Modified Blumgart Mattress Suture Versus Conventional Interrupted Suture in Pancreaticojejunostomy During Pancreaticoduodenectomy: Randomized Controlled Trial

Seiko Hirono, Manabu Kawai, Ken-Ichi Okada, Motoki Miyazawa, Yuji Kitahata, Shinya Hayami, Masaki Ueno, Hiroki Yamaue, Seiko Hirono, Manabu Kawai, Ken-Ichi Okada, Motoki Miyazawa, Yuji Kitahata, Shinya Hayami, Masaki Ueno, Hiroki Yamaue

Abstract

Objective: This study used a randomized controlled trial (RCT) to evaluate whether mattress suture of pancreatic parenchyma and the seromuscular layer of jejunum (modified Blumgart method) during pancreaticojejunostomy (PJ) decreases the incidence of clinically relevant postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD).

Background: Several studies reported that mattress suture of Blumgart anastomosis in PJ could reduce POPF rate. This, however, is the first RCT.

Methods: Between June, 2013 and May, 2017, 224 patients scheduled for PD were enrolled in this study in Wakayama Medical University Hospital. Enrolled patients were randomized to either interrupted suture or modified Blumgart mattress suture. The primary endpoint was the incidence of grade B/C POPF based on the International Study Group on Pancreatic Fistula criteria. This RCT was registered with ClinicalTrials.gov (NCT01898780).

Results: Patients were randomized to either interrupted suture (103 patients) or modified Blumgart mattress suture (107 patients) and were analyzed by intention-to-treat. Grade B/C POPF occurred in 7 patients (6.8%) in the interrupted suture group and 11 (10.3%) in the mattress suture group (P = 0.367). Mortality within 90 days was 0 in both groups. There were no significant differences in all postoperative complications between the interrupted suture group and the modified Blumgart mattress suture group.

Conclusions: Mattress suture of pancreatic parenchyma and the jejunal seromuscular layer during PJ (modified Blumgart technique) did not reduce clinically relevant POPF compared with interrupted suture.

Conflict of interest statement

All authors declare no conflict of interest concerning this study.

Figures

FIGURE 1
FIGURE 1
(A) Interrupted suture method. (i) The jejunal seromuscular layer was approximated to the pancreatic parenchyma of the stump with interrupted penetrating sutures, using 4–0 MONOFLEN. (ii) Anastomosis was performed in a duct-to-mucosa fashion using a single layer of interrupted 5–0 double-armed, polydioxanone suture (PDS-II). (iii) After a 5-Fr polyethylene pancreatic stent tube was placed at the pancreaticojejunal anastomotic site during duct-to-mucosa anastomosis, suture of pancreatic parenchyma and seromuscular layer of jejunum was tied. (B) Modified Blumgart mattress suture method; transpancreatic suture starts from anterior to posterior, straight through the pancreas using 4–0 MONOFLEN. Suture was placed through the seromuscular layer of jejunal posterior wall from back to front in the direction of short axis, followed by replacement of mattress suture from front to back of posterior wall of the jejunum in the direction of the short axis, and then a full thickness pancreas bite from posterior to anterior was performed (i). Anastomosis between the pancreatic duct and mucosal layer of the jejunum was then performed (ii), and then after completion of duct-to-mucosa anastomosis and placement of internal stent, sutures were placed through the seromuscular layer of jejunal anterior wall in the direction of short axis (iii). This procedure completely covered the pancreatic stump with jejunal serosa (iv).
FIGURE 2
FIGURE 2
(A) Computed tomography (CT) finding around pancreaticojejunostomy (PJ) on postoperative day 4. We measured maximal area of interspace between the cut surface of the pancreas and jejunal wall (B) and maximal areas of intra-abdominal fluid collection around the pancreatic anastomosis at the PJ by CT findings (C).
FIGURE 3
FIGURE 3
Consort flow diagram for the trial.
FIGURE 4
FIGURE 4
Receiver-operating characteristics analyses for prediction of grade B/C postoperative pancreatic fistula (POPF) by assessment of maximal area of intra-abdominal fluid collection around the pancreatic anastomosis (A) and maximal area of interspace between pancreas and jejunum at pancreaticojejunostomy (B). The area under the curve (AUC) of intra-abdominal fluid collection was 0.873 and AUC of interspace between pancreas and jejunum was 0.756.

