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A simple and safe anastomosis for pancreatogastrostomy using one binding purse-string and two transfixing mattress sutures.

Bartsch DK, Langer P, Kanngießer V, Fendrich V, Dietzel K - Int J Surg Oncol (2012)

Bottom Line: Operative mortality was zero, and morbidity was 34.3%.All fistulas resolved without further intervention.The described technique is a simple and safe reconstruction procedure after PD that warrants further evaluation.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Philipps University of Marburg, Baldingerstrasse 35043 Marburg, Germany.

ABSTRACT
Pancreatic anastomotic leakage remains a persistent problem after pancreaticoduodenectomy (PD), especially in the presence of a soft, nonfibrotic pancreas. A modified technique for pancreatogastrostomy was devised, which combines one binding purse-string and two transfixing mattress sutures between the pancreatic stump and the posterior gastric wall. This technique was applied in 35 patients after PD for malignant and benign diseases of whom 10 (28.6%) had a soft pancreas. Median time for the anastomosis was 18 minutes. Operative mortality was zero, and morbidity was 34.3%. Three (8.6%) patients developed a pancreatic fistula (2 type A, 1 type B) as classified according to the International Study Group on pancreatic fistula. All fistulas resolved without further intervention. The described technique is a simple and safe reconstruction procedure after PD that warrants further evaluation.

No MeSH data available.


Related in: MedlinePlus

Mobilised pancreatic remnant with a lost drain inserted into the main pancreatic duct.
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Related In: Results  -  Collection


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fig1: Mobilised pancreatic remnant with a lost drain inserted into the main pancreatic duct.

Mentions: After the pancreaticoduodenectomy, any bleedings from the cut surface of the pancreatic stump were stopped by bipolar electrical coagulation or absorbable sutures (PDS 5.0, Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany). Then the pancreatic remnant was mobilized 2 to 3 cm from the splenic vein and the surrounding tissues. A polyethylene 5 cm pancreatic tube, 5.0 or 7.5 French (Peter Pflugbeil GmbH, Zorneding, Germany) was introduced into the main pancreatic duct to insure its patency. This lost drain was fixed to the main pancreatic duct by a 5.0 absorbable suture (vicryl rapide 5-0 P-3, 45 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany). Two transient holding sutures (vicryl plus 2.0 MH, 70 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany) were positioned at the cranial and caudal proximal end of the pancreatic remnant (Figure 1). Then a transverse full-thickness incision was made on the posterior wall of the stomach with a length of at most 2 cm, to ensure tight adherence of the gastric wall to the pancreatic remnant after completion of anastomosis (Figure 2). The appropriate position of the incision was selected, so that the pancreatic stump could enter this hole without tension. Then a 5-cm longitudinal incision was created in the anterior gastric wall opposite to the dorsal wall incision. Through the incision of the anterior gastric wall, a full-thickness purse-string suture (PDS II 2.0 MH plus, 70 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany), taking about 1 cm of the whole posterior gastric wall, was preplaced (Figures 3(a) and 3(b)). The pancreatic remnant was then pulled with slide tension on the holding sutures through the whole in the posterior gastric wall into the stomach. This manoeuvre was performed very gently to ensure tight wrapping of the posterior gastric wall around the pancreatic remnant and to avoid laceration of the pancreas. Ideally, the pancreatic remnant should protrude above the posterior gastric wall by 2 cm. Afterwards mattress sutures were preplaced through the posterior gastric wall and the pancreas, one cranial and one caudal of the main pancreatic duct. These sutures were carried out with double-armed straight needles (PDS II 4.0 MH, 70 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany) passing in an U-like fashion. Each U-like suture runs from the mucosal surface to the serosal surface of the caudal posterior gastric wall, just above the preplaced purse-string suture, then straight through the ventral to the dorsal surface of the pancreas, and finally from the serosal surface to the mucosal surface of the cranial posterior gastric wall (Figure 4). The threads near the centre of the pancreatic stump were placed carefully to avoid passing through the main pancreatic duct containing the catheter. First the U-like mattress sutures and then the purse-string suture were ligated (Figure 5). Finally, the pancreatic remnant was revised for any minor bleedings. A nasogastric tube was positioned just above the PG before closure of the anterior gastric wall. The gastrostomy on the anterior gastric wall was closed with all layer single sutures (PDS II 2-0 JB, 70 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany). An end-to-side hepaticojejunostomy and antecolic end-to-side gastrojejunostomy in case of standard PD or antecolic duodenojejunostomy in case of PPPD were performed to complete the reconstruction.


