Technique of Pancreaticojejunostomy

Video Type: CVideo
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Author: Tovy Kamine
Published:
Specialties: General Surgery
Schools: BIDMC, Harvard Medical School, Harvard Medical School
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Basic Info

Contributors: Emily Gross and  Mark Callery

This video demonstrates an end-to-side duct-to-mucosa pancreaticojejunostomy as part of a pancreaticoduodenectomy to resect a pancreatic head neoplasm. The patient is a 69 year-old female who experienced months of right upper quadrant abdominal pain and had labs consistent with biliary obstruction. Work-up with endoscopic retrograde cholangiopancreatography (ERCP) identified an ampullary mass that was biopsied and returned as ampullary carcinoma.

DOI: http://dx.doi.org/10.17797/dyb8dqxxnr

Editor Recruited By: Jeffrey B. Matthews, MD

Advanced

Procedure

Indications

1. Malignant or pre-malignant neoplasm in pancreatic head (including adenocarcinoma, neuroendocrine tumor). 2.Cholangiocarcinoma in peri-ampullar region. 3. Ampullary carcinoma.

Contraindications

The contraindications for pancreaticoduodenectomy include: 1. Superior mesenteric, celiac, or hepatic artery tumor involvement (note: not an absolute contraindication if vascular reconstruction is possible) 2. Metastatic disease

Instrumentation

Setup

The patient lies supine on the operating table with arms tucked at the sides. The abdomen is prepped up to the subcostal margin and Ioban film is applied over the operative field. A right subcostal incision extending across the midline is performed and a self-retaining Bookwalter retractor is placed to aid in exposure. The basic steps of the pancreaticojejunostomy are as follows: 1) Following completion of the resection portion of the pancreaticoduodenectomy the jejunum is passed under the superior mesenteric vessels into the right upper quadrant of the abdomen, near the cut surface of the pancreas. 2) The pancreas had been previously divided with a vascular load of a TA stapler, the staple line is removed with Metzenbaum scissors until pancreatic secretions are noted from the pancreatic duct. 3) Any bleeding from the pancreatic parenchyma is controlled with the electrosurgical pencil, as the pancreaticoduodenal vessels are already controlled with the stapler. 4) The pancreatic duct is probed to ensure patency. 5) eight to ten stiches are placed around the circumference of the pancreatic duct (in a manner similar to a clock face) using 5-0 Maxon sutures which are then shodded. 6) A towel is placed over the anterior sutures and the posterior sutures are draped over these to maintain the orientation. 7) the posterior pancreatic parenchyma is sutured to the jejunal limb posterior to the location of the future anastomosis to anchor it using 3-0 silk sutures. 8) The electrosurgical pencil is used to make an opening in the jejunum to match the luminal size of the pancreatic duct. 9) The sutures of the posterior wall of the anastomosis are sutured to the posterior wall of the jejunotomy. 10) Care is maintained when passing these sutures off to the scrub tech to ensure constant safety around the needles. 11) Should a pancreatic duct stent be desired due to a small duct, a 5 French pediatric feeding tube is cut to the appropriate length and used as a pancreatic duct stent. 12) The anterior wall sutures are placed in the same fashion as the posterior wall sutures. 13) 3-0 silk sutures are placed on the sides and anterior portion of the pancreatic parenchyma to secure it to the jejunum. 14) The jejunal limb is secured to the retroperitoneal fat near the place it passes under the mesenteric vessels to prevent tension on the anastomosis or internal hernia. 15) Upon completion of the pancreaticojejunostomy, the hepaticojejunostomy is performed, followed by duodenojejunostomy.

Preoperative Workup

In the setting of a neoplasm, pancreatic protocol CT scan of the abdomen should be obtained to determine respectability, and endoscopic ultrasound (EUS) with transluminal fine needle aspiration (FNA) is used to assess cytology. Tumor markers (CA 19-9, CEA) are obtained. Diagnostic laparoscopy can be used immediately pre-operatively to assess feasibility of the operation and avoid nontherapeutic laparotomy.

