Duct-to-mucosa PancreatojejunoStomy is a Safe Technique of Reconstruction after Pancreatoduodenectomy

Background: A duct-to-mucosa pancreatojejunostomy is technically difficult to perform than Dunking procedure after pancreatoduodenectomy. In contrast, the incidence of anastomotic dehiscence is more in Dunking than duct-to-mucosa procedure. Duct-to-mucosa technique is rarely practiced in our country because of technical difficulties and lack of experiences. Objectives: This study was undertaken to evaluate the safety ofduct-to-mucosa procedure in our patients with pancreatoduodenectomy. Methods: We have performed pancreatojejunostomy in 14 consecutive patients using a duct-to-mucosa technique and the result was assessed. Results: No patients developed pancreato-jejunal leakage; however, 6 of 14 patients developed complications not related to operative techniques (wound infections; 3, jejunal fistula following removal of jejunal feeding tube; 1, renal dysfunction; 1, delayed gastric emptying; 1) which were managed conservatively. There were no postoperative deaths in the present series and the median postoperative hospital stay was 20.3 days. The follow-up period ranged from 1 to 12 months and all patients are surviving with good health during this period. Conclusion: Pancreatojejunostomy by duct-to-mucosal technique is a safe method of pancreatojejunostomy after pancreatoduodenectomy.


Introduction:
Pancreatojejunostomy after pancreatoduo -denectomy is a complicated surgery; the success of which depends on the absence of leakage.There are several anastomotic techniques used to establish the pancreato-jejunonal continuity, among them the most used are the single layer between the pancreatic capsule and the jejunum (Dunking technique)1, the pancreatogas-trostomy2 in single or double layer and the duct to mucosa technique'-t.Which technique is superior to others still debatable?Few reports have shown that Duct-to -muc o s a p ancre ato -j ej uno stomy i s a superior technique with a yery low risk of postoperative pancre atic fistula formation'-', but the technique is difficult and requires an extensive skill to construct the anastomo- sis.In contrast, other techniques are relatively easy to Address of correspondence: Dr. Bidhan C Das, Assistant Professor Hepato-B iliary-Pancreatic Division Department of Surgery, B SMMU Mobile : +8 8 0-17 I 18 8 9 5 6 5, E-mail : db idhan@yahoo.com 54 perfonrr, but the leaking rate is higher3-t.whilst a report show that duct-to-mucosa technique bear the similar incidence of in terms of anastomotic dehiscence when compare to other techniques".For fuither understanding the fact, we have applied duct-to-mucosa technique after pancreatoduodenectomy for reconstruction in consecu- tive 14 patients; the result of the procedure is satisfactory.
The utiliry safety and results of operative technique are described in this study.
12.After removal of specimen, the distal end of Roux-en-Y was completed by 4-5 interrupted 4-0 vicryl suture loop was brought to pancreatic field through mesocolon (Fig. lb).The anterior and posterior duct to mucosal layer behind the transverse colon.A small opening was made by was strengthened by anterior and posterior pancreatic diathermy in the jejunum 2.5-3 cm away from the closed capsule-parenchyma to seromuscular layer of jejunum end at the anti-mesenteric border of distal end of Rouxsuturing with 3-0 vicryl (Fig. lc).
en-Y loop where the expected anastomosis to be done.A BMI feeding tube of pancreatic duct size was introduced from the side of the distal end of Roux-en-Y loop and was brought through the previously made jejunal opening.The jejunal loop was brought to pancreatic stump.A 4-0 vicryl suture was passed (outside in) from the corner of the pancreatic duct to jejunal opening (inside out).Similar sufuring was taken at the opposite corner of pancreatic duct and jejunal opening, and rest 3 to 4 suturing are taken for completing the posterior wall of pancreatojejunal anastomosis (Fig. 1a).Thus the posterior duct-to mucosal anastomosis was completed.The stent tube that akeady brought through jejunal opening was passed to pancre atic duct.The anterior layer of pancreatojejunal anastomosis cm from the pancreatic anastomosis, using 3-0 vicryl intemrpted sufures.Gastro-jejunal anastomosis was performed 40-50 cm further down the bili ary anastomosis in two layers using 3-0 vicryl continuous suture.Ajejunal in two layers using 3-0 vicryl continuous suture.A jejunal feeding tube was inserted about 30-40 cm down to gastro- jejunal anastomosis for early postoperative enteral nutrition.A silicon drain tube of 24-28F size was inserted through a separated stab wound at the right side of the abdomen and kept in right subhepatic region.
A11 patients were given 800-1500 Kcal energy in the form of 25% glucose, l0% aminoacid and fatty acid solution with appropriate fluid and electrolytes in the first 4 to 5 postoperative days through central venous line.Jejunal feeding was started from the 5'h to 6'h postoperative day when bowel sound returned.Oral feeding was started from Stn to 10'h postoperative day.Broad spectrum antibiotics, adequate analgesia, vitamins and minerals supplementa- tion were given according to the needs.Daily electrolytes, Hb, blood sugar and creatinine were measured in the early postoperative period and corrected accordingly.General care (mouth and skin care), breathing exercise, and early mobilizations were given as a routine work.

