Colonial Wig Pancreaticojejunostomy

This is a novel method of pancreaticojejunostomy, the one part of a pancreaticoduodenectomy reconstruction that is still plagued with a high leak rate. The main advantages of this technique are that it is easy to perform, learn and teach, and that it has a very low associated leak rate. Demonstrating this procedure with me will be Dr.Shirali Patel, another pancreatic and hepatobiliary surgeon.

First, perform a pancreaticoduodenectomy according to standard protocols. When the pancreas is visible, place four full thickness transpancreatic 3-0 silk stay sutures on the superior and inferior edges of the pancreas and then divide the pancreatic neck between the sutures. Then place a crile clamp on each of the silk sutures and complete the resection in standard fashion.

After removal of the specimen, dissect the posterior surface of the pancreas free from the retroperitoneum for several centimeters and then bring the stapled end of the jejunum into position. To create the anastomosis, first use two 3-0 silks to place the colonial wig sutures. For the first one, take a generous seromuscular anti-mesenteric bite through the jejunum one to two centimeters from the staple line and then a full thickness bite through the pancreas a few centimeters from the cut surface of the pancreas at the inferior border of the pancreas.

The other 3-0 silk colonial wig sutures should join the superior border of the pancreas and the anti-mesenteric jejunum about six centimeters distal to the first one. Use electrocautery to make an approximately two centimeter jejunotomy along the anti-mesenteric border of the jejunum, just large enough to accommodate the pancreas remnant but no bigger. Leaving the colonial wig sutures untied, place two 3-0 silk horizontal outer sutures between the posterior pancreas and the posterior jejunum about one to 1.5 centimeters from the jejunotomy and about 1.5 to two centimeters from the cut surface of the pancreas.

Use a 3-0 Vicryl suture with a straightened needle to place one new suture through the full thickness of the anterior portion of the jejunotomy into the lumen and then through the pancreas superior to the pancreatic duct about one centimeter from the cut surface and just a few millimeters from the superior border of the pancreas. Next, take a full thickness bite through the posterior wall in to out of the jejunum. And with the needle at the bottom of the U, turn the needle 180 degrees to reverse the path.

Now while traveling posterior to anterior and taking a full thickness bite through the pancreas just superior to the pancreatic duct, use a metallic probe in the pancreatic duct to make sure that the needle does not puncture the duct. Finally, take a full thickness in to out bite through the anterior jejunum. Then place a second new suture in a similar fashion but inferior to the pancreatic duct, taking care not to include the pancreatic duct in the suture and again to encompass most of the pancreatic parenchyma inferior to the duct.

Now attach a French eye needle to the previously placed stay stitches on the pancreatic remnant and take a full thickness bite in to out through the jejunum. Do this with both tails of both stay sutures. Apply gentle tension to a tail of the U suture to be sure that it pulls or saws easily back and forth demonstrating that the U suture follows a direct path posterior through the jejunum, pancreas and jejunum, again back up through the jejunum, pancreas and jejunum, and that the pancreas is deeply invaginated in the jejunum.

Do not overdo this. And then tie the U sutures, the stay sutures, and the colonial wig sutures. If the stay sutures do not adequately dunk the corners of the pancreatic cut surface, an additional stay suture can be placed to better invaginate and secure the corners deep within the jejunotomy.

The jejunum should now look much like a colonial wig fitted snugly around the sides of a colonial wig's head. To provide the final outer layer, place several interrupted 3-0 silk sutures very closely together in a vertical fashion between the anterior surface of the pancreatic remnant and the cut edge of the jejunum to hermetically seal the redundant cuff of jejunum. Now wrap the pancreaticojejunostomy anastomosis with a harvested tongue of healthy omentum.

Here the harvested tongue of omentum is sutured in place with 3-0 silk sutures and then place zero, one or two 19 French round fluted drains depending on surgeon preference and fistula risk. Then perform the remainder of the reconstruction as previously described. At the end of the procedure, extubated when the patient is stable from a hemodynamic and respiratory standpoint and admit the patient to the intensive care unit for overnight close monitoring.

In this series, there were three grade A clinically insignificant fistulas, four grade B and zero grade C clinically relevant post-operative pancreatic fistulas in the control pancreatoduodenectomy group. In the colonial wig pancreaticojejunostomy group, the clinically relevant post-operative pancreatic fistula rate was zero among the eligible cases with one grade A post-operative pancreatic fistula in the colonial wig group. The lower post-operative pancreatic fistula rate in the colonial wig group was not due to the presence of lower risk glands in that group and the two groups were similar regarding other important parameters such as gland texture, pancreatic duct diameter, distribution of pathologies and estimated blood loss.

While attempting this procedure, it is important to remember that the best anastomosis may be the one that you are most comfortable performing.