The Distribution Of Main Pancreatic Duct At The Stamp Of Pancreas During Pancreaticojejunostomy

Background and PurposePancreaticoduodenectomy (PD) is a complex procedure commonly performed in appropriately selected patients with benign and malignant diseases of the pancreas and peri-ampullary region. Pancreatic leakage is the most dangerous complication after PD, and its mortality varies from 20% to 40%. Prevention of pancreatic leakage is the key to performing pancreaticoduodenectomy. The improvement of pancreaticojejunostomy is important for prevention of pancreatic leakage. However, several advances in leak tightness, anastomotic blood supply and tension at the anastomosis of pancreaticojejunostomy have occurred in the last decades. But the rate of pancreatic leakage remains high, even at high-volume centers. Anatomists found that most of the pancreatic ducts were located posteriorly in the neck of pancreas. When a pancreaticojejunostomy is to be carried out, it indicates the need for great precaution in the placing of sutures to avoid suturing over the pancreatic duct. In order to analyze the critical region of pancreatic duct injury and investigate the risk factor of pancreatic leakage after pancreaticojejunostomy. we measured the location of the pancreatic duct with intraoperative ultrasound and rulers during pancreaticoduodenectomy.Material and MethodThe location of the main pancreatic duct at the pancreatic remnant were measured in 16 patients who had been performed pancreaticojejunostomy by one attending surgeon at the Department of General Surgery of Sir Run Run Shaw Hospital from Aug 2010 to Feb 2011. The locations of the major pancreatic duct at the previously transected surfaces of pancreatic remnant which were the cut edge of the pancreatic neck (Section 1). the transection plane 2cm to the left of the cut edge (Section 2) and 3cm to the left of the cut edge (Section 3). respectively, were then noted in the relation to the anterior (a), posterior (b). superior(c), and inferior (d) surfaces of the pancreas.In these 16 patients,8 cases were male and 8 cases were female, and the ratio of male to female was 1:1. The age varied from 37 to 83 years old. with the average of 56. All of the patients had epigastric pain,13 patients had obstructive jaundice (81.3%).14 patients received pancreaticoduodenectomy (87.5%),1 patient received pancreaticoduodenectomy and distal gastrectomy (8.3%),1 patient received segmental pancreatic resection and pancreaticojejunostomy (8.3%). Pancreaticojejunostomy was performed in all patients, which contained 10 cases of binding pancreaticojejunostomies and 6 cases of duct-to-mucosa end-to-side pancreaticojejunostomies.ResultsThe average operation time was 5.7 hours. The average blood loss was 621.9 ml. There were no pancreatic leakage and no death. The mean hospital stay after operation was 20.1 days. There were 6 patients with complications (20%).The pathologic diagnosis were 6 cases of pancreatic carcinoma,3 cases of peri-ampullary carcinoma,2 cases of distal bile duct carcinoma.1 case of pancreatic intraductal papillary mucinous neoplasm.1 case of pancreatic myxoadenoma,l case of pancreatic serous cystadenoma, 1 case of chronic pancreatitis and 1 case of pancreatic solid pseudopapillary tumor.At the cut edge of the pancreatic neck (Section 1), the transection plane 2cm to the left of the cut edge (Section 2) and 3cm to the left of the cut edge (Section 3), both distances from the pancreatic duct to the superior and the inferior surface of the pancreas were above 1 cm. At Section 1, the distance from the pancreatic duct to the anterior surface was 7.9±3.1 mm. and to the posterior surface was 3.5±2.6 mm,10 of 16 patients (62.5%) had the contiguity of the pancreatic duct to the posterior cut edge (≤3 mm);at Section 2.the distance from the pancreatic duct to the anterior surface was 5.2±2.0 mm. and to the posterior surface was 4.7±1.4 mm,4 of 16 patients (25%) had the contiguity of the pancreatic duct to the posterior surface (≤3 mm);at Section 3,the distance from the pancreatic duct to the anterior surface was 5.4±2.3 mm. and to the posterior surface was 4.8±1.7 mm.4 of 16 patients (25%) had the contiguity of the pancreatic duct to the posterior cut surface (≤3 mm). ConclusionIn most cases, at the cut edge of the pancreatic neck, the distance from the pancreatic duct to the to the posterior surface was less than 3 mm, it was at high risk for pancreatic duct injury in the pancreaticoduodenectomy; At the transection plane 2cm and 3cm to the left of the cut edge, the pancreatic duct was found on the midway between the anterior and posterior surfaces of the pancreatic remnant. But the pancreatic ducts were located posteriorly and anteriorly (≤3 mm) in 50% of all cases.To avoid suturing over the duct, a stent should be placed in the pancreatic duct of the pancreatic remnant before the pancreaticojejunostomy. Cutting the pancreas back 1.0-2.0 cm to the left of the neck of the pancreas could be chosen if the pancreatic duct was too small to place a stent.