Journal of Surgical Oncology 2001;76:138±140

HOW I DO IT

Safe Pancreaticojejunostomy After Whipple Procedure:Modi®ed Technique

JUAN CELIS, MD,* FRANCISCO BERROSPI, MD, ELOY RUIZ, MD,AND EDUARDO PAYET, MD

Department of Abdominal Surgery, Instituto de Enfermedades NeoplaÂsicas, Lima, PeruÂ

INTRODUCTION

Although the operative mortality rate of the proximalpancreaticoduodenectomy (PD) has notably decreased,the incidence of the morbidity remains high [1±3]. Theleakage of the pancreaticojejunostomy after PD is recog-nized as an important complication that may lead tomortality [4]. Different techniques for the management ofthe pancreatic remnant after PD have been recommended[5] but the problem seems to be unsolved.

Pancreaticojejunostomy is one of the most commontypes of reconstruction after PD but there are severalways to perform it [5]. Recently, the dunking pancrea-ticojejunostomy, described by Desjardins in 1907, hasbeen advocated in a modi®ed fashion [6].

This article describes in detail a simple technique forperforming a safe leakproof dunking pancreaticojeju-nostomy after PD.

SURGICAL TECHNIQUE

After the pancreaticoduodenal resection is completed,the proximal cut end of the pancreas stump is freed about4 cm from the splenomesenteric trunk. Hemostaticsutures (polypropylene 2/0) are placed on either side ofthe line of transection of the pancreas. These sutureswill be used as a traction guide to invaginate the pancreasonto the jejunum. Additional hemostatic sutures (poly-propylene 4/0) are placed on the pancreas stump. Care istaken to avoid closing the pancreatic duct. No stents areused.

To perform the anastomosis we bring the proximal endof the jejunum through the mesocolon. Then a runningsuture (polypropylene 2/0) is placed around the cut end ofthe bowel in a purse string-fashion (Fig. 1). Alternatively,a purse-string clamp may be used. We have never use theautomatic purse-string device. The long strands of thehemostatic sutures of the pancreas are now passed intothe open end of the jejunum and out through the wall,superiorly and inferiorly, about 4 cm from the cut end ofthe jejunum (Fig. 2). In this way the pancreas is ready to

be invaginated into the intestine by gentle traction ofthese sutures and by pulling the jejunum in the oppositedirection over the pancreas. Finally, the traction suturesand the purse-string suture are secured. Interruptedsutures (polypropylene 4/0), two in the anterior aspectand two in the posterior aspect of the anastomosis, areadded to avoid slippage of the jejunum. These suturesincorporate the purse-string (Fig. 3). No attempt shouldbe made to invert the intestine.

Biliary and gastric or duodenal anastomosis are per-formed 10 and 30 cm downstream from the pancreatico-jejunostomy, respectively.

Once all the anastomosis is ®nished, a soft nasogastrictube (12F) is inserted into the afferent loop with its tipplaced between the pancreatic and biliary anastomosis(Fig. 4). This tube is used as a decompressive jejunostomyand eventually as a catheter for a contrast roentgenogramto evaluate the integrity of the anastomosis. In the case ofa non-dilated hepatic duct, a Kehr tube replaces decom-pressive jejunostomy.

RESULTS

We have successfully used this technique in 59 conse-cutive Whipple procedures between January 1994 andDecember 1998. All the patients had the dunking pan-creaticojejunostomy regardless of the characteristics ofthe pancreas stump (soft or hard pancreas, dilated or non-dilated pancreatic duct). Twenty-one patients presentedpost operative complications (morbidity 35.6%). Onlyone patient (1.7%) developed a pancreaticojejunostomydehiscence that healed with conservative treatment. Nopost-operative death has occurred.

DISCUSSION

The pancreaticojejunostomy is the authors' preferredmethod for management of the pancreas stump after PD.

*Correspondence to: Juan Celis, MD, Department of Abdominal Surgery,Instituto de Enfermedades NeoplaÂsicas, Av Angamos Este 2520, Lima 34-Peru. Fax: 00-51-1-4481214. E-mail: jcelis@inen.sld.pe

Accepted 3 May 2000

ß 2001 Wiley-Liss, Inc.

The classic invaginating pancreaticojejunostomy involvesplacing one or two layers of interrupted sutures all aroundthe anastomosis with the risk of tearing the pancreatictissue and caudal pancreatic veins. Each suture is, there-fore, a potential point of leakage.

We have modi®ed the dunking pancreaticojejuno-stomy described by Spivack [6] who only uses a purse-string suture to tie the jejunum around the pancreas stump.We have added to this technique four `̀ anchoring'' inter-rupted sutures and a decompressive tube to drain theanastomosis. The `̀ anchoring'' sutures were added be-cause we observed slippage of the intestine out of thepancreas stump. Several authors have proposed someother modi®cations to dunking pancreaticojejunostomy

with excellent results. The Brewer technique is similar toours but its anastomosis needs multiple Lembert suturesaround the jejunum and pancreas stump instead of asingle purse-string suture [7]. Other investigators haverecommended another variation of dunking pancreatico-jejunostomy for soft pancreas only [8]. Those methodsrequire multiple one- or two-row sutures to create theanastomosis. The risk of dehiscence is reduced with ourtechnique because it needs no more than four sutures thatmeans less tissue damage. Concerning decompression ofthe jejunal limb we believe that diverting both pancreatic

Fig. 1. A purse-string suture is placed around the cut end of thejejunum.

Fig. 2. Two sutures are placed across the pancreas stump and passedtrough the wall of the open jejunum 4 cm from the cut edge.

Fig. 3. The jejunum is secure with four `̀ anchoring'' sutures toprevent slippage of the intestine.

Fig. 4. Reconstruction of the alimentary tract after pancreaticoduo-denectomy.

Pancreaticojejunostomy 139

and biliary secretions plays an important role in pre-venting anastomosis breakdown. The secretions accumu-lated in the jejunal limb may disrupt the anastomosis bychemical (proteolytic enzymes) or physical action (dilata-tion of the intestine) so we added a tube jejunostomy or aKehr tube as recommended by Keck [9]. We consider thatexclusive pancreatic diversion [8,10,11] is insuf®cient.

With this type of anastomosis we have observed asharp reduction in dehiscence of pancreaticojejunostomy(1.7%) as well as global operative morbidity and morta-lity. Our results have encouraged us to continue its use inevery pancreaticojejunostomy.

In conclusion, we have developed a simple, quick,universal anastomosis and, the most important feature, ithas proved to be safe in both soft and hard pancreas.

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140 Celis et al.