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Modified technique of pancreaticogastrostomy for soft pancreas with two continuous hemstitch sutures: a single-center prospective study.

Zhu F, Wang M, Wang X, Tian R, Shi C, Xu M, Shen M, Han J, Luo N, Qin R - J. Gastrointest. Surg. (2013)

Bottom Line: This study presents a new technique of PG for a soft, nonfibrotic pancreas with double-binding continuous hemstitch sutures and evaluates its safety and reliability.The median time for the anastomosis was 12 min (range, 8-24).The described technique is a simple and safe reconstruction procedure after PD, especially for patients with a soft and fragile pancreas.

View Article: PubMed Central - PubMed

Affiliation: Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030, PR China.

ABSTRACT
Postoperative pancreatic fistula (POPF) remains a persistent problem after pancreaticoduodenectomy (PD), especially in the presence of a soft, nonfibrotic pancreas. To reduce the risk of POPF, pancreaticogastrostomy (PG) is an optional reconstruction technique for surgeons after PD. This study presents a new technique of PG for a soft, nonfibrotic pancreas with double-binding continuous hemstitch sutures and evaluates its safety and reliability. From January 2011 to June 2012, 92 cases of patients with periampullary malignancy with a soft pancreas underwent this technique. A modified technique of PG was performed with two continuous hemstitch sutures placed in the mucosal and seromuscular layers of the posterior gastric wall, respectively. Then the morbidity and mortality was calculated. This technique was applied in 92 patients after PD all with soft pancreas. The median time for the anastomosis was 12 min (range, 8-24). Operative mortality was zero, and morbidity was 16.3 % (n = 15), including hemorrhage (n = 2), biliary fistula (n = 2), pulmonary infection (n = 1), delayed gastric emptying (DGE; n = 5, 5.4 %), abdominal abscess (n = 3, one caused by PF), and POPF (n = 2, 2.2 %). Two patients developed a pancreatic fistula (one type A and one type B) classified according to the International Study Group on Pancreatic Fistula. The described technique is a simple and safe reconstruction procedure after PD, especially for patients with a soft and fragile pancreas.

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Colored picture showed procedures of pancreaticogastrostomy. a The pancreatic stump (PS) were prepared, and a seromuscular incision is made in the posterior gastric wall (PGW) exposing the gastric mucosa. b A seromuscular continuous hemstitch suture was preplaced in the seromuscular gastric wall and a lateral stab incision was made in the mucosal layer of the posterior gastric wall. c A continuous hemstitch suture was preplaced around the mucosal incision (MI). d The pancreatic remnant was pulled into the stomach. The seromuscular continuous hemstitch suture (seromuscular suture (SS)) was tied at the lowest part of the pancreatic remnant. e The preset suture placed in the mucosal layer of the posterior gastric wall (mucosal suture (MS)) was drawn into the gastric cavity and tied. f The gastrojejunostomy (GJ) was constructed in the posterior gastric wall. g the distal gastric stump was closed using another linear gastrointestinal stapler. h The pancreaticogastrostomy (PG) and gastrojejunostomy were completed. SJ stump of the jejunum, AGW anterior gastric wall
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Fig1: Colored picture showed procedures of pancreaticogastrostomy. a The pancreatic stump (PS) were prepared, and a seromuscular incision is made in the posterior gastric wall (PGW) exposing the gastric mucosa. b A seromuscular continuous hemstitch suture was preplaced in the seromuscular gastric wall and a lateral stab incision was made in the mucosal layer of the posterior gastric wall. c A continuous hemstitch suture was preplaced around the mucosal incision (MI). d The pancreatic remnant was pulled into the stomach. The seromuscular continuous hemstitch suture (seromuscular suture (SS)) was tied at the lowest part of the pancreatic remnant. e The preset suture placed in the mucosal layer of the posterior gastric wall (mucosal suture (MS)) was drawn into the gastric cavity and tied. f The gastrojejunostomy (GJ) was constructed in the posterior gastric wall. g the distal gastric stump was closed using another linear gastrointestinal stapler. h The pancreaticogastrostomy (PG) and gastrojejunostomy were completed. SJ stump of the jejunum, AGW anterior gastric wall

Mentions: Any bleeding from the cut surface of the pancreatic stump was stopped using electrical coagulation or absorbable sutures (4-0 PDS-II). The remnant of the pancreas was dissected from the splenic vein and the surrounding tissues for a distance of approximately 2 cm from its cut edge. Several small veins running between the pancreas and the splenic vein were carefully ligated and divided. After adequate isolation when the isolated pancreatic remnant was pulled forward, the splenic artery and splenic vein could be seen and separated from a small area of the pancreas site to be pulled into the stomach. The main pancreatic duct location in the pancreatic stump was then identified with probes and a plastic stent (2- to 3-mm diameter, a disposable nelaton catheter, Suzhou Riyuexing Plastic Co. Ltd, Suzhou, China) was inserted into the pancreatic duct for approximately 3–5 cm with approximately 3 cm left outside the duct (about eight centimeters in total length). Once the suture was tied, the stent was fixed to the pancreatic duct to avoid inadvertent pancreatic duct ligation (Fig. 1a).Fig. 1


Modified technique of pancreaticogastrostomy for soft pancreas with two continuous hemstitch sutures: a single-center prospective study.

