Influence of the type of pancreatic anastomosis on direct results of pylorus-preserving pancreatoduodenectomy

• Shevchenko T.V.
• Gurmikov B.N.
• Turchenko I.A.
• Karmazanovsky G.G.
• Stepanova Yu.A.
• Kovalenko Yu.A.
• Chzhao A.V.
• Kozlov I.A.
• Ikramov R.Z.

Abstract

Chose of the type of pancreatojejunostomy while proceeding pylorus-preserving pancreaticoduodenectomy (pPD) is one of the main problems in modern pancreatic surgery.

Aim. Compare the direct results of pPD using different types of pancreatojejunostomies.

Material and methods. A retrospective cohort study examined the results of pPD performed on 48 patients between 2019 and 2023. Patients were divided into three groups according to the PDA technique: group 1 (15 cases) – two-row PDA “end-to-side” with separate suturing of the main pancreatic duct (MPD) into the jejunum and attachment of the parenchyma of the gland to the serous-muscular layer of the intestine with interrupted sutures; group 2 (23 patients) – single-row “end-to-end” invagination PDA; group 3 (10 people) – double-row PDA with the use of through “P” shaped sutures and with separate suturing of the MPD into the jejunum (Blumgart’s method). The groups are homogeneous in terms of age, sex and nature of the underlying disease.

Results. There was difference in the groups in terms of pancreas density. Group 1: soft pancreas – 14, firm – 1; group 2: soft – 11, firm – 12; group 3: soft – 10 (p=0.008). Average time of operation in groups 1, 2, 3 was 462 (265–573) min, 425 (270–655) min and 373 (275–455) min respectively (p=0.0091). Pancreatic anastomosis leakage in groups 1, 2, 3 was 7, 9 and 0 cases respectively (p=0.037). Postoperative pancreatitis among groups was: 1 – 5, 2 – 7, 3 – 2; number of gross postoperative complications (Clavien–Dindo ≥3b): 1 – 6, 2 – 10, 3 – 1; average postoperative hospital stay: 1 – 21.46 (11–50) days; 2 – 20.75 (8–47) days; 3 – 16.9 (10–36) days, significant difference was not discovered .

Conclusion. The results obtained allow us to conclude that the formation of pancreatic anastomosis with Blumgart technique is preferable, since it significantly reduces the time of surgical intervention and reduces the risk of anastomosis failure.

Keywords:pylorus-preserving pancreaticoduodenectomy; pancreaticojejunostomy; pancreatic head cancer; terminal pancreatic duct cancer; direct results

References

1.     Kaprin A.D. Malignant neoplasms in Russia in 2017 (morbidity and mortality). Moscow: MNIOI im. P.A. Gertsena – filial FGBU «NMITs radiologii» Minzdrava Rossii, 2018: 250 p. (in Russian)

2.     Gorin D.S., Kriger A.G., Solodky V.A., Shuinova E.A., Goncharov S.V., Akhaladze G.G., et al. Pancreaticoduodenectomy – results and prospects (two-center study). Khirurgiya. Zhurnal imeni N.I. Pirogova [Surgery. The Journal named after N.I. Pirogov]. 2023; (5): 13–21. DOI: https://doi.org/10.17116/hirurgia202305113  (in Russian)

3.     Kotel’nikov A.G., Patyutko Yu.I., Podluzhny D.V., Saakyan M.S., Kudashkin N.E., Polyakov A.N., et al. Pancreatodigestive anastomosis is the key to a favorable outcome of pancreaticoduodenal resection. Annaly khirurgicheskoy gepatologii [Annals of Surgical Hepatology]. 2022; 27 (3): 92–9. DOI: https://doi.org/10.16931/1995-5464.2022-3-92-99  (in Russian)

4.     van Roessel S., Mackay T.M., Tol J.A.M.G., van Delden O.M., van Lienden K.P., Nio C.Y., et al. Impact of expanding indications on surgical and oncological outcome in 1434 consecutive pancreatoduodenectomies. HPB (Oxford). 2019; 21 (7): 865–75. DOI: https://doi.org/10.1016/j.hpb.2018.10.020  

5.     Merath K., Mehta R., Tsilimigras D.I., Farooq A., Sahara K., Paredes A.Z., et al. In-hospital mortality following pancreatoduodenectomy: a comprehensive analysis. J Gastrointest Surg. 2020; 24 (5): 1119–26. DOI: https://doi.org/10.1007/s11605-019-04307-9  