Results:
The diameter of the main pancreatic duct in all 14 patients was 5 firm or more.The median operative time was 4.8 hours (3.5 to 6.0 hours), and the median per operative blood loss was 301 ml (100 to 640 m1).Postoperative recovery from anesthesia was smooth in 13 patients except one who needed ICU support for delayed recovery from anesthesia for 48 hours.There was no perioperative death or major complications like pancreato-jejunal, bilio- enteric leakage.Six of 1 4 patrents developed postoperative complications (wound infections; 3, jejunal fistula following removal of jejunal feeding tube; 1, renal dysfunction; 1, delayed gastric emptying; 1).The median postoperative hospital stay was 20.3 days (14 to 34 days), (Table 2).The follow-up period ranged from 1 to 12 months and all patients are surviving with good health during this period.Reconstructive surgery after pancreatoduo-denectomy is a complex procedure.It is composed of pancreatojejunostomy, heap-ticojejunostomy and gastrojejunostomy.

Table -II
Pancreatojejunostomy carries probably the highest risk of failure of all other anastomoses.This may be partly due to the fact that it is afi anastomosis between a solid organ and a hollow viscus and to the harmful liquid content which is the pancre aticjuice with its enzyme activated by the presence of bile or even by the gut content and microbial flora.

Conclusion:
Considering our findings and reported results in the literature it car be concluded that pancreato-jejunostomy by duct-to-mucosal technique is a safe method of pancreatoje- junostomy after pancreatoduodenectomy in selected cases in our context; however multicentre rando-mtzed controlled trials are needed for final comment.
preserving pancreatoduodenectomy, PD: Pancreatoduodenectomy Fig-l : Methods of duct-to-mucosal anastomosis Out c om e of p ancre ato duo d ene ct omy (pancreatoj ejunostomy was done using duct-to-mucosa technique in all patients)

Table - I
Duct-to-mucosa Dancreatoieiunostomy is a safe technique ofreconstuction after Dancreatoduodenectomv.Patients, procedures, status ofpancreatic duet and number stitches requiredfor duct-to-mucos a p ancreatoj ej unos tomy after pancreatoduodmectomy Once the anastomosis breaks the mortalrty rate becomes tremendously high.Total pancreatectomy is sometimes required for saving patients life.If patient survives the total pancreatectomy, quality of life affects severely afterwards.Various types of anastomosis have been developed with an attempt to prevent such disas- atic sfump after pancreatoduodenectomy indicate that probably, there is no single one which is clearly superior to the others in terms of dehiscence, fistula Duct-to-mucosa pancreatoieiunostomy is a safe technique ofreconstruction afterDancreatoduodenectomy.Bidhan C Das et al formation and related deaths6.Although the Dunking procedure is easy to perforun, anastomotic dehiscence is higher.On the other hand duct-mucosal anastomosis is technically difficult, but leakage rate is lower.Furguson and WangesteenT were the first to report a new interesting experimental technique for pancreato-j ejunal anatomosis, directly approximating the jejunal mucosa to the main paincre atic duct epithelium (duct-to -muco sa) sub sequently described by Madden8.The incidence of leakage is however different among previous reports with conflicting results'-".However several authors reported better results with duct-to-mucosa techniquet'-'3 than end to end or end to side Dunking techniquell.our result with duct-to- mucosa technique is excellent as we didn't face afiy leakage of pancreato-jejunal anastomosis in consecutive 14 patrents.Fortunately, in all cases the main pancreatic diameter was 5 mm or more and hence the duct-to-mucosal anastomosis was relatively easier.In patients where the pancreatic duct diameter is less than 5 ffiffi, magnifring loops (microsurgical procedure) can be used for perform- ing this anatomosis.Duct-to-mucosa technique in a non dilated pancre atic duct is a more time consuming and demanding technique, necessarily requiring a microsurgi- cal, skill, Dunking procedure may be considered as an alternative option to them.Sikora and posneru, Marcus et dl'o,and Suzuki et alls also preferred the selective duct-tomucosa technique in presence of firm fibrotic pancreas with duct diameter of 5 mm or more; dunking technique in presence of friable pancreas and non dilated main pancre- atic duct.Regarding the use of suture materials, types of sufuring, use of stenting, although a few studies''" have, othersl'''u did not show any significant differences between uses of sufure materials, continuous or intemrpted sufur- irg, and uses stent or without stent in terms of anastomotic dehiscence. pancre