Zhu F, Wang M, Wang X, Tian R, Shi C, Xu M, Shen M, Han J, Luo N, Qin R - J. Gastrointest. Surg. (2013)

Colored picture showed procedures of pancreaticogastrostomy. a The pancreatic stump (PS) were prepared, and a seromuscular incision is made in the posterior gastric wall (PGW) exposing the gastric mucosa. b A seromuscular continuous hemstitch suture was preplaced in the seromuscular gastric wall and a lateral stab incision was made in the mucosal layer of the posterior gastric wall. c A continuous hemstitch suture was preplaced around the mucosal incision (MI). d The pancreatic remnant was pulled into the stomach. The seromuscular continuous hemstitch suture (seromuscular suture (SS)) was tied at the lowest part of the pancreatic remnant. e The preset suture placed in the mucosal layer of the posterior gastric wall (mucosal suture (MS)) was drawn into the gastric cavity and tied. f The gastrojejunostomy (GJ) was constructed in the posterior gastric wall. g the distal gastric stump was closed using another linear gastrointestinal stapler. h The pancreaticogastrostomy (PG) and gastrojejunostomy were completed. SJ stump of the jejunum, AGW anterior gastric wall
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3674402&req=5

Fig1: Colored picture showed procedures of pancreaticogastrostomy. a The pancreatic stump (PS) were prepared, and a seromuscular incision is made in the posterior gastric wall (PGW) exposing the gastric mucosa. b A seromuscular continuous hemstitch suture was preplaced in the seromuscular gastric wall and a lateral stab incision was made in the mucosal layer of the posterior gastric wall. c A continuous hemstitch suture was preplaced around the mucosal incision (MI). d The pancreatic remnant was pulled into the stomach. The seromuscular continuous hemstitch suture (seromuscular suture (SS)) was tied at the lowest part of the pancreatic remnant. e The preset suture placed in the mucosal layer of the posterior gastric wall (mucosal suture (MS)) was drawn into the gastric cavity and tied. f The gastrojejunostomy (GJ) was constructed in the posterior gastric wall. g the distal gastric stump was closed using another linear gastrointestinal stapler. h The pancreaticogastrostomy (PG) and gastrojejunostomy were completed. SJ stump of the jejunum, AGW anterior gastric wall
Mentions: Any bleeding from the cut surface of the pancreatic stump was stopped using electrical coagulation or absorbable sutures (4-0 PDS-II). The remnant of the pancreas was dissected from the splenic vein and the surrounding tissues for a distance of approximately 2 cm from its cut edge. Several small veins running between the pancreas and the splenic vein were carefully ligated and divided. After adequate isolation when the isolated pancreatic remnant was pulled forward, the splenic artery and splenic vein could be seen and separated from a small area of the pancreas site to be pulled into the stomach. The main pancreatic duct location in the pancreatic stump was then identified with probes and a plastic stent (2- to 3-mm diameter, a disposable nelaton catheter, Suzhou Riyuexing Plastic Co. Ltd, Suzhou, China) was inserted into the pancreatic duct for approximately 3–5 cm with approximately 3 cm left outside the duct (about eight centimeters in total length). Once the suture was tied, the stent was fixed to the pancreatic duct to avoid inadvertent pancreatic duct ligation (Fig. 1a).Fig. 1

Bottom Line: This study presents a new technique of PG for a soft, nonfibrotic pancreas with double-binding continuous hemstitch sutures and evaluates its safety and reliability.The median time for the anastomosis was 12 min (range, 8-24).The described technique is a simple and safe reconstruction procedure after PD, especially for patients with a soft and fragile pancreas.

View Article: PubMed Central - PubMed

Affiliation: Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030, PR China.

ABSTRACT
Postoperative pancreatic fistula (POPF) remains a persistent problem after pancreaticoduodenectomy (PD), especially in the presence of a soft, nonfibrotic pancreas. To reduce the risk of POPF, pancreaticogastrostomy (PG) is an optional reconstruction technique for surgeons after PD. This study presents a new technique of PG for a soft, nonfibrotic pancreas with double-binding continuous hemstitch sutures and evaluates its safety and reliability. From January 2011 to June 2012, 92 cases of patients with periampullary malignancy with a soft pancreas underwent this technique. A modified technique of PG was performed with two continuous hemstitch sutures placed in the mucosal and seromuscular layers of the posterior gastric wall, respectively. Then the morbidity and mortality was calculated. This technique was applied in 92 patients after PD all with soft pancreas. The median time for the anastomosis was 12 min (range, 8-24). Operative mortality was zero, and morbidity was 16.3 % (n = 15), including hemorrhage (n = 2), biliary fistula (n = 2), pulmonary infection (n = 1), delayed gastric emptying (DGE; n = 5, 5.4 %), abdominal abscess (n = 3, one caused by PF), and POPF (n = 2, 2.2 %). Two patients developed a pancreatic fistula (one type A and one type B) classified according to the International Study Group on Pancreatic Fistula. The described technique is a simple and safe reconstruction procedure after PD, especially for patients with a soft and fragile pancreas.

Show MeSH
Related in: MedlinePlus