6.     Barreto S.G., Shukla P.J. Different types of pancreatico-enteric anastomosis. Transl Gastroenterol Hepatol. 2017; 2: 89. DOI: https://doi.org/10.21037/tgh.2017.11.02   

7.     Gurmikov B.N., Bolokov M.S., Gurmikova N.L. Long-term results of surgical treatment of pancreatic cancer. Literature review. Kubanskiy nauchniy meditsinskiy vestnik [Kuban Scientific Medical Bulletin]. 2017; 1 (2): 142–7. DOI: https://doi.org/10.25207/1608-6228-2017-2-142-147  (in Russian)

8.     You Y., Han I.W., Choi D.W., Heo J.S., Ryu Y., Park D.J., et al. Nomogram for predicting postoperative pancreatic fistula. HPB (Oxford). 2019; 21 (11): 1436–45. DOI: https://doi.org/10.1016/j.hpb.2019.03.351  

9.     Kawaida H., Kono H., Hosomura N., Amemiya H., Itakura J., Fujii H., et al. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol. 2019; 25 (28): 3722–37. DOI: https://doi.org/10.3748/wjg.v25.i28.3722  

10. Ellis R.J., Brock Hewitt D., Liu J.B., Cohen M.E., Merkow R.P., Bentrem D.J., et al. Preoperative risk evaluation for pancreatic fistula after pancreaticoduodenectomy. J Surg Oncol. 2019; 119 (8): 1128–34. DOI: https://doi.org/10.1002/jso.25464  

11. Mungroop T.H., van Rijssen L.B., van Klaveren D., Smits F.J., van Woerden V., Linnemann R.J., et al.; Dutch Pancreatic Cancer Group. Alternative fistula risk score for pancreatoduodenectomy (a-FRS): design and international external validation. Ann Surg. 2019; 269 (5): 937–43. DOI: https://doi.org/10.1097/SLA.0000000000002620  

12. Asari S., Matsumoto I., Toyama H., Shinzeki M., Goto T., Ishida J., et al. Preoperative independent prognostic factors in patients with borderline resectable pancreatic ductal adenocarcinoma following curative resection: the neutrophil-lymphocyte and platelet-lymphocyte ratios. Surg Today. 2016; 46 (5): 583–92. DOI: https://doi.org/10.1007/s00595-015-12063  

13. Callery M.P., Pratt W.B., Kent T.S., Chaikof E.L., Vollmer C.M. Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013; 216 (1): 1–14. DOI: https://doi.org/10.1016/j.jamcollsurg.2012.09.002  

14. Xiang Y., Wu J., Lin C., Yang Y., Zhang D., Xie Y., et al. Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature. Expert Rev Gastroenterol Hepatol. 2019; 13 (8): 797–806. DOI: https://doi.org/10.1080/17474124.2019.1640601  

15. Kakita A., Takahashi T., Yoshida M., Furuta K. A simpler and more reliable technique of pancreatojejunal anastomosis. Surg Today. 1996; 26 (7): 532–5. DOI: https://doi.org/10.1007/BF00311562

16. Brennan M. Pancreaticojejunostomy. In: L.H. Blumgart, Y. Fong (eds). Surgery of the Liver and Biliary Tract. 3rd ed. Philadelphia: Saunders, 2000; 3: 1073–89.

17. Ricci C., Ingaldi C., Alberici L., Pagano N., Mosconi C., Marasco G., et al. Blumgart anastomosis after pancreaticoduodenectomy. a comprehensive systematic review, meta-analysis, and meta-regression. World J Surg. 2021; 45 (6): 1929–39. DOI: https://doi.org/10.1007/s00268-021-06039-x  

18. Li Y.T., Zhang H.Y., Xing C., Ding C., Wu W.M., Liao Q., et al. Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy. World J Gastroenterol. 2019; 25 (20): 2514–23. DOI: https://doi.org/10.3748/wjg.v25.i20.2514  

19. Egorov V.I., Petrov R.V. Simple and reliable pancreatoenteroanastomosis. Khirurgiya. Zhurnal imeni N.I. Pirogova [Surgery. The Journal Named after N.I. Pirogov]. 2017; (11): 60–8. DOI: https://doi.org/10.17116/hirurgia20171160-68  (in Russian)

All articles in our journal are distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0 license)