A simple and safe anastomosis for pancreatogastrostomy using one binding purse-string and two transfixing mattress sutures.

Bartsch DK, Langer P, Kanngießer V, Fendrich V, Dietzel K - Int J Surg Oncol (2012)

Mobilised pancreatic remnant with a lost drain inserted into the main pancreatic duct.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3303764&req=5

fig1: Mobilised pancreatic remnant with a lost drain inserted into the main pancreatic duct.
Mentions: After the pancreaticoduodenectomy, any bleedings from the cut surface of the pancreatic stump were stopped by bipolar electrical coagulation or absorbable sutures (PDS 5.0, Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany). Then the pancreatic remnant was mobilized 2 to 3 cm from the splenic vein and the surrounding tissues. A polyethylene 5 cm pancreatic tube, 5.0 or 7.5 French (Peter Pflugbeil GmbH, Zorneding, Germany) was introduced into the main pancreatic duct to insure its patency. This lost drain was fixed to the main pancreatic duct by a 5.0 absorbable suture (vicryl rapide 5-0 P-3, 45 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany). Two transient holding sutures (vicryl plus 2.0 MH, 70 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany) were positioned at the cranial and caudal proximal end of the pancreatic remnant (Figure 1). Then a transverse full-thickness incision was made on the posterior wall of the stomach with a length of at most 2 cm, to ensure tight adherence of the gastric wall to the pancreatic remnant after completion of anastomosis (Figure 2). The appropriate position of the incision was selected, so that the pancreatic stump could enter this hole without tension. Then a 5-cm longitudinal incision was created in the anterior gastric wall opposite to the dorsal wall incision. Through the incision of the anterior gastric wall, a full-thickness purse-string suture (PDS II 2.0 MH plus, 70 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany), taking about 1 cm of the whole posterior gastric wall, was preplaced (Figures 3(a) and 3(b)). The pancreatic remnant was then pulled with slide tension on the holding sutures through the whole in the posterior gastric wall into the stomach. This manoeuvre was performed very gently to ensure tight wrapping of the posterior gastric wall around the pancreatic remnant and to avoid laceration of the pancreas. Ideally, the pancreatic remnant should protrude above the posterior gastric wall by 2 cm. Afterwards mattress sutures were preplaced through the posterior gastric wall and the pancreas, one cranial and one caudal of the main pancreatic duct. These sutures were carried out with double-armed straight needles (PDS II 4.0 MH, 70 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany) passing in an U-like fashion. Each U-like suture runs from the mucosal surface to the serosal surface of the caudal posterior gastric wall, just above the preplaced purse-string suture, then straight through the ventral to the dorsal surface of the pancreas, and finally from the serosal surface to the mucosal surface of the cranial posterior gastric wall (Figure 4). The threads near the centre of the pancreatic stump were placed carefully to avoid passing through the main pancreatic duct containing the catheter. First the U-like mattress sutures and then the purse-string suture were ligated (Figure 5). Finally, the pancreatic remnant was revised for any minor bleedings. A nasogastric tube was positioned just above the PG before closure of the anterior gastric wall. The gastrostomy on the anterior gastric wall was closed with all layer single sutures (PDS II 2-0 JB, 70 cm; Ethicon, Johnson & Johnson Medical GmbH, Norderstedt, Germany). An end-to-side hepaticojejunostomy and antecolic end-to-side gastrojejunostomy in case of standard PD or antecolic duodenojejunostomy in case of PPPD were performed to complete the reconstruction.

Bottom Line: Operative mortality was zero, and morbidity was 34.3%.All fistulas resolved without further intervention.The described technique is a simple and safe reconstruction procedure after PD that warrants further evaluation.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Philipps University of Marburg, Baldingerstrasse 35043 Marburg, Germany.

ABSTRACT
Pancreatic anastomotic leakage remains a persistent problem after pancreaticoduodenectomy (PD), especially in the presence of a soft, nonfibrotic pancreas. A modified technique for pancreatogastrostomy was devised, which combines one binding purse-string and two transfixing mattress sutures between the pancreatic stump and the posterior gastric wall. This technique was applied in 35 patients after PD for malignant and benign diseases of whom 10 (28.6%) had a soft pancreas. Median time for the anastomosis was 18 minutes. Operative mortality was zero, and morbidity was 34.3%. Three (8.6%) patients developed a pancreatic fistula (2 type A, 1 type B) as classified according to the International Study Group on pancreatic fistula. All fistulas resolved without further intervention. The described technique is a simple and safe reconstruction procedure after PD that warrants further evaluation.

No MeSH data available.


Related in: MedlinePlus