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Pancreaticogastrostomy in pure laparoscopic pancreaticoduodenectomy--A novel pancreatic-gastric anastomosis technique.

Matsuda M, Haruta S, Shinohara H, Sasaki K, Watanabe G - BMC Surg (2015)

Bottom Line: This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized.ISRCTN16761283 .Registered 16 January 2015.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan. eastcliff.on.sea@gmail.com.

ABSTRACT

Background: Although many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not commonly performed because of the technical difficulty of pancreatic resection and the associated reconstruction procedures. Several pancreatic-enteric anastomosis techniques for LPD have been reported, but most are adaptations of open procedures. To accomplish pure LPD, we consider it necessary to establish new pancreatic-enteric anastomosis techniques that are specifically developed for LPD and are safe and feasible to perform.

Results: One patient developed a postoperative pancreatic fistula (International Study Group of Pancreatic Fistula criteria, grade B) and subsequent postoperative delayed gastric emptying (International Study Group of Pancreatic Surgery criteria, grade C). No other major complications occurred. We developed a novel pancreatic-gastric anastomosis technique that enabled us to safely perform pure LPD. The main pancreatic duct was stented with a 4-Fr polyvinyl catheter during pancreatic resection. A small hole was created in the posterior wall of the stomach and was bluntly dilated. A 5-cm incision was made in the anterior stomach, and the pancreatic drainage tube was passed into the stomach through the hole in the posterior wall. The remnant pancreas was pulled into the stomach, and was easily positioned and secured in place with only four to six sutures between the pancreatic capsule and the gastric mucosa. We used this technique to perform pure LPD in five patients between December 2012 and July 2013.

Conclusions: Our new technique is technically easy and provides secure fixation between the gastric wall and the pancreas. This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized. Although this technique requires further investigation as it may increase the risk of delayed gastric emptying, it may be a useful method of performing pancreaticogastrostomy in pure LPD.

Trial registration: ISRCTN16761283 . Registered 16 January 2015.

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Related in: MedlinePlus

A 5-cm vertical incision was made in the anterior wall of the stomach just ventral to the planned anastomotic site, using laparoscopic coagulation shears. A: photo, B: illustration
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Fig3: A 5-cm vertical incision was made in the anterior wall of the stomach just ventral to the planned anastomotic site, using laparoscopic coagulation shears. A: photo, B: illustration

Mentions: After excision of the proximal portion of the pancreas, the specimen was removed via the umbilical trocar site, which was extended to 3 cm. The distal portion of the remnant pancreas was dissected from the splenic artery, splenic vein, and connecting tissues with laparoscopic coagulation shears, for up to 3 cm beyond the transection plane, in preparation for invagination into the stomach. Two anchoring sutures (Ti-Cron™ 3–0, Covidien) were placed in the remnant pancreas, 2 cm distal to the transection plane (Fig. 1 and Additional file 1). After deciding the site of the anastomosis (usually the posterior wall of the lower body of the stomach), a small hole was made in the gastric serosa at the planned anastomotic site by electrocautery, and the hole was bluntly dilated with forceps (Fig. 2 and Additional file 2). A 5-cm vertical incision was then made in the anterior wall of the stomach just ventral to the planned anastomotic site with laparoscopic coagulation shears (Fig. 3 and Additional file 3). The two anchoring sutures and the stenting tube were passed through the hole at the anastomotic site and pulled into the stomach using forceps introduced through the gastric incision. The remnant pancreas was then pulled into the stomach through the hole at the anastomotic site and fixed in place with the anchoring sutures, taking care not to injure the pancreas (Fig. 4 and Additional file 4). After pulling the remnant pancreas 2–3 cm into the stomach, four to six interrupted sutures (Vicril™ 3–0, Ethicon) were placed between the pancreatic capsule and the gastric mucosa (Fig. 5 and Additional file 5). The stenting tube was passed through the incision in the anterior wall of the stomach, and the incision was closed with a continuous absorbable suture (PDS™ 4–0, Ethicon). The stenting tube was then passed through the abdominal wall (usually left subcostal) to form a gastrostomy (Fig. 6). Fibrin glue was placed around the PG site for protection. A prophylactic drainage tube (Multi-Channel™ Drainage Set 6.5 mm, Covidien) was placed at the pancreatic anastomosis.Fig. 1


Pancreaticogastrostomy in pure laparoscopic pancreaticoduodenectomy--A novel pancreatic-gastric anastomosis technique.

