Background. One of the most critical steps of the pancreaticoduodenectomy (PD) is the treatment of pancreatic stump, because anastomotic leak is the cause of major morbidity and mortality due to the intra-peritoneal release of enterokinase and the activation of pancreatic enzymes, with subsequent septic and hemorrhagic complications. There is still no universally accepted technique for pancreaticojejunostomy (PJ) and there are two widely used methods to accomplish an end-to-side PJ: duct-to-mucosa PJ or invagination PJ. Methods. From October 2008 to October 2016 we performed 401 pancreatic resection of which 187 were PD. From November 2010 we used in 84 patients a new personal invagination PJ technique (piPJ). This technique consists of a particular double layer of stitches: the outer layer is a monofilament non absorbable interrupted sutures (using 5-0 polypropylene suture) to reach the invagination of the pancreatic stump and with the knot falling on the bowel; a small enterotomy is made in the jejunum, of the same size and exactly opposite with respect to the location of the pancreatic duct, and a stent is inserted inside the duct. The internal layer is a row of continuous running non absorbable suture (using 5-0 polypropylene suture), placed between the pancreatic capsule and the siero-muscular layer of the jejunum. We hereby describe the technical details, the methods, the devices and the cornerstones of this piPJ. The Fistula Risk Score, the presence of post-operative pancreatic fistulas, POPF (ISGPF Classification) and the perioperative outcomes, were evaluated on this group of patients. Result. POPF occurred in 14/84 (16.67%). Grade A of POPF was found in 9/84 patients (10.71%), Grade B of POPF in 4/84 patients (4.76%). The presence of Grade C pancreatic fistulas was documented in one 1/84 patients (1.19%). Patients were stratified into four groups according to the risk of pancreatic fistula (Fistula Risk Score, FRS): negligible, low, intermediate and high risk. We documented that the fistula rate in patients with high risk (FRS 7-10) was less than the expected found from literature (21,43% vs 50,0%, classification proposed by Miller), while with low and intermediate FRS was comparable to that expected (5,88% vs 11,4% and 20,83% vs 30,2% respectively). The re-operation rate was 3.58% (3/84): two of these for bleeding and one for POPF grade C. The overall mortality rate was 2.38% (2/84) and the specific mortality rate for POPF was 1.19% (1/84). Mean operative time was 437.44 ± 82.90 min. Mean postoperative hospital stay was 18.82 ± 11.89 days. Conclusions. The piPJ technique was found to be safe and resulted in satisfactory postoperative outcomes. The percentage of pancreatic fistula less than expected in particular for the "difficult" pancreas with high FRS, including soft gland texture and small pancreatic duct diameter. Comparative prospective studies with other techniques are necessary to draw conclusions.
PANCREATICOJEJUNOSTOMY: THE MOST DELICATE ANASTOMOSES. DESCRIPTION, TECHNICAL DETAILS AND RESULTS OF A PERSONAL TECHNIQUE
Morelli, L;Furbetta, N;Di Franco, Gregorio;Palmeri, M;Guadagni, S;Bianchini, M;Stefanini, G;Cremonini, C;PALMA A, De;Caramella, D;Gambaccini, D;Marchi, S;CANDIO G, Di;Mosca, F
2017-01-01
Abstract
Background. One of the most critical steps of the pancreaticoduodenectomy (PD) is the treatment of pancreatic stump, because anastomotic leak is the cause of major morbidity and mortality due to the intra-peritoneal release of enterokinase and the activation of pancreatic enzymes, with subsequent septic and hemorrhagic complications. There is still no universally accepted technique for pancreaticojejunostomy (PJ) and there are two widely used methods to accomplish an end-to-side PJ: duct-to-mucosa PJ or invagination PJ. Methods. From October 2008 to October 2016 we performed 401 pancreatic resection of which 187 were PD. From November 2010 we used in 84 patients a new personal invagination PJ technique (piPJ). This technique consists of a particular double layer of stitches: the outer layer is a monofilament non absorbable interrupted sutures (using 5-0 polypropylene suture) to reach the invagination of the pancreatic stump and with the knot falling on the bowel; a small enterotomy is made in the jejunum, of the same size and exactly opposite with respect to the location of the pancreatic duct, and a stent is inserted inside the duct. The internal layer is a row of continuous running non absorbable suture (using 5-0 polypropylene suture), placed between the pancreatic capsule and the siero-muscular layer of the jejunum. We hereby describe the technical details, the methods, the devices and the cornerstones of this piPJ. The Fistula Risk Score, the presence of post-operative pancreatic fistulas, POPF (ISGPF Classification) and the perioperative outcomes, were evaluated on this group of patients. Result. POPF occurred in 14/84 (16.67%). Grade A of POPF was found in 9/84 patients (10.71%), Grade B of POPF in 4/84 patients (4.76%). The presence of Grade C pancreatic fistulas was documented in one 1/84 patients (1.19%). Patients were stratified into four groups according to the risk of pancreatic fistula (Fistula Risk Score, FRS): negligible, low, intermediate and high risk. We documented that the fistula rate in patients with high risk (FRS 7-10) was less than the expected found from literature (21,43% vs 50,0%, classification proposed by Miller), while with low and intermediate FRS was comparable to that expected (5,88% vs 11,4% and 20,83% vs 30,2% respectively). The re-operation rate was 3.58% (3/84): two of these for bleeding and one for POPF grade C. The overall mortality rate was 2.38% (2/84) and the specific mortality rate for POPF was 1.19% (1/84). Mean operative time was 437.44 ± 82.90 min. Mean postoperative hospital stay was 18.82 ± 11.89 days. Conclusions. The piPJ technique was found to be safe and resulted in satisfactory postoperative outcomes. The percentage of pancreatic fistula less than expected in particular for the "difficult" pancreas with high FRS, including soft gland texture and small pancreatic duct diameter. Comparative prospective studies with other techniques are necessary to draw conclusions.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