Anatomy and Landmarks

In cases of a very small pancreatic duct where duct to mucosa anastomosis cannot be performed, or when the pancreatic duct cannot be localized, a large jejunotomy can be performed and the whole neck of the pancreas invaginated into the jejunum.

Advantages/Disadvantages

The advantage of performing duct to mucosa anastomosis in this fashion is a decreased leak rate compared to invagination of the pancreas into the jejunum. A pediatric feeding tube may be used as a pancreatic duct stent if the pancreatic duct is small.

Complications/Risks

Intra-operative complications include damage to the pancreas, pancreatic duct, jejunum or mesenteric vessels. The most common post-operative complication related to the pancreaticojejunostomy is pancreatic fistula formation, occurring in 10-15% of patients. Post-operative complications seen in a pancreaticoduodenectomy but not specific to the pancreaticojejunostomy include delayed gastric emptying, bleeding, pancreatic insufficiency, and impaired glucose tolerance.

Disclosure of Conflicts

Intra-operative complications include damage to the pancreas, pancreatic duct, jejunum or mesenteric vessels. The most common post-operative complication related to the pancreaticojejunostomy is pancreatic fistula formation, occurring in 10-15% of patients. Post-operative complications seen in a pancreaticoduodenectomy but not specific to the pancreaticojejunostomy include delayed gastric emptying, bleeding, pancreatic insufficiency, and impaired glucose tolerance.

Acknowledgements

Tom Laws, BIDMC Media Services, who assisted in filming and editing this video

References

Fathy O, Wahab MA, Elghwalby N, Sultan A, EL-Ebidy G, Hak NG, Abu Zeid M, Abd-Allah T, El-Shobary M, Fouad A, Kandeel T, Abo Elenien A, Abd El-Raouf A, Hamdy E, Sultan AM, Hamdy E, Ezzat F. 216 cases of pancreaticoduodenectomy: risk factors for post-operative complications. Hepatogastroenterology. 2008 May-Jun;55(84):1098-8.

Fisher WE, Andersen DK, Windsor JA, Saluja AK, Brunicardi F. Pancreas. In:Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz's Principles of Surgery, 10e. New York, NY: McGraw-Hill; 2014.

Jin Xu, Bo Zhang, Si Shi, Yi Qin, Shunrong Ji, Wenyan Xu, Jiang Liu, Liang Liu, Chen Liu, Jiang Long, Quanxing Ni, and Xianjun Yu. Papillary-like main pancreatic duct invaginated pancreaticojejunostomy versus duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized trial. Surgery 2015;158:1211-8.

Lermite E, Sommacale D, Piardi T, Arnaud JP, SAuvanet A, Dejong CH, Pessaux P. Complications after pancreatic resection: diagnosis, prevention and management. Clin Res Hepatol Gastroenterol. 2013 Jun;37(3):230-9.

Liu FB, Chen JM, Geng W, Xie SX, Zhao YJ, Yu LQ, Geng XP. Pancreaticogastrostomy is associated with significantly less pancreatic fistula than pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: a meta-analysis of seven randomized controlled trials. HPB. 2015 Feb;17(2):123-30.

Menaham B, Guittet L, Mulliri A, Alves A, Lubrano J. Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials. Ann Surg. 2015 May;261(5)882-7.

Sharpe SM, Talamonti MS, Wang CE, Prinz RA, Roggin KK, Bentrem DJ, Winchester DJ, Marsh RD, Stocker SJ, Baker MS. Early National Experience with Laparoscopic Pancreaticoduodenectomy for Ductal Adenocarcinoma: A comparison of Laparoscopic Pancreaticoduodenectomy and Open Pancreaticoduodenectomy from the National Cancer Data Base. J Am Coll Surg. 2015 Jul;221(1):175-84.

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