Application of Simplified Stent-bridging Pancreaticogastrostomy in Open Pancreaticoduodenectomy

Application of Simplified Stent-Bridging Pancreaticogastrostomy in Open Pancreaticoduodenectomy.Introduction. Pancreaticoduodenectomy, PD, has shown progressive outcomes. Nevertheless, it continues to pose certain challenges due to its inherent complexity.

Clinically relevant postoperative pancreatic fistula, POPF, may lead to intra-abdominal infection, hemorrhage, and potentially life-threatening outcomes. The surgeons have increasingly recognized the importance of an evidence-based reconstructive approach, improving patient outcomes and advancing clinical standards to minimize the risks of POPF. Among various pancreatic anastomoses in Pancreaticojejunostomy, PJ, or pancreaticogastrostomy, PG, studies failed to demonstrate significant difference in outcomes.

The single or double layer invaginating PG anastomosis, where the remnant pancreatic stump is inserted into the gastric cavity with an external stent is the preferred variant in PG.However, this method entails risks of stent slipping out or occlusion. The use of internal stents entails the risk of migration in up to 17%of patients, and biodegradable internal stents are rather unsuccessfully. The potential mechanism underlying POPF mainly comprise minor leakage of sutures, poor blood supply at the anastomosis site, anastomotic tension, and anastomotic delay healing.

Also suture material induced changes in the pancreas similar to those of accurate pancreatitis, which supports the rationale for using thinner or fewer sutures. In this video case presentation, we present the stent-bridging PG, which utilizes an appropriately-sized polyethylene catheter to bridge the Wirsung duct and the stomach, aiming to simplify reconstruction and facilitate controlled pancreatic juice diversion. For soft pancreas with small duct diameters an improved peridural catheter is utilized.

However, the clinical evidence regarding the stent is not yet entirely clear. The anastomoses over internal or externalized stents depend on the surgeon. The issue of the long-term follow-up for the internal stents still needs to be addressed and further clinical validation in a randomized setting is necessary.Protocol.

Ethics approval is not required for this procedure as part of routine clinical care. Informed consent is obtained from the individual participant in the study. The patient is a 70-year-old female diagnosed with a pancreatic head malignancy, presented with progressive jaundice, which remained painless for three months.

Preoperative contrast-enhanced CT scan reveals a pancreatic head malignancy involving the descending section of the adjacent duodenum and the portal vein, superior mesenteric vein. The patient is a 70-year-old female with a pancreatic malignancy presenting with progressive jaundice, remained painless for three months. Contrast-enhanced CT showed a pancreatic malignancy involving of the descending section of adjacent duodenum and portal vein, superior mesenteric vein, as well as atrophy of the pancreatic body and tail, dilation of the pancreatic duct and intrahepatic and extrahepatic bile ducts.

Following open subtotal stomach-preserving pancreaticoduodenectomy, the subsequent phase involves simplified stent-bridging pancreaticogastrostomy, PG.The pancreatic stump was isolated for two centimeter to facilitate the stent-bridging PG.A compatible polyethylene catheter, usually 6 to 10 French with lateral orifices was positioned in the Wirsung duct, aiming to direct the pancreatic juice into the gastric lumen. Continuous suture of the pancreatic stump was performed to achieve remnant hemostasis and secure the pancreatic duct stent. The Wirsung duct and the stent were closely tied with nonabsorbable suture crossing the pancreatic parenchyma for the sake of prevention of stent dislodging and of pancreatic leakage.

A full-layer hole approximately equivalent to the caliber of the Wirsung duct was made on the poster wall of the stomach directly above the pancreatic stump to ensure a tight bridging. Two seromuscular purse-string sutures were applied around the incision for fixation. The distal end of the stent was inserted into the gastric lumen as an internal drainage.

The stomach was pulled down to fixed closely, adjacent to the pancreatic remnant. The two purse-string sutures were tightened with proper tension to prevent pancreatic stent occlusion. Thus, the procedure of the stent-bridging PG completed.

Two easy-flow drains were placed in the proximity of the pancreatic and biliary anastomoses. The pancreatic stump and the gastric wall were drawn close and the relatively short length of sinus allows the gastric wall as a serosal envelope to protect the anastomosis. The omental flap, along with portions of peritoneal fat was utilized to localize the anastomotic site to completely drain the pancreatic fluid in case of pancreatic leakage.

The postoperative CT scan confirmed optimal positioning and the secure fixation of the stent with no evidence of fluid around the anastomosis, peripancreatic exudation or pancreatic duct dilation. The operation time was six hours with 100 milliliter blood loss. The patient's postoperative course was uncomplicated.

No pancreatic leak was detected. The intra-abdominal drains were removed at postoperative day five and the patient discharged on postoperative day eight. Pathology revealed a three-centimeter pancreatic poor to moderate differentiated adenocarcinoma, R0 resection, and 22 negative lymph nodes with one malignancy.

The novel approach of the stent-bridging PG demonstrated its potential as a standardized pancreatic anastomosis in pancreaticogastrostomy.