What are the types of pancreatic anastomosis performed after pancreaticoduodenectomy?

Types of Pancreatic Anastomosis After Pancreaticoduodenectomy

The Blumgart pancreaticojejunostomy—a modified duct-to-mucosa technique using trans-pancreatic U-sutures—should be your default reconstruction method after pancreaticoduodenectomy because it markedly reduces severe postoperative complications and mortality compared with other anastomotic techniques. 1

Primary Anastomotic Options

After pancreaticoduodenectomy, pancreatic reconstruction can be achieved through two main approaches:

1. Pancreaticojejunostomy (PJ)

This involves anastomosing the pancreatic remnant to a jejunal loop, with two principal technical variations:

• Duct-to-mucosa technique: The pancreatic duct is directly sutured to the jejunal mucosa, creating a precise anastomosis between ductal and mucosal layers 2, 3
• Invagination technique: The entire pancreatic remnant is telescoped into the jejunal lumen 4, 3

2. Pancreaticogastrostomy (PG)

The pancreatic remnant is anastomosed to the posterior wall of the stomach, also performed as either duct-to-mucosa or invagination 4, 3

The Blumgart Modification: Technical Superiority

The Blumgart modification combines duct-to-mucosa principles with trans-pancreatic U-sutures that provide gentle circumferential compression of the pancreatic remnant, facilitating a secure and low-tension anastomosis. 1

Key Technical Points:

• Meticulous execution under magnification with careful preservation of pancreatic microcirculation has been reported to virtually eliminate postoperative pancreatic fistula formation 1, 5
• Critical pitfall: When tying the trans-pancreatic U-sutures, avoid overtightening—excessive tension compromises parenchymal perfusion and paradoxically increases fistula risk 1, 5

Comparative Outcomes Between PJ and PG

Randomized trials demonstrate no overall difference in outcomes between pancreaticojejunostomy and pancreaticogastrostomy, indicating that pancreaticogastrostomy is an acceptable alternative when jejunal reconstruction is unsuitable 1, 6

• Network meta-analysis of 16 RCTs (2396 patients) showed PG is not superior to invagination PJ or duct-to-mucosa PJ for preventing postoperative pancreatic fistula 4
• Meta-analysis of 3 RCTs revealed no significant difference between PJ and PG regarding overall complications, pancreatic fistula, intra-abdominal collections, or mortality 6

Duct-to-Mucosa vs. Invagination: A Critical Distinction

Within both PJ and PG approaches, the duct-to-mucosa method is significantly safer than invagination, with pancreatic leak rates of 3.2% versus 17.5% (P < 0.05). 3

• Duct-to-mucosa technique provides better duct patency and lower pancreatic atrophy compared with invagination 3
• In one series of 55 consecutive patients using duct-to-mucosa PJ with jejunal serosa resection (layer-to-layer technique), there was zero pancreatic anastomotic leakage 2
• The invagination method leads to progressive main pancreatic duct dilation and pancreatic thickness reduction over time 3

Specialized Techniques for Chronic Pancreatitis

In the context of chronic pancreatitis surgery (distinct from pancreaticoduodenectomy for malignancy), drainage procedures include:

• Modified Puestow procedure (lateral pancreaticojejunostomy): The dilated pancreatic duct is opened longitudinally and anastomosed to proximal jejunum 7
• Frey procedure: Combines lateral pancreaticojejunostomy with coring of the pancreatic head 7

What NOT to Use Routinely

Routine prophylactic use of octreotide, fibrin glue, or pancreatic duct stents does NOT reduce postoperative pancreatic fistula incidence in prospective randomized trials and should not be employed routinely. 1, 5

• Octreotide administration provides no advantage over well-executed anastomosis 5
• Fibrin-glue sealants fail to lower fistula incidence 5
• Pancreatic duct stents have not demonstrated fistula reduction in prospective randomized investigations 5

Clinical Algorithm for Technique Selection

For standard pancreaticoduodenectomy:

1. First choice: Blumgart pancreaticojejunostomy (modified duct-to-mucosa with trans-pancreatic U-sutures) 1
2. Alternative: Standard duct-to-mucosa pancreaticogastrostomy if jejunal anatomy is unfavorable 1, 3
3. Avoid: Invagination techniques due to significantly higher leak rates 3

For trauma patients: Both pancreaticojejunostomy and pancreaticogastrostomy are equally effective when performed by experienced surgeons, allowing choice based on injury pattern and surgeon expertise 1