Pancreatojejunostomy. Evolution of Thinking and Modern Trends

Cover Page

Cite item

Full Text

Open Access Open Access
Restricted Access Access granted
Restricted Access Subscription or Fee Access

Abstract

Pancreatojejunostomy is a key stage in performing pancreatoduodenal resection, as it is one of the major factors for developing postoperative pancreatic fistulas. The paper demonstrates the evolution of thinking in the global surgical community regarding interventions on the pancreas in general and pancreatodigestive anastomosis in particular. The attitude of pancreatologists to pancreato-digestive anastomosis has undergone radical changes since the end of the 19th century to the present day. For a long time, surgeons were restricted to perform only partial resections of the head of the pancreas, based on the postulates of its inviolability. However, the rapid development of medical technologies and surgical art throughout the 20th century led to the formation of an algorithm for pancreatoduodenal resection in its modern version, as well as the creation of numerous techniques for forming an anastomosis between the remnant of the pancreas and the small intestine. The article describes and illustrates the main modern technologies for forming a pancreatic anastomosis. Based on the data of the world literature, modern technologies for pancreatic anastomosis, their features, advantages and disadvantages are assessed. Additional options to prevent pancreatic fistulas during the pancreatojejunostomy are highlighted. Modern techniques for predicting complications during pancreatoduodenal resection are also described.

