duct support tube was inserted into the opening of jejunum, and the purse-string anastomosis technique was used to suture pancreatic duct and opening of the jejunum by 4-0 prolene suture [Figure 2]c. When performing the external layer anastomosis for anterior wall of the pancreas, the single-layer continuous anastomosis technique was used to suture the anterior wall of pancreas and the lateral wall of the jejunum by 4-0 prolene suture. The final suture line knotted with the first U-shaped suture line [Figure 2]d. Sometimes, when the external anterior wall was sutured, the side wall of the jejunum and the pancreas section are not completely matched; in this case, the external anterior wall should be sutured again by using single-layer continuous suture method to match with the side wall of the jejunum completely.{Figure 1}
Figure 2: Anastomosis steps. (a) Fix the pancreatic duct support tube. (b) Anastomosis technique for posterior wall of the pancreas. (c) Anastomosis technique for pancreatic duct. (d) Anastomosis technique for anterior wall of the pancreas

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 ¤ Results Top


The clinical data and final pathological diagnosis included are shown in [Table 1]. The overall incidence of complications was 25.7%. According to the definition of the International Study Group of pancreatic fistula, the overall incidence of pancreatic fistula was 17.1%, including 4 cases of biochemical leak (11.4%), 2 cases of grade B (5.7%) and no case with grade C pancreatic fistula. The statistics of other complications are shown in [Table 2]. One patient had lower gastrointestinal hemorrhage after LPD due to the rectal polyps.
Table 1: Clinical and pathological data

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Table 2: Postoperative complications

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 ¤ Discussion Top


Through the clinical practice of 35 patients, we have confirmed that the above-mentioned pancreaticojejunostomy technique is a safe, feasible and easy-to-master method and has also obtained acceptable results in terms of pancreatic fistula rate and complications. This anastomosis technique is more suitable for patients with softer pancreatic parenchyma and thin pancreatic ducts, because whether it is a U-shaped anastomosis or a purse-string anastomosis, there is no need to adjust the angle of suture needle repeatedly and the total number of sutures was relatively fewer, which undoubtedly reduced the operative difficulty and avoided tears in the pancreatic parenchyma. In addition, the fewer number of suture layers and needles also reduce the ischemia at the anastomosis and facilitate the healing of the pancreaticojejunostomy partly. Some studies have put a result that a small gap would be formed between purse-string anastomosis and external anastomosis which allowed the pancreatic juice from the branch pancreatic duct to flow to the jejunum through the anastomotic fistula;[6] although this conclusion is novel, it obviously needs further research to confirm. In fact, just like many other methods of pancreaticojejunostomy, this technology only provides a different suturing method to complete pancreaticojejunostomy, and the technology itself does not bring clear clinical benefits to patients. The optimal technique of pancreaticojejunostomy is always controversial. Although the invagination is much simpler than the duct-to-mucosal anastomosis, the latter is beneficial to the healing of the pancreaticojejunostomy and the prevention of haemorrhage of the pancreatic stump. Bing's anastomosis is another common anastomosis technique used in our centre.[1] Compared with Bing's anastomosis, this method is easier to operate. However, in the face of the obvious dilated pancreatic duct due to obstruction, whether the purse-string anastomosis can achieve a satisfactory pancreatic fistula rate requires further exploration. An ideal pancreaticojejunostomy should have universal applicability, while our method is more applicable for patients with thin pancreatic ducts and soft pancreatic parenchyma. If it is promoted to a wider range of patients, our method also needs to compare with other methods. In short, the most important thing in the choice of pancreaticojejunostomy is to choose the most skilled and confident method for the surgeon.


 ¤ Conclusion Top


This anastomosis technique of pancreaticojejunostomy was a promising way. Of course, its validity should be confirmed by larger studies.

Acknowledgement

This study was funded by the Key Research and Development Projects in Sichuan Province, China (Nengwen Ke 2020YFS0262). Thanks to Ms Xinjie Li for drawing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ¤ References Top

1.
de Rooij T, Klompmaker S, Abu Hilal M, Kendrick ML, Busch OR, Besselink MG. Laparoscopic pancreatic surgery for benign and malignant disease. Nat Rev Gastroenterol Hepatol 2016;13:227-38.  Back to cited text no. 1
    
2.
Cai Y, Luo H, Li Y, Gao P, Peng B. A novel technique of pancreaticojejunostomy for laparoscopic pancreaticoduodenectomy. Surg Endosc 2019;33:1572-7.  Back to cited text no. 2
    
3.
Kang CM, Lee SH, Chung MJ, Hwang HK, Lee WJ. Laparoscopic pancreatic reconstruction technique following laparoscopic pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci 2015;22:202-10.  Back to cited text no. 3
    
4.
Kim SC, Song KB, Jung YS, Kim YH, Park DH, Lee SS, et al. Short-term clinical outcomes for 100 consecutive cases of laparoscopic pylorus-preserving pancreatoduodenectomy: Improvement with surgical experience. Surg Endosc 2013;27:95-103.  Back to cited text no. 4
    
5.
Wang M, Xu S, Zhang H, Peng S, Zhu F, Qin R. Imbedding pancreaticojejunostomy used in pure laparoscopic pancreaticoduodenectomy for nondilated pancreatic duct. Surg Endosc 2017;31:1986-92.  Back to cited text no. 5
    
6.
Mitsuyoshi A, Hamada S, Ohe H, Fujita H, Okabe H, Inoguchi K. Proposal for a safe and functional pancreaticojejunostomy technique from a histopathological perspective. World J Surg 2018;42:4090-6.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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