Title : Using a New Double Invaginated Pancreatojejunal Anastomosis with Drainage of pancreatic Duct at Pancreaticoduoden-Ectomy
BACKGROUND: Pancreatoduodenectomy (PD) is the most invasive and complex operative procedure of GI tract surgery most commonly performed for the pancreatic head and periampullary area malignancy with morbidity rate 40-50% and mortality on average 5%. Following the PD the pancreatic anastomosis,which is the most important component of reconstruction, carries the highest risk of leak and cause of morbidity and mortality. The incidence of postoperative pancreatic fistula (POPF) rate is estimated to be 5% to 30% and so, the pancreatic anastomosis is still “Achilles” heel of pancreatic surgery and achieving a “zero percent” of POPF rate remains a “dream” of every pancreatic surgeon. More than 80 different methods of pancreaticoenteric reconstruction have been proposed,illustrating the complexity of surgical techniques as well as the absence of the “ideal” pancreatic anastomosis.
METHODS: Our data from 2013 to 2017 include the last series of 29 cases of PD for 14 pancreatic and 15 ampullary tumors.There were 12 females and 17 males(average age 57,range 43-78 years).The standard “classic” Whipple procedure was performed at 18 cases and “modified”pylorus-preserving variant(ppPD) – in 11 cases. 28 cases of pancreaticojejunostomy and 1 pancreaticogastrostomy were created.Percutaneous biliary drainage procedure was performed at 18 and dual decompression with the pancreatic duct – at 6 cases. In 23 cases the biliary drainage was used as transanastomotic stent during hepaticojejunostomy and in 5 cases the pancreatic duct drainage was also used as transanastomitic stent at our method of performing the double invaginated pancreatojejunostomy.
RESULTS: There was no operative mortality in our series of PD. Three patients developed surgical site infection, 2 - dehiscence of abdominal wound closure and 3 patients experienced pancreatic leak and abscess,which required interventional radiologic and intensive care management. Two patients required reinterventional surgical procedure: 1 case of necrohaemorrhagic pancreatitis and 1- of arrosive bleeding and 5 patients died at follow up period (6 months – 3 years).The main operative time was 5 hours and the median length of stay was 12 days overall.There was no postoperative pancreatic fistula in our last series of PD,where preoperative biliary and pancreatic duct drainage and our modified double invaginated pancreatojejunostomy was performed. The transanastomotic biliary and pancreatic catheters were removed 3-4 weeks after surgery when control X-ray examination revealed complete capacity and leak resistance of both anastomoses without any contrast extravasation.
CONCLUSIONS: Based on our limited experience we can conclude,that preoperative percutaneous biliary and pancreatic drainage is feasible, safe, effective and realistic miniinvasive procedure. External biliary and pancreatic duct drainage with a stents can effectively reduce the POPF and overall morbidity rates in patients undergoing pancreatoduodenectomy. Our preliminary results of using the double invaginated pancreatojejunostomy with transanastomotic stent and external pancreatic duct drainage are very encouraging and indicate that this technique is less complicated and time consuming,very safe, simple, easy to perform and also applicable almost to all situations.