End-to-end Invaginated Pancreaticojejunostomy With Three Overlapping U-sutures After Pancreaticoduodenectomy

BackgroundPancreaticoduodenectomy (PD) is among the most complicated procedures of alimentary tract surgery, and is also regarded as the only potential approach to radical cure for patients with resectable pancreatic head and periampullary malignancy. It has evolved over time into a relatively safe procedure in recent decades. Its mortality has been markedly reduced mostly due to both advances and innovations in surgical techniques and the enhancements in perioperative cares, and is reported below5%recently in high-volume centers. Nevertheless, morbidity after PD remains considerably high, with its rate ranging from30%to50%. Postoperative pancreatic fistula or leakage, commonly giving rise to the subsequent intra-abdominal infection, abscess, hemorrhage, delayed gastric emptying and wound infection directly or indirectly, has long been existing as the most complex and sinister of the postoperative complications. Furthermore, pancreatic fistula with its subsequent complications remains a major cause of death after pancreaticoduodenectomy. The management of the pancreatic remnant thus becomes an important and intractable problem. According to the results of several large scale clinical researches, pancreaticojejunostomy is the most favored procedure of reconstructing the pancreaticoenteric continuity. To date, a vast variety of techniques and modifications for pancreaticojejunostomy has been employed all over the world, and more than70kinds of procedures developed. However, the lack of multi-centric large sample researches and prospective randomized controlled trials lowers the reliability of those innovative reports, and the safety of those pancreaticojejunostomy techniques and there efficacies to minimize postoperative pancreatic fistula are therefore hardly approved in a wide range of areas. In additions, the efficiency and availability of current modifications and innovated techniques are also controversial. Most of those methods require sophisticated sewing and comparatively long operative durations, while some of the others keep a relatively high selectivity towards either the texture of the pancreas or the diameter of the main pancreatic duct. There are, moreover, some of those procedures which must be achieved under the help of special tools, biological materials or microscopes, and thus become even harder to be popularized and widely applied. Therefore, the strategy to avoid pancreatic fistula as well as the standardization of the selecting and exerting the pancreaticojejunostomy has become a controversial problem, even to the most experienced hepatopancreatobiliary surgeons in large medical centers.ObjectivesTo solve the problems on the security, efficiency and availability of pancreaticojejunostomy, we have originated a simple and safe technique since2009, named end-to-end invaginated pancreaticojejunostomy with three overlapping U-sutures. In this study, we compared this novel technique with the traditional invaginated pancreaticojejunostomy, and additionally we analyzed the independent risk factors correlated to pancreatic fistula after PD.Materials and MethodsWe divided the total49patients who received either end-to-end invaginated pancreaticojejunostomy or traditional invaginated pancreaticojejunostomy during February2007to September2011into U-suture group and Traditional group respectively. The former group contained27patients and the latter included22patients. Using a retrospective cohort design, two groups were compared in respect of demographic materials, medical histories, preoperative and intraoperative data, pathological diagnosis, postoperative complications and clinical courses. The above-mentioned data of the total49cases were also analyzed with regard to the presence of postoperative pancreatic fistula, thus to research their correlation to such a complication.ResultsThe differences between the two groups on demographics, medical histories and preoperative data represented no statistical significance. Duration of operation in U-suture group (410min,325-640min) was shorter than that of Traditional group (442.5min,350-675min), and the difference was statistically significant (P=0.026). Postoperative complications were less common in U-suture group (33.3%) than in Traditional group (45.5%), though the difference had no statistical significance. Postoperative pancreatic fistula had been found less often in U-suture group (11.1%) compared to Traditional group (40.9), and the difference did have statistical significance (P=0.016). Postoperative hospital stays of U-suture group (18d,10-48d) also resulted shorter than that of Traditional group (24.5d,15-56d), and the difference was statistically significant. Pancreas with soft texture (OR9.145,95%CI1.612-51.892) and the using of traditional invaginated pancreaticojejunostomy (OR10.031,95%CI1.777-56.612) were strongly, especially the latter, correlated to the presence of postoperative pancreatic fistula.Conclusion1. The texture of pancreas and the anastomotic type of pancreaticoduodenectomy were proved in this study to be the two independent risk factors correlated to postoperative pancreatic fistula.2. The end-to-end invaginated pancreaticojejunostomy with three overlapping U-sutures, representing both simplicity and celerity, while reducing the occurrence of pancreatic fistula effectively at the same time, could be regarded as a novel surgical technique of pancreaticojejunostomy with comparatively high security and applicability.3. The superiority of our procedure needs to be validated in large cohort series and prospective randomized trials in the future.