Matsuda M, Haruta S, Shinohara H, Sasaki K, Watanabe G - BMC Surg (2015)

A 5-cm vertical incision was made in the anterior wall of the stomach just ventral to the planned anastomotic site, using laparoscopic coagulation shears. A: photo, B: illustration
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4487839&req=5

Fig3: A 5-cm vertical incision was made in the anterior wall of the stomach just ventral to the planned anastomotic site, using laparoscopic coagulation shears. A: photo, B: illustration
Mentions: After excision of the proximal portion of the pancreas, the specimen was removed via the umbilical trocar site, which was extended to 3 cm. The distal portion of the remnant pancreas was dissected from the splenic artery, splenic vein, and connecting tissues with laparoscopic coagulation shears, for up to 3 cm beyond the transection plane, in preparation for invagination into the stomach. Two anchoring sutures (Ti-Cron™ 3–0, Covidien) were placed in the remnant pancreas, 2 cm distal to the transection plane (Fig. 1 and Additional file 1). After deciding the site of the anastomosis (usually the posterior wall of the lower body of the stomach), a small hole was made in the gastric serosa at the planned anastomotic site by electrocautery, and the hole was bluntly dilated with forceps (Fig. 2 and Additional file 2). A 5-cm vertical incision was then made in the anterior wall of the stomach just ventral to the planned anastomotic site with laparoscopic coagulation shears (Fig. 3 and Additional file 3). The two anchoring sutures and the stenting tube were passed through the hole at the anastomotic site and pulled into the stomach using forceps introduced through the gastric incision. The remnant pancreas was then pulled into the stomach through the hole at the anastomotic site and fixed in place with the anchoring sutures, taking care not to injure the pancreas (Fig. 4 and Additional file 4). After pulling the remnant pancreas 2–3 cm into the stomach, four to six interrupted sutures (Vicril™ 3–0, Ethicon) were placed between the pancreatic capsule and the gastric mucosa (Fig. 5 and Additional file 5). The stenting tube was passed through the incision in the anterior wall of the stomach, and the incision was closed with a continuous absorbable suture (PDS™ 4–0, Ethicon). The stenting tube was then passed through the abdominal wall (usually left subcostal) to form a gastrostomy (Fig. 6). Fibrin glue was placed around the PG site for protection. A prophylactic drainage tube (Multi-Channel™ Drainage Set 6.5 mm, Covidien) was placed at the pancreatic anastomosis.Fig. 1

Bottom Line: This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized.ISRCTN16761283 .Registered 16 January 2015.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Toranomon Hospital, 2-2-2 Toranomon Minato-ku, Tokyo, 105-8470, Japan. eastcliff.on.sea@gmail.com.

ABSTRACT

Background: Although many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not commonly performed because of the technical difficulty of pancreatic resection and the associated reconstruction procedures. Several pancreatic-enteric anastomosis techniques for LPD have been reported, but most are adaptations of open procedures. To accomplish pure LPD, we consider it necessary to establish new pancreatic-enteric anastomosis techniques that are specifically developed for LPD and are safe and feasible to perform.

Results: One patient developed a postoperative pancreatic fistula (International Study Group of Pancreatic Fistula criteria, grade B) and subsequent postoperative delayed gastric emptying (International Study Group of Pancreatic Surgery criteria, grade C). No other major complications occurred. We developed a novel pancreatic-gastric anastomosis technique that enabled us to safely perform pure LPD. The main pancreatic duct was stented with a 4-Fr polyvinyl catheter during pancreatic resection. A small hole was created in the posterior wall of the stomach and was bluntly dilated. A 5-cm incision was made in the anterior stomach, and the pancreatic drainage tube was passed into the stomach through the hole in the posterior wall. The remnant pancreas was pulled into the stomach, and was easily positioned and secured in place with only four to six sutures between the pancreatic capsule and the gastric mucosa. We used this technique to perform pure LPD in five patients between December 2012 and July 2013.

Conclusions: Our new technique is technically easy and provides secure fixation between the gastric wall and the pancreas. This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized. Although this technique requires further investigation as it may increase the risk of delayed gastric emptying, it may be a useful method of performing pancreaticogastrostomy in pure LPD.

Trial registration: ISRCTN16761283 . Registered 16 January 2015.

Show MeSH
Related in: MedlinePlus