Extended pancreatic transection for secure pancreatic reconstruction during pancreaticoduodenectomy

Abstract

Backgrounds/aims: Pancreaticoduodenectomy (PD) is associated with various surgical complications including healing failure of the pancreaticojejunostomy (PJ). This study intended to ensure blood supply to the pancreatic stump through extended pancreatic transection (EPT).

Methods: This study assessed whether EPT reduces PJ-associated complications and whether EPT is harmful on the remnant pancreatic function. The EPT group included 19 patients undergoing PD, pylorus-preserving PD (PPPD) or hepatopancreaticoduodenectomy. The propensity score matched control group included 45 patients who had undergone PPPD. Pancreatic transection was performed at the level of the celiac axis in the EPT group, by which the pancreatic body was additionally removed by 3 cm in length comparing with the conventional pancreatic transection.

Results: A small invagination fissure suspected as the embryonic fusion site was identified at the ventro-caudal edge of the pancreatic body in all patients undergoing EPT. A sizable fissure permitting easy separation of the pancreatic parenchyma was identified in 15 of 19 patients (78.9%). The incidence of significant postoperative pancreatic fistula was significantly lower in the EPT group than in the control group (p=0.047). There was no significant increase in the postoperative de novo diabetes mellitus in EPT group (p=0.60).

Conclusions: The EPT technique contributes to the prevention of major pancreatic fistula without impairing remnant pancreatic function. EPT is feasible for routine clinical application or at least in patients with any known risk of PJ leak.

Keywords: Complication; Pancreatic leak; Pancreaticojejunostomy.

Figures

Fig. 1. Case 1 details. A 57-year-old male patient undergoing pylorus-preserving pancreaticoduodenectomy with extended pancreatic transection technique for distal bile duct cancer. (A) An invagination fissure (arrow) is identified. (B) The pancreatic body was transected at the celiac axis level. (C) A small pancreatic duct located at the center of the pancreatic stump was identified. (D) Duct-to-mucosa pancreaticojejunostomy was performed.

Fig. 2. Case 2 details. A 62-year-old male patient undergoing hepatopancreaticoduodenectomy including right hepatectomy, caudate lobectomy, pylorus-preserving pancreaticoduodenectomy with extended pancreatic transection technique, and portal vein resection and interposition graft for intrahepatic cholangiocarcinoma. (A) An invagination fissure (arrow) is identified. (B) The pancreatic body was transected at the celiac axis level.

Fig. 3. Computed tomography follow-up of case 1. (A) Preoperative image shows abundant pancreatic parenchyma with a small pancreatic duct. (B) Post-operation 1-week image shows secure attachment of the jejunal limb wall at the pancreatic stump.

Fig. 4. Computed tomography follow-up of case 2. (A) Preoperative image shows abundant pancreatic parenchyma with a small pancreatic duct. (B) Post-operation 1-week image shows secure attachment of the jejunal limb wall at the pancreatic stump. (C) Post-operation 1-year image shows intact perfusion status of the remnant pancreas with mild pancreatic parenchymal atrophy.