Full Text

Restricted Access

About the authors

Ivan A. Turchenko

Vishnevsky National Medical Research Center of Surgery

Author for correspondence.
Email: iturchenko57@gmail.com

Postgraduate Student at the Oncology Department of Surgical Methods of Treatment

Russian Federation, Moscow

Tatiana V. Shevchenko

Vishnevsky National Medical Research Center of Surgery

Email: shev.tanechka@gmail.com

Ph.D., Surgeon at the Oncology Department of Surgery and Anticancer Drug Therapy

Russian Federation, Moscow

Yulia A. Stepanova

Vishnevsky National Medical Research Center of Surgery

Email: stepanovaua@mail.ru

M.D., Professor, Senior Researcher at the Department of Ultrasound

Russian Federation, Moscow

Vladimir S. Ruzavin

Vishnevsky National Medical Research Center of Surgery

Email: mfruzavin@yandex.ru

Ph.D., Surgeon at the Oncology Department of Surgical Methods of Treatment

Russian Federation, Moscow

Anatoly Yu. Popov

Vishnevsky National Medical Research Center of Surgery

Email: popov_63@mail.ru

Ph.D., Head of the Department of Antitumor Drug Therapy

Russian Federation, Moscow

Beslan N. Gurmikov

Vishnevsky National Medical Research Center of Surgery

Email: Gurmikov@mail.ru

M.D., Head of the Oncology Department of Surgical Methods of Treatment

Russian Federation, Moscow

References

  1. Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of vater. Ann Surg. 1935;102(4):763-79. doi: 10.1097/00000658-193510000-00023
  2. Karim SAM, Abdulla KS, Abdulkarim QH, Rahim FH. The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study. Int J Surg. 2018;52:383-387. doi: 10.1016/j.ijsu.2018.01.041
  3. Kaprin AD, Kostin AA, Nikiforov PV, Egorov VI, Grishin NA, Lozhkin MV, Petrov LO, Bykasov SA, Sidorov DV. Pancreatoduodenectomy: learning curve within single multi-field center. Hirurgiya. Zhurnal im. N.I. Pirogova. 2018; 4: 17-23. (in Russ.) doi: 10.17116/hirurgia2018417-23
  4. Enderes J, Pillny C, Standop J, Manekeller S, Kalff JC, Glowka TR. Operative Re-Intervention following Pancreatoduodenectomy: What Has Changed over the Last Decades. J Clin Med. 2022;11(24):7512. doi: 10.3390/jcm11247512
  5. Kovalenko ZA, Egorov VI, Petrov RV, Ananev DP, Fainstein IA, Dalgatov KD. Resectable periampullary tumor in patients with previous pancreatitis. What type of surgical procedure to choose? Hirurgiya. Zhurnal im. N.I. Pirogova. 2021; 6: 5-9. (in Russ.) doi: 10.17116/hirurgia20210615
  6. Gurmikov BN, Bolokov MS, Gurmikova NL. Long-term results of surgical treatment for pancreatic cancer. A review of literature. Kubanskij nauchnyj medicinskij vestnik. 2017; 1(2): 142-147. (in Russ.) doi: 10.25207/1608-6228-2017-2-142-147
  7. Kotelnikov AG, Patyutko YuI, Podluzhny DV, Saakyan MS, Kudashkin NE, Polyakov AN, Tikhonov PA, Suleimanov EA, Stilidi IS. Pancreatodigestive anastomosis: the key to a favorable outcome of pancreaticoduodenal resection. Annaly hirurgicheskoj gepatologii. 2022; 27(3): 92-99. (in Russ.) doi: 10.16931/1995-5464.2022-3-92-99
  8. Griffin JF, Wolfgang C. The history and evolution of pancreaticoduodenectomy. In Pancreatic Cancer: With Special Focus on Topical Issues and Surgical Techniques. Springer Berlin Heidelberg. 2017; 175-183. doi: 10.1007/978-3-662-47181-4_14
  9. Halsted WS Contributions to the Surgery of the Bile Passages, Especially of the Common Bile-Duct. The New England Journal of Medicine. 1899; 14(1): 645-654.
  10. Shalimov AA. Bolezni podzheludochnoj zhelezy i ih hirurgicheskoe lechenie. M.: Medicina. 1970; 280. (in Rus)
  11. Whipple AO. The rationale of radical surgery for cancer of the pancreas and ampullary region. Ann Surg. 1941; 114(4): 612-5. doi: 10.1097/00000658-194111440-00008
  12. Hunt VC. Surgical management of carcinoma of the ampulla of vater and of the periampullary portion of the duodenum. Ann Surg. 1941; 114(4): 570-602. doi: 10.1097/00000658-194110000-00006
  13. Griffin JF, Poruk KE, Wolfgang CL. Pancreatic cancer surgery: past, present, and future. Chin J Cancer Res. 2015;27(4):332-48. doi: 10.3978/j.issn.1000-9604.2015.06.07
  14. Child CG III Carcinoma of duodenum: one-stage radical pancreaticoduodenectomy preserving the external pancreatic secretion, case report. Ann Surg. 1941; 11(8): 838–842.
  15. Chang Wu B, Wlodarczyk J, Nourmohammadi Abadchi S, Shababi N, Cameron JL, Harmon JW. Revolutionary transformation lowering the mortality of pancreaticoduodenectomy: a historical review. Gastroenterology. 2023;1(2):e100014. doi: 10.1136/egastro-2023-100014
