TECHNICAL DETAILS OF A MODIFIED END-TO-SIDE INVAGINATION TECHNIQUE OF PANCREATOJEJUNOSTOMY

Introduction: the treatment of pancreatic stump is a critical step of pancreaticoduodenectomy (PD) because leaks from this anastomosis incur major morbidity and mortality. We describe the technical details of a modified end-to-side, invagination pancreatojejunostomy (mPJ). Methods: this technique consists of a particular double layer of stiches: the outer layer is a monofilament not absorbable interrupted U-stiches (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 exactly opposite 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 suture, placed between the pancreatic capsule/parenchima and the sieromuscular layer of the jejunum. Results: the mPJ technique combines the advantages of the previous techniques and could mitigate their weaknesses: the small incision of the jejunal wall together with the running suture for the inner layer that creates a waterproof suture line, allows to drain into the jejunum the pancreatic juice from the secondary duct; the outer layer, thanks to the knots tied on the jejunum, protect the first layer and minimise the risk of pancreatic capsule laceration. Conclusions: the mPJ technique is safe and reproducible. In our experience, it is associated with a lower pancreatic fistula rate than expected especially for the pancreas with soft gland texture and small pancreatic duct diameter.