Application Of Modified End-to-side Pancreaticojejunostomy In Pancreaticoduodenectomy

Background:At present,pancreaticoduodenectomy?PD?is the best surgical strategy for benign and malignant lesions of the pancreas head and periampullary tumor.Since 1941,Whipple^[1]completed the first standard pancreaticoduodenectomy based on the original techniques of Codivilla^[2]and Hunt^[3],and reconstructed the digestive tract according to the bile duct,pancreas,stomach and jejunum.After decades of continuous improvement and innovation by surgical experts,PD has become increasingly mature technique.However,this operation is complex and risky.Postoperative complications are still high,such as pancreatic fistula,biliary fistula,hemorrhage,gastric emptying disorder,lymphatic leakage,and abdominal infection.Pancreatic fistula is the most common complication and one of the most serious complications after PD,and also one of the important causes of death after PD.According to literature reports,the incidence of pancreatic fistula after PD is5%²5%,and the mortality rate is 20%⁴0%^[5].At present,most scholars believe that the main factors related to the occurrence of pancreatic fistula include patient's condition,pancreatic texture,pancreatic duct thickness,pancreaticojejunostomy,perioperative management,operator's experience and technology,etc^[6-9].Among them,pancreaticojejunostomy is the most important factor for the occurrence of pancreatic fistula after operation.Up to now,more than 80 types of pancreaticojejunostomy were reported^[10].However,it has not been determined which type of pancreaticojejunostomy has absolute advantage in reducing the incidence of postoperative complications^[11].In the past,traditional end-to-side pancreaticojejunal mucosal anastomosis has some problems,such as uneven force at the pancreaticojejunal anastomotic site,different gap sizes and more suture needles,which lead to pancreatic fistula and other complications.Here,to effectively reduce the incidence of pancreatic fistula after PD and the mortality rate of perioperative patients,we improved a new pancreaticojejunal anastomosis method based on the traditional end-to-side pancreaticojejunostomy technology and continuous pancreatic duct-jejunum suture,pancreatic rupture end and jejunal seromuscular layer penetrating U-type suture technology.Objective:To evaluate the clinical value of modified end-to-side pancreaticojejunostomy in pancreaticoduodenectomy.Methods:From January 2016 to January 2019,85 patients with benign and malignant lesions of the pancreas head and periampullary tumor underwent pancreatico-duodenectomy at Organ Transplantation Center in the Affiliated Hospital of University of Electronic Science and Technology&Sichuan Provincial People's Hospital were retrospectively analyzed.Among them,43 patients underwent modified end-to-side pancreaticojejunostomy?Improved Group?,42patients underwent traditional end-to-side pancreaticojejunostomy?Traditional Group?.The general conditions?gender,age,anesthesia grade,body mass index,concomitant diseases,pathological types,pancreatic duct diameter?of the two groups were compared.Preoperative laboratory-related laboratory indicators?TBIL,DBIL,ALT,ALB,WBC,NEU,HGB?were compared.Intraoperative conditions?operation time,pancreaticojejunostomy time,bleeding volume?,postoperative conditions?gastrointestinal decompression time?,and postoperative complications and prognosis?pancreatic fistula,biliary fistula,intra-abdominal hemorrhage,lymphatic leakage,gastric emptying disorder,reoperation,death?.Results:There were no significant differences in gender,age,anesthesia grade,body mass index,concomitant diseases,pathological types,pancreatic duct diameter,preoperative physical and chemical indexes,operation time,bleeding volume,gastrointestinal decompression time,intraperitoneal hemorrhage,lymphatic leakage,delayed gastric emptying and the incidence of reoperation between the two groups?P>0.05?.The results found that the time of pancreaticojejunostomy in Improved Group was shorter than that in Traditional Group?P<0.05?,and the total incidence of pancreatic fistula in Improved Group was significantly lower than that in Traditional Group?P<0.05?,in which the incidence of grade A pancreatic fistula in Improved Group was 4.7%?2 cases?and that of grade A pancreatic fistula in Traditional Group was 7.1%?3 cases?,there was no statistical difference between the two groups?P>0.05?.The incidence of B/C pancreatic fistula in Improved Group?0%?was significantly lower than the incidence of B/C pancreatic fistula in Traditional Group?11.9%in grade B and 9.4%in grade C??P<0.05?.In addition,The Improved Group can lower the perioperative mortality and have a better prognosis than the Traditional Group.Conclusions:The results suggested that compared with the traditional end-to-side pancreaticojejunostomy,the modified end-to-side pancreaticojejunostomy can effectively reduce the incidence of pancreatic fistula and perioperative mortality.It is a relatively safe method of pancreaticojejunostomy in pancreatico-duodenectomy and has a certain clinical popularization value.