  16. Cattell RB. A technic for pancreatoduodenal resection. Surg Clin North Am. 1948;28:761-75. doi: 10.1016/s0039-6109(16)32452-5
  17. Lin PW, Lee JC, Lee PC, Chang TW, Hung CJ, Chang YC. A simple, secure and universal pancreaticojejunostomy following pancreaticoduodenectomy. HPB Surg. 1997;10(5):305-10. doi: 10.1155/1997/10729
  18. Van Roessel S, Mackay TM, Tol JAMG, van Delden OM, van Lienden KP, Nio CY, Phoa SSKS, Fockens P, van Hooft JE, Verheij J, Wilmink JW, van Gulik TM, Gouma DJ, Busch OR, Besselink MG. Impact of expanding indications on surgical and oncological outcome in 1434 consecutive pancreatoduodenectomies. HPB (Oxford). 2019; 21(7):865-875. doi: 10.1016/j.hpb.2018.10.020
  19. Merath K, Mehta R, Tsilimigras DI, Farooq A, Sahara K, Paredes AZ, Wu L, Ejaz A, Pawlik TM. In-hospital Mortality Following Pancreatoduodenectomy: a Comprehensive Analysis. J Gastrointest Surg. 2020;24(5):1119-1126. doi: 10.1007/s11605-019-04307-9
  20. Kawaida H, Kono H, Hosomura N, Amemiya H, Itakura J, Fujii H, Ichikawa D. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol. 2019;25(28):3722-3737. doi: 10.3748/wjg.v25.i28.3722
  21. Olakowski M, Grudzińska E, Mrowiec S. Pancreaticojejunostomy-a review of modern techniques. Langenbecks Arch Surg. 2020;405(1):13-22. doi: 10.1007/s00423-020-01855-6
  22. Cao Z, Luo W, Qiu J, Liu Y, Zheng L, Zhang T. Is Invagination Anastomosis More Effective in Reducing Clinically Relevant Pancreatic Fistula for Soft Pancreas After Pancreaticoduodenectomy Under Novel Fistula Criteria: A Systematic Review and Meta-Analysis. Front Oncol. 2020;10:1637. doi: 10.3389/fonc.2020.01637
  23. Xiang Y, Wu J, Lin C, Yang Y, Zhang D, Xie Y, Yao X, Zhang X. Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature. Expert Rev Gastroenterol Hepatol. 2019;13(8):797-806. doi: 10.1080/17474124.2019.1640601
  24. Shevchenko TV, Gurmikov BN, Turchenko IA, Karmazanovsky GG, Stepanova YuA, Kovalenko YuA, Zhao AV, Kozlov IA, Ikramov RZ. The influence of the method of forming pancreaticodigestive anastomosis on the immediate results of pylorus-preserving pancreaticoduodenectomy. Klinicheskaya i eksperimental'naya hirurgiya. Zhurnal imeni akademika B.V. Petrovskogo. 2023; 11(3): 84-91. (in Russ.) doi: 10.33029/2308-1198-2023-11-3-84-91
  25. XY, Zhi XT. End-to-End Invaginated Pancreaticojejunostomy with Three Overlapping U-Sutures-A Safe and Simple Method of Pancreaticoenteric Anastomosis. J Invest Surg. 2015;28(2):115-9. doi: 10.3109/08941939.2014.982313
  26. Wang D, Liu X, Wu H, Liu K, Zhou X, Liu J, Guo W, Zhang Z. Clinical evaluation of modified invaginated pancreaticojejunostomy for pancreaticoduodenectomy. World J Surg Oncol. 2020;18(1):75. doi: 10.1186/s12957-020-01851-6
  27. Peng SY, Wang JW, Li JT, Mou YP, Liu YB, Cai XJ. Binding pancreaticojejunostomy--a safe and reliable anastomosis procedure. HPB (Oxford). 2004;6(3):154-60. doi: 10.1080/13651820410016598
  28. Shinde RS, Acharya R, Chaudhari VA, Bhandare MS, Shrikhande SV. Pancreaticojejunostomy for Pancreatico-enteric Anastomosis after Pancreaticoduodenectomy: one procedure with multiple techniques. Surgery in Practice and Science. 2020; 3: 100019. doi: 10.1016/j.sipas.2020.100019
  29. Hai H, Li Z, Zhang Z, Cheng Y, Liu Z, Gong J, Deng Y. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev. 2022;3(3):CD013462. doi: 10.1002/14651858.CD013462.pub2
  30. Zhang B, Li L, Liu H, Li L, Wang H, Li Y, Wang Y, Sun B, Chen H. A modified single-needle continuous suture of duct-to-mucosa pancreaticojejunostomy in pancreaticoduodenectomy. Gland Surg. 2023;12(12):1642-1653. doi: 10.21037/gs-23-340
  31. Sun Y, Yu XF, Yao H, Xu S, Ma YQ, Chai C. Safety and feasibility of modified duct-to-mucosa pancreaticojejunostomy during pancreatoduodenectomy: A retrospective cohort study. World J Gastrointest Surg. 2023;15(9):1901-1909. doi: 10.4240/wjgs.v15.i9.1901
  32. Kakita A, Takahashi T, Yoshida M, Furuta K. A simpler and more reliable technique of pancreatojejunal anastomosis. Surg Today. 1996;26(7):532-5. doi: 10.1007/BF00311562
  33. Blumgart LH, Fong Y. Surgery of the Liver and Biliary Tract. 3rd edn. M.: Saunders Co Ltd., New York. 2000; 2180.
  34. Gupta V, Kumar S, Gupta V, Joshi P, Rahul R, Yadav RK, Dangi A, Chandra A. Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes. Hepatobiliary Pancreat Dis Int. 2019;18(2):181-187. doi: 10.1016/j.hbpd.2019.01.007