References

    1. McPhee JT, Hill JS, Whalen GF, et al. Perioperative mortality for pancreatectomy: a national perspective. Ann Surg 2007; 246:246–253.
    1. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. New Engl J Med 2009; 361:1368–1375.
    1. Kimura W, Miyata H, Gotoh M, et al. A pancreaticoduodenectomy risk model derived from 8575 cases from a national single-race population (Japanese) using a web-based data entry system. Ann Surg 2014; 259:773–780.
    1. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017; 161:584–591.
    1. Tani M, Kawai M, Hirono S, et al. Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy. Br J Surg 2014; 101:1084–1091.
    1. Keck T, Wellner UF, Bahra M, et al. Pancreatogastrostomy versus pancreatojejunostomy for RECOnstruction after PANCreatoduodenectomy (RECOPANC, DRKS 0000767). Ann Surg 2016; 263:440–449.
    1. Buren II GV, Bloomston M, Hughes S, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg 2014; 259:605–612.
    1. Bai X, Zhang Q, Gao S, et al. Duct-to-mucosa vs invagination for pancreaticojejunostomy after pancreaticoduodenectomy: a prospective, randomized controlled trial from a single surgeon. J Am Coll Surg 2016; 222:10–18.
    1. Nakeeb AE, Hemaly ME, Askr W, et al. Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized study. Int J Surg 2015; 16:1–6.
    1. Fernandez-Cruz L, Cosa R, Blanco L, et al. Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy. A prospective randomized study. Ann Surg 2008; 248:930–938.
    1. Topal B, Fieuws S, Aerts R, et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial. Lancet Oncol 2013; 14:655–662.
    1. Figueras J, Sabater L, Planellas P, et al. Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy on the rate and severity of pancreatic fistula after pancreaticoduodenectomy. Br J Surg 2013; 100:1597–1605.
    1. Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995; 222:580–592.
    1. Bassi C, Falconi M, Molinari E, et al. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy. Results of a comparative study. Ann Surg 2005; 242:767–773.
    1. Duffas JP, Suc B, Msika S, et al. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg 2005; 189:720–729.
    1. Wellner UF, Sick O, Olscheqski M, et al. Randomized controlled single-center trial comparing pancreatogastrostomy versus pancreaticojejunostomy after partial pancreatoduodenectomy. J Gastrointest Surg 2012; 16:1686–1695.
    1. Tani M, Kawai M, Hirono S, et al. A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy. Am J Surg 2010; 199:759–764.
    1. Jang JY, Kim SW, Choi SH, et al. Randomized multicentre trial comparing external and internal pancreatic stenting during pancreaticoduodenectomy. Br J Surg 2016; 103:668–675.
    1. Motoi F, Egawa S, Rikiyama T, et al. Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. Br J Surg 2012; 99:524–531.
    1. Warren KW, Cattell RB. Basic techniques in pancreatic surgery. Surg Clin Nortb Am 1956; 36:707–724.
    1. Kakita A, Takahashi T, Yoshida M, et al. A simple and more reliable technique of pancreatojejunal anastomosis. Surg Today 1996; 26:532–535.
    1. Brennan M. Blumgart LH, Fong Y. Pancreaticojejunostomy. Surgery of the liver and biliary tract 3rd ed.Philadelphia: Saunders; 2000. 1073–1089.
    1. Grobmyer SR, Kooby D, Blumgart LH, et al. Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications. J Am Coll Surg 2010; 210:54–59.
    1. Kleespies A, Rentsch M, Seeliger H, et al. Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection. Br J Surg 2009; 96:741–750.
    1. Fujii T, Sugimoto H, Yamada S, et al. Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study. J Gastrointest Surg 2014; 18:1108–1115.
    1. Oda T, Hashimoto S, Miyamoto Y, et al. The tight adaptation at pancreatic anastomosis without pancrenchymal laceration: an institutional experience in introducing and modifying the new procedure. World J Surg 2015; 39:2014–2022.
    1. Neychev VK, Saldinger PF. Minimizing shear and compressive stress during pancreaticojejunosotmy. Rationale of a new technical modification. JAMA Surg 2014; 149:203–207.
    1. Kawai M, Tani M, Hirono S, et al. Pylorus ring resection reduces delayed gastric emptying in patients undergoing pancreatoduodenectomy. A prospective, randomized, controlled trial of pylorus-resecting versus pylorus-preserving pancreatoduodenectomy. Ann Surg 2011; 253:495–501.
    1. Hirono S, Kawai M, Tani M, et al. Indication of the use of an interposed graft during portal vein and/or superior mesenteric vein reconstruction in pancreatic resection based on perioperative outcomes. Langenbecks Arch Surg 2014; 399:461–471.
    1. Tani M, Terasawa H, Kawai M, et al. Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy. Results of a prospective, randomized, controlled trial. Ann Surg 2006; 243:316–320.
    1. Kawai M, Tani M, Terasawa H, et al. Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection. Prospective study for 104 consecutive patients. Ann Surg 2006; 244:1–7.
    1. Shimizu A, Kawai M, Hirono S, et al. Postoperative visceral tissue assessed by computed tomography is a predictor for severe complications after pancreaticoduodenectomy. J Gastrointest Surg 2018; 22:77–87.
    1. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142:761–768.
    1. Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142:20–25.
    1. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of survey. Ann Surg 2004; 240:205–213.
    1. Bassi C, Molinari E, Malleo G, et al. Early versus late drain removal after standard pancreatic resection: Results of a prospective randomized trial. Ann Surg 2010; 252:207–214.
    1. Tranchart H, Gaujoux S, Rebours V, et al. Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy. Ann Surg 2012; 256:139–145.
    1. Ahmad SA, Edward MJ, Sutton JM, et al. Factors influencing readmission after pancreaticoduodenectomy: a multi-institutional study of 1302 patients. Ann Surg 2012; 256:529–537.
    1. Tani M, Onishi H, Kinoshita H, et al. The evaluation of duct-to-mucosal pancreaticojejunostomy in pancreaticoduodenectomy. World J Surg 2005; 29:76–79.

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다