What is the recommended order of anastomosis in a Whipple (pancreaticoduodenectomy) procedure?

Order of Anastomosis in Whipple Procedure

The standard reconstruction sequence after pancreaticoduodenectomy involves three anastomoses performed in the following order: pancreaticojejunostomy (or pancreaticogastrostomy) first, followed by hepaticojejunostomy, and finally gastrojejunostomy (or duodenojejunostomy in pylorus-preserving procedures).

Standard Reconstruction Sequence

First Anastomosis: Pancreatic Reconstruction

• The pancreatic anastomosis is performed first because it is the most technically demanding and carries the highest risk of complications. 1
• Pancreaticojejunostomy has traditionally been the standard reconstruction technique, though pancreaticogastrostomy is an equally effective alternative in selected cases performed by experienced surgeons. 1
• The National Comprehensive Cancer Network notes that both pancreato-jejunostomy and pancreato-gastrostomy reconstructions are equally effective when performed by experienced surgeons. 1

Technical considerations for the pancreatic anastomosis:

• End-to-side, mucosa-to-mucosa pancreaticojejunostomy (intubated) has demonstrated superior safety profiles compared to end-to-end techniques in preventing pancreatic fistulas. 2
• Research shows that end-to-side anastomosis can reduce pancreatic leak rates to near zero when performed with meticulous attention to technique and blood supply. 2
• Pancreaticogastrostomy may offer advantages in reducing anastomotic leak rates compared to pancreaticojejunostomy, with some studies showing zero leaks versus 20% leak rates with jejunal anastomosis. 3

Second Anastomosis: Biliary Reconstruction

• The hepaticojejunostomy (or choledochojejunostomy) is performed second, typically 40-60 cm distal to the pancreatic anastomosis on the same jejunal limb. 1
• This anastomosis reconstructs biliary continuity and is generally more straightforward than the pancreatic anastomosis. 1

Third Anastomosis: Gastric Reconstruction

• The gastrojejunostomy (or duodenojejunostomy in pylorus-preserving procedures) is performed last, typically 10-15 cm distal to the biliary anastomosis. 4
• In standard Whipple, the stomach is divided at the level of the pylorus or distal stomach. 4
• In pylorus-preserving Whipple, the pylorus is preserved and the duodenum is divided distal to it. 4

Critical Technical Points

Pylorus Preservation Decision

• Pylorus-preserving pancreaticoduodenectomy remains an acceptable alternative to classic pancreaticoduodenectomy with antrectomy, though benefits regarding quality of life and nutritional status are inconsistent. 1
• Pylorus-preserving technique with ante-colic (rather than retro-colic) duodenojejunostomy may result in less delayed gastric emptying. 5

Vascular Considerations

• Complete mobilization of the portal and superior mesenteric veins from the uncinate process must be achieved before beginning reconstruction. 4
• If tumor infiltration into the portal or superior mesenteric vein is suspected, partial or complete vein resection and reconstruction should be performed before proceeding with anastomoses. 4

Common Pitfalls to Avoid

Performing anastomoses out of sequence can lead to:

• Increased technical difficulty due to limited working space. 1
• Higher risk of tension on anastomoses, particularly the pancreatic anastomosis. 2
• Inadequate assessment of pancreatic remnant viability before committing to reconstruction. 1

Critical errors in pancreatic anastomosis:

• Inadequate attention to blood supply during suture placement significantly increases fistula risk. 1
• Using end-to-end techniques when end-to-side mucosa-to-mucosa approaches have demonstrated superior outcomes. 2, 6
• Failing to recognize that no pancreatic duct is too small or pancreas too soft to permit effective anastomosis when proper technique is used. 2

Special Circumstances

Trauma and Damage Control Settings

• In trauma requiring pancreaticoduodenectomy, damage control techniques with staged reconstruction should be strongly considered, as this approach improves survival and reduces complications. 1
• The operation has better results when performed in a staged fashion in patients with destructive injuries of the duodenal-pancreatic complex. 1

High-Risk Pancreatic Remnants

• When the pancreatic remnant is particularly soft or the duct is very small, binding pancreaticojejunostomy techniques (where serosa-muscular sheath of jejunum is bound to pancreatic remnant) have shown zero fistula rates in case series. 7