  35. Li Z, Wei A, Xia N, Zheng L, Yang D, Ye J, Xiong J, Hu W. Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis. Sci Rep. 2020;10(1):17896. doi: 10.1038/s41598-020-74812-4
  36. Cao F, Tong X, Li A, Li J, Li F. Meta-analysis of modified Blumgart anastomosis and interrupted transpancreatic suture in pancreaticojejunostomy after pancreaticoduodenectomy. Asian J Surg. 2020;43(11):1056-1061. doi: 10.1016/j.asjsur.2020.01.011
  37. Ricci C, Ingaldi C, Alberici L, Pagano N, Mosconi C, Marasco G, Minni F, Casadei R. Blumgart Anastomosis After Pancreaticoduodenectomy. A Comprehensive Systematic Review, Meta-Analysis, and Meta-Regression. World J Surg. 2021;45(6):1929-1939. doi: 10.1007/s00268-021-06039-x
  38. PARANOIA Study Group; Writing committee; Pande R, Halle-Smith JM, Phelan L, Thorne T, Panikkar M, Hodson J, Roberts KJ; Steering committee; Arshad A, Connor S, Conlon KC, Dickson EJ, Giovinazzo F, Harrison E, de Liguori Carino N, Hore T, Knight SR, Loveday B, Magill L, Mirza D, Pandanaboyana S, Perry RJ, Pinkney T, Siriwardena AK, Satoi S, Skipworth J, Stättner S, Sutcliffe RP, Tingstedt B. External validation of postoperative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis. HPB (Oxford). 2022;24(3):287-298. doi: 10.1016/j.hpb.2021.10.006
  39. Yamamoto Y, Sakamoto Y, Nara S, Esaki M, Shimada K, Kosuge T. A preoperative predictive scoring system for postoperative pancreatic fistula after pancreaticoduodenectomy. World J Surg. 2011;35(12):2747-55. doi: 10.1007/s00268-011-1253-x
  40. Roberts KJ, Karkhanis S, Pitchaimuthu M, Khan MS, Hodson J, Zia Z, Mehrzad H, Marudanayagam R, Muiesan P, Isaac J, Mirza D, Sutcliffe RP. Comparison of preoperative CT-based imaging parameters to predict postoperative pancreatic fistula. Clin Radiol. 2016;71(10):986-992. doi: 10.1016/j.crad.2016.06.108
  41. Gagnière J, Abjean A, Franz M, Aumont O, Pereira B, Dupré A, Veziant J, Le Roy B, Boyer L, Pezet D, Buc E. A Normal Preoperative Lipase Serum Level Is an Easy and Objective Risk Factor of Pancreatic Fistula After Pancreaticoduodenectomy. Pancreas. 2017;46(9):1133-1140. doi: 10.1097/MPA.0000000000000905
  42. Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013 Jan;216(1):1-14. doi: 10.1016/j.jamcollsurg.2012.09.002
  43. Zhang W, Wei Z, Che X. Effect of polyglycolic acid mesh for prevention of pancreatic fistula after pancreatectomy: A systematic review and meta-analysis. Medicine (Baltimore). 2020;99(34):e21456. doi: 10.1097/MD.0000000000021456
  44. Deng Y, He S, Cheng Y, Cheng N, Gong J, Gong J, Zeng Z, Zhao L. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev. 2020;3(3):CD009621. doi: 10.1002/14651858.CD009621.pub4
  45. Andreasi V, Partelli S, Crippa S, Balzano G, Tamburrino D, Muffatti F, Belfiori G, Cirocchi R, Falconi M. A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy. HPB (Oxford). 2020;22(9):1227-1239. doi: 10.1016/j.hpb.2020.05.003
  46. Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, Yeo CJ, Fernandez-delCastillo C, Dervenis C, Halloran C, Gouma DJ, Radenkovic D, Asbun HJ, Neoptolemos JP, Izbicki JR, Lillemoe KD, Conlon KC, Fernandez-Cruz L, Montorsi M, Bockhorn M, Adham M, Charnley R, Carter R, Hackert T, Hartwig W, Miao Y, Sarr M, Bassi C, Büchler MW; International Study Group of Pancreatic Surgery (ISGPS). Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2017;161(5):1221-1234. doi: 10.1016/j.surg.2016.11.021
  47. Jiang Y, Chen Q, Wang Z, Shao Y, Hu C, Ding Y, Shen Z, Jin M, Yan S. The Prognostic Value of External vs Internal Pancreatic Duct Stents in CR-POPF after Pancreaticoduodenectomy: A Systematic Review and Meta-analysis. J Invest Surg. 2021;34(7):738-746. doi: 10.1080/08941939.2019.1691687
  48. Guo C, Xie B, Guo D. Does pancreatic duct stent placement lead to decreased postoperative pancreatic fistula rates after pancreaticoduodenectomy? A meta-analysis. Int J Surg. 2022;103:106707. doi: 10.1016/j.ijsu.2022.106707
  49. Chen K, Liu Z, Yang B, Ma Y, Zhang S, Shao Z, Yang Y, Tian X. Efficacy and safety of early drain removal following pancreatic resections: a meta-analysis. HPB (Oxford). 2023;25(5):485-496. doi: 10.1016/j.hpb.2023.02.005
  50. Wu AGR, Mohan R, Fong KY, Chen Z, Bonney GK, Kow AWC, Ganpathi IS, Pang NQ. Early vs late drain removal after pancreatic resection-a systematic review and meta-analysis. Langenbecks Arch Surg. 2023;408(1):317. doi: 10.1007/s00423-023-03053-6

