Practice of Modified Triple-Layer Duct-to-Mucosa Pancreaticojejunostomy with Resection of Jejunal Serosa During Pancreaticoduodenectomy_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

 XUSong ,  TIANBo-le , SUAn-ping , ZHANGZhao-da , ZHANGYi , LIUXu-bao , HUWei-ming , MAIGang

Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China;

Corresponding author：

TIANBo-le, Email: bo-le@medmail.com.cn

Keywords：

Pancreaticoduodenectomy; Pancreaticojejunostomy; Pancreatic fistula

DOI：

10.7507/1007-9424.20140194

Video：

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Objective To evaluate the postoperative complications after pancreaticoduodenectomy with modified triple-layer(MTL) duct-to-mucosa pancreaticojejunostomy and with resection of jejunal serosa, analyse the risk factors of pancreatic fistula, and compare effects with two-layer(TL) duct-to-mucosa pancreaticojejunostomy. Methods Data on 184 consecutive patients who underwent the two methods of pancreaticojejunostomy during standard PD between January 1, 2010 and January 31, 2013 were collected retrospectively. The risk factors of pancreatic fistula were investigated by using univariate and multivariate analyses. Results A total of 88 patients received TL and 96 underwent MTL. Rate of pancreatic fistula for the entire cohort was 8.2%(15/184). There were 11 fistulas(12.5%) in the TL group and four fistulas(4.2%) in the MTL group(P=0.039). Body mass index, pancreatic texture, pancreatic duct diameter, and methods of pancreaticojejunostomy had significant effects on the formation of pancreatic fistula on univariate analysis. Multivariate analysis showed that pancreatic duct diameter less than 3 mm and TL were the significant risk factors of pancreatic fistula. Conclusions MTL technique effectively reduced the pancreatic fistula rate after PD in comparison with TL, especially in patients with pancreatic duct diameter less than 3 mm.

Citation： XUSong, TIANBo-le, SUAn-ping, ZHANGZhao-da, ZHANGYi, LIUXu-bao, HUWei-ming, MAIGang. Practice of Modified Triple-Layer Duct-to-Mucosa Pancreaticojejunostomy with Resection of Jejunal Serosa During Pancreaticoduodenectomy. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2014, 21(7): 809-815. doi: 10.7507/1007-9424.20140194 Copy

1.	Grobmyer SR, Rivadeneira DE, Goodman CA, et al. Pancreatic anastomotic failure after pancreaticoduodenectomy[J]. Am J Surg, 2000, 180(2):117-120.
2.	Gouma DJ, van Geenen RC, van Gulik TM, et al. Rates of complications and death after pancreaticoduodenectomy:risk factors and the impact of hospital volume[J]. Ann Surg, 2000, 232(6):786-795.
3.	Kleespies A, Albertsmeier M, Obeidat F, et al. The challenge of pancreatic anastomosis[J]. Langenbecks Arch Surg, 2008, 393(4):459-471.
4.	Oneil Machado N. Pancreatic fistula after pancreatectomy:definitions, risk factors, preventive measures, and management review[J]. Int J Surg Oncol, 2012, 2012:602478.
5.	Ohwada S, Tanahashi Y, Ogawa T, et al. In situ vs. ex situ pancreatic duct stents of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy with billroth I-type reconstruction[J]. Arch Surg, 2002, 137(11):1289-1293.
6.	Batignani G, Fratini G, Zuckermann M, et al. Comparison of Wirsung-jejunal duct-to-mucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy[J]. Hepatobiliary Pancreat Dis Int, 2005, 4(3):450-455.
7.	Rodríguez JR, Germes SS, Pandharipande PV, et al. Implications and cost of pancreatic leak following distal pancreatic resection[J]. Arch Surg, 2006, 141(4):361-366.
8.	Khan AW, Agarwal AK, Davidson BR. Isolated Roux Loop duct-to-mucosa pancreaticojejunostomy avoids pancreatic leaks in pancreaticoduodenectomy[J]. Dig Surg, 2002, 19(3):199-204.
9.	Bassi C, Falconi M, Molinari E, et al. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy:results of a prospective randomized trial[J]. Surgery, 2003, 134(5):766-771.
10.	Hosotani R, Doi R, Imamura M. Duct-to mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatoduodenectomy[J]. World J Surg, 2002, 26(1):99-104.
11.	Berger AC, Howard TJ, Kennedy EP, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial[J]. J Am Coll Surg, 2009, 208(5):738-747.
12.	Hayashibe A, Kameyama M. The clinical results of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy in consecutive 55 cases[J]. Pancreas, 2007, 35(3):273-275.
13.	Hayashibe A, Sakamoto K, Shinbo M, et al. The surgical procedure and clinical results of the duct to mucosa pancreaticojejunostomies with resection of jejunal serosa[J]. Int J Surg, 2005, 3(3):188-192.
14.	Ibrahim S, Tay KH, Launois B, et al. Triple-layer duct-tomucosa pancreaticojejunostomy after pancreaticoduodenectomy[J]. Dig Surg, 2006, 23(5-6):296-302.
15.	Suc B, Msika S, Fingerhut A, et al. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection:prospective randomized trial[J]. Ann Surg, 2003, 237(1):57-65.
16.	Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula:an international study group (ISGPF) definition[J]. Surgery, 2005, 138(1):8-13.
17.	Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery:a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)[J]. Surgery, 2007, 142(5):761-768.
18.	Ihse I, Anderson H, Andren-Sandberg. Total pancreatectomy for cancer of the pancreas:is it appropriate?[J]. World J Surg, 1996, 20(3):288-293.
19.	Topal B, Fieuws S, Aerts R, et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours:a multicentre randomised trial[J]. Lancet Oncol, 2013, 14(13):655-662.
20.	Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy[J]. Ann Surg, 1995, 222(4):580-588.
21.	Bassi C, Falconi M, Molinari E, et al. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy:results of a comparative study[J]. Ann Surg, 2005, 242(6):767-771.
22.	Duffas JP, Suc B, Msika S, et al. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy[J]. Am J Surg, 2005, 189(6): 720-729.
23.	Shen Y, Jin W. Reconstruction by pancreaticogastrostomy versus pancreaticojejunostomy following pancreaticoduodenectomy:A meta-analysis of randomized controlled trials[J]. Gastroenterol Res Pract, 2012, 2012:627095.
24.	Peng SY, Wang JW, Lau WY, et al. Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy:a prospective randomized trial[J]. Ann Surg, 2007, 245(5):692-698.
25.	Maggiori L, Sauvanet A, Nagarajan G, et al. Binding versus conventional pancreaticojejunostomy after pancreaticoduodenectomy:a case-matched study[J]. J Gastrointest Surg, 2010, 14(9):1395-1400.
26.	Targarona J, Barreda L, Pando E, et al. Is Peng's pancreaticojejunal anastomosis more effective than mucosa-mucosa anastomosis in duodenopancreatectomy for pancreatic and peri-ampullary tumours?[J]. Cir Esp, 2013, 91(3):163-168.
27.	Osada S, Imai H, Sasaki Y, et al. Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications[J]. JOP, 2012, 13(1):1-6.
28.	Strasberg SM, Drebin JA, Mokadam NA, et al. Prospective trial of a blood supply-based technique of pancreaticojejunostomy: effect on anastomotic failure in the Whipple procedure[J]. J Am Coll Surg, 2002, 194(6):746-758.
29.	EI Nakeeb A, Salah T, Sultan A, et al. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience)[J]. World J Surg, 2013, 37(6):1405-1418.
30.	Shimoda M, Katoh M, Yukihiro I, et al. Body mass index is a risk factor of pancreatic fistula after pancreaticoduodenectomy[J]. Am Surg, 2012, 78(2):190-194.
31.	Gaujoux S, Cortes A, Couvelard A, et al. Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy[J]. Surgery, 2010, 148(1): 15-23.

1. Grobmyer SR, Rivadeneira DE, Goodman CA, et al. Pancreatic anastomotic failure after pancreaticoduodenectomy[J]. Am J Surg, 2000, 180(2):117-120.
2. Gouma DJ, van Geenen RC, van Gulik TM, et al. Rates of complications and death after pancreaticoduodenectomy:risk factors and the impact of hospital volume[J]. Ann Surg, 2000, 232(6):786-795.
3. Kleespies A, Albertsmeier M, Obeidat F, et al. The challenge of pancreatic anastomosis[J]. Langenbecks Arch Surg, 2008, 393(4):459-471.
4. Oneil Machado N. Pancreatic fistula after pancreatectomy:definitions, risk factors, preventive measures, and management review[J]. Int J Surg Oncol, 2012, 2012:602478.
5. Ohwada S, Tanahashi Y, Ogawa T, et al. In situ vs. ex situ pancreatic duct stents of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy with billroth I-type reconstruction[J]. Arch Surg, 2002, 137(11):1289-1293.
6. Batignani G, Fratini G, Zuckermann M, et al. Comparison of Wirsung-jejunal duct-to-mucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy[J]. Hepatobiliary Pancreat Dis Int, 2005, 4(3):450-455.
7. Rodríguez JR, Germes SS, Pandharipande PV, et al. Implications and cost of pancreatic leak following distal pancreatic resection[J]. Arch Surg, 2006, 141(4):361-366.
8. Khan AW, Agarwal AK, Davidson BR. Isolated Roux Loop duct-to-mucosa pancreaticojejunostomy avoids pancreatic leaks in pancreaticoduodenectomy[J]. Dig Surg, 2002, 19(3):199-204.
9. Bassi C, Falconi M, Molinari E, et al. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy:results of a prospective randomized trial[J]. Surgery, 2003, 134(5):766-771.
10. Hosotani R, Doi R, Imamura M. Duct-to mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatoduodenectomy[J]. World J Surg, 2002, 26(1):99-104.
11. Berger AC, Howard TJ, Kennedy EP, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial[J]. J Am Coll Surg, 2009, 208(5):738-747.
12. Hayashibe A, Kameyama M. The clinical results of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy in consecutive 55 cases[J]. Pancreas, 2007, 35(3):273-275.
13. Hayashibe A, Sakamoto K, Shinbo M, et al. The surgical procedure and clinical results of the duct to mucosa pancreaticojejunostomies with resection of jejunal serosa[J]. Int J Surg, 2005, 3(3):188-192.
14. Ibrahim S, Tay KH, Launois B, et al. Triple-layer duct-tomucosa pancreaticojejunostomy after pancreaticoduodenectomy[J]. Dig Surg, 2006, 23(5-6):296-302.
15. Suc B, Msika S, Fingerhut A, et al. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection:prospective randomized trial[J]. Ann Surg, 2003, 237(1):57-65.
16. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula:an international study group (ISGPF) definition[J]. Surgery, 2005, 138(1):8-13.
17. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery:a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)[J]. Surgery, 2007, 142(5):761-768.
18. Ihse I, Anderson H, Andren-Sandberg. Total pancreatectomy for cancer of the pancreas:is it appropriate?[J]. World J Surg, 1996, 20(3):288-293.
19. Topal B, Fieuws S, Aerts R, et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours:a multicentre randomised trial[J]. Lancet Oncol, 2013, 14(13):655-662.
20. Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy[J]. Ann Surg, 1995, 222(4):580-588.
21. Bassi C, Falconi M, Molinari E, et al. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy:results of a comparative study[J]. Ann Surg, 2005, 242(6):767-771.
22. Duffas JP, Suc B, Msika S, et al. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy[J]. Am J Surg, 2005, 189(6): 720-729.
23. Shen Y, Jin W. Reconstruction by pancreaticogastrostomy versus pancreaticojejunostomy following pancreaticoduodenectomy:A meta-analysis of randomized controlled trials[J]. Gastroenterol Res Pract, 2012, 2012:627095.
24. Peng SY, Wang JW, Lau WY, et al. Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy:a prospective randomized trial[J]. Ann Surg, 2007, 245(5):692-698.
25. Maggiori L, Sauvanet A, Nagarajan G, et al. Binding versus conventional pancreaticojejunostomy after pancreaticoduodenectomy:a case-matched study[J]. J Gastrointest Surg, 2010, 14(9):1395-1400.
26. Targarona J, Barreda L, Pando E, et al. Is Peng's pancreaticojejunal anastomosis more effective than mucosa-mucosa anastomosis in duodenopancreatectomy for pancreatic and peri-ampullary tumours?[J]. Cir Esp, 2013, 91(3):163-168.
27. Osada S, Imai H, Sasaki Y, et al. Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications[J]. JOP, 2012, 13(1):1-6.
28. Strasberg SM, Drebin JA, Mokadam NA, et al. Prospective trial of a blood supply-based technique of pancreaticojejunostomy: effect on anastomotic failure in the Whipple procedure[J]. J Am Coll Surg, 2002, 194(6):746-758.
29. EI Nakeeb A, Salah T, Sultan A, et al. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience)[J]. World J Surg, 2013, 37(6):1405-1418.
30. Shimoda M, Katoh M, Yukihiro I, et al. Body mass index is a risk factor of pancreatic fistula after pancreaticoduodenectomy[J]. Am Surg, 2012, 78(2):190-194.
31. Gaujoux S, Cortes A, Couvelard A, et al. Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy[J]. Surgery, 2010, 148(1): 15-23.

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CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Practice of Modified Triple-Layer Duct-to-Mucosa Pancreaticojejunostomy with Resection of Jejunal Serosa During Pancreaticoduodenectomy

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