Supplementary files

Supplementary Files
Action
1. JATS XML
Download
2. Fig. 1. Schematic representation of invagination pancreatojejunostomy: a – formation of the posterior lip of the anastomosis: fixation of the pancreatic capsule to the serous-muscular sheath of the small intestine (outer row), fixation of the pancreatic stump cut to the lumen of the small intestine (inner row); b – formation of the anterior lip of the anastomosis: fixation of the pancreatic capsule to the serous-muscular sheath of the small intestine (external row), fixation of the pancreatic stump cut to the lumen of the small intestine (internal row).

Download (281KB)
Indexing metadata
3. Fig. 2. Schematic representation of pancreatojejunostomy performed using the Peng technique: a – the stump of the intestine is turned out, the mucosa-submucosa layer is removed circularly, the cut of the stump of the pancreas is fixed to the capsule along the edge of the mucosa-submucosa layer; b – the small intestine stump is put on the PG, additional fixation to the capsule. The anastomosis is completed with a ligature through the opening of the intestinal mesentery.

Download (211KB)
Indexing metadata
4. Fig. 3. Schematic representation of pancreatojejunostomy performed using the «duct-to-mucosa» technique: a – formation of the posterior lip of the anastomosis, fixation of the stump of the pancreas to the small intestine. Separate stitching of the main pancreatic duct into the opening of the small intestine wall; b – formation of the anterior lip of the anastomosis. Sutures grasp the pancreatic capsule and the serous-muscular layer of the small intestine.

Download (286KB)
Indexing metadata
5. Fig. 4. Schematic representation of pancreatojejunostomy performed using the Kakita technique: a – suturing of the serous-muscular layer of the small intestine in the transverse direction, then stitches are passed through the entire thickness of the stump of the pancreas; b – approximation of the small intestine and pancreatic stump, suturing of the main pancreatic duct into the opening of the small intestine wall; c – formation of the anterior lip of the anastomosis. Sutures broadly grasp the serous-muscular layer of the small intestine and pass through the pancreatic parenchyma.

Download (393KB)
Indexing metadata
6. Fig. 5. Schematic representation of pancreatojejunostomy performed using the Blumgart technique: a – suturing of the small intestine serous-muscular layer in longitudinal direction, suturing through the parenchyma of the stump of the pancreas; b – approximation of the small intestine and the pancreatic stump, suturing of the main pancreatic duct into the opening of the small intestine wall; c – formation of the anterior lip of the anastomosis. Sutures are passed through the serous-muscular case of the small intestine in the transverse direction. When knots are tied, rolls of the serous-muscular layer of the small intestine are formed on the anterior and posterior lips of the anastomosis.

Download (409KB)
Indexing metadata

Copyright (c) 2025 Turchenko I.A., Shevchenko T.V., Stepanova Y.A., Ruzavin V.S., Popov A.Y., Gurmikov B.N.

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies