Pancreaticojejunostomy
Carlos Fernandez-del Castillo, MD
' anagement of the pancreatic remnant following pan-
M .creatoduodenectomy has been the subject of many
publications and controversies. Ligation of the pancreatic
duct without anastomosis was once used extensively, but
was associated with an inordinately high rate of fistula for-
mation and has been largely abandoned. 1,2 Some groups in
Europe have successfully occluded the pancreatic duct with
prolamine or neoprene, 3'4 but this remains an uncommon
technique. Drainage of the pancreatic remnant into the gas-
trointestinal tract is the preferred approach.
The pancreaticoenteric anastomosis can be performed
in many ways. Variations include drainage into the stom-
ach or the jejunum, a duct-to-mucosa or an intussuscep-
ted anastomosis, use of the side or the end of the j e j u n u m
or isolated loops of bowel, and use of stents. 2'5-7 Propo-
nents of the various techniques base their preference on
From Massachusetts General Hospital and Harvard Medical School, Boston,
MA.
Address reprint requests to Carlos Fern~mdez-del Castillo, MD, Associate Pro-
fessor of Surgery, Massachusetts General Hospital and Harvard Medical School, 15
Parkman St, ACC/336, Boston, MA 02114.
Copyright 9 2001 by W.B. Saunders Company
1524-153X/0U0301-0004535.00/0
doi:10.1053/otgn.2001.21895
Operative T e c h n i q u e s in General Surgery, Vol 3, No 1 (March), 2001: pp 45-53
increased safety, decreased rate of fistula, or ease of per-
formance.
Our preferred approach has been a stented end-to-side
duct-to-mucosa pancreaticojejunostomy. In our experi-
ence, this is technically feasible in more than 96% of
patients. In the rare patient with a duct smaller than 1.5
mm, or even no duct that can be identified, we use an
invaginated end-to-end anastomosis.
Besides being an integral aspect of reconstruction after
pancreatoduodenectomy, pancreaticojejunostomy is also
used following middle segment pancreatectomy. This is a
less common operation, usually reserved for benign cystic
lesions or islet cell tumors located in the neck or proximal
body of the pancreas, s After resection, the cephalic end is
oversewn, and the remaining distal pancreas is anasto-
mosed to the jejunum.
45
46 Carlos Fernandez-del Castillo

SURGICAL TECHNIQUE

1 The pancreatic duct is identified within the transected pancreas. Its diam-
eter varies from 1.5 m m to more than 1 cm, depending on the underlying
pathology. Using 5-0 absorbable multifilament, stitches are placed into the duct
lumen, first at the 12 o'clock radius, then at the 9 and 3 o'clock radii, and then
two more between these (at the 10:30 and 1:30 radii). The needles are left in
place, and the layer of sutures is covered with a towel. For small ducts, 5-0
Vicryl (Ethicon, Inc., Somerville, NJ) with a very small needle (TF) is useful.
Pancreaticojejunostomy 47

2 A small incision is made in the antimesenteric border of the jejunum, a few centime-
ters proximal to the distal stapled end, which has been invaginated with 3-0 silk. A Jake-
Schnidt clamp is then introduced through the incision and brought out through the
anterior wall of the jejunum to grab the end of the pancreatic stent. We use a #5 pediatric
feeding tube as the stent.
48 Carlos Fernandez-del Castillo

i /:

3 The stent is delivered through the anumesenteric incision and kept aside.
Pancreaticoj ejunostomy 49

4 The posterior row of sutures, both inner and outer, are placed. 3-0 silk sutures are used for the
outer layer, from the posterior capsule of the pancreas to the seromuscutar layer of the jejunum.
Usually three or four sutures are placed before the level of the pancreatic duct is reached. Placement
of the pancreatic duct sutures are then completed (at the 4:30, 6, and 7:30 o'clock radii), with the full
thickness of the jejunum taken under the stent. The remaining posterior outer layer of silk stitches are
placed and all posterior sutures are tied and cut, except for the corners, which are left in place.
50 Carlos Fernandez-del Castillo

.\

5 The stent is introduced into the pancreatic duct and advanced until resistance is felt.
It is then withdrawn two or three centimeters, and fixed at its exit from the jejunum with
4-0 catgut.
Pancreaticoj ejunostomy 51

6 The anterior inner layer is completed by taking the previously placed sutures of the
pancreatic duct through the jejunum. When dealing with a small pancreatic duct, the
pancreatic stent is particularly useful for this step, because it ensures that the posterior wall
of the jejunum is not taken inadvertently with the sutures. The sutures are then tied and cut.
52 Carlos Fern~mdez-delCastillo

!!

7 The anastomosis is completed with 3-0 silk sutures from the capsule of the pancreas to the jejunum.
Usually six sutures are sufficient. If the resection was a pancreatoduodenectomy, then an end-to-side
bilioenteric anastomosis is constructed upstream from the pancreatojejunostomy.

Postoperative Care
In the past, pancreatoduodenectomy was associated with
inordinately high mortality rates, with many deaths di-
rectly or indirectly related to failure of the pancreaticoen-
teric anastomosis. Pancreatic fistula commonly led to sep-
sis, intraabdominal hemorrhage, and the need for further
intervention. 2,9
The morbidity and mortality of pancreatic resection
has decreased over the last 20 years, and several large
series have described pancreatoduodenectomy mortality
rates below 2%. l~ Although the rate of pancreatic fis-
tula has also decreased, fistula still occurs in 6% to 18% of
patients. 7"12'13 But the consequences of leakage from the
pancreatic anastomosis are less serious today, and the vast
majority of patients are treated conservatively with drain
management alone.
It is our practice at the conclusion of the operation to
place two flat Jackson-Pratt drains in the vicinity of the
biliary and pancreatic anastomoses, one anterior to and
one posterior to the jejunal loop. On the fifth postopera-
tive day, we measure the amylase level in the drainage. If
this level is less than three times the normal serum value,
and the fluid is nonbilious, we remove one drain that
same day and the remaining one the day after. If the
amylase level is high and the drainage output is less than
30 mL per day, we also remove the drain. If both the
amylase and output are high, we wait until the seventh
postoperative day to start advancing the drains, usually 2
cm per day. We believe that drain advancement allows for
gradual closure of the fistula. It is quite possible that the
presence of the drain with negative suction in the vicinity
of the anastomosis may be responsible for some pancre-
atic fistulae; however, this has proven to be a safe ap-
proach, and drain placement is routine in our practice.
In a recent 10-year experience at the Massachusetts
General Hospital with 489 pancreatoduodenectomies,
the rate of pancreatic fistula formation was 11%. 14 Al-
though pancreatic fistula proved to be an independent
predictor of a longer postoperative stay, 50 of 56 fistulae
Pancreaticojejunostomy
closed spontaneously with drain advancement; only five
required percutaneous drain placement, and one necessi-
tated reoperation for the fistula.
The use of octreotide to inhibit pancreatic secretion
and thus decrease the rate of pancreatic fistula is contro-
versial. Although several European series have shown its
utility 15'16 and one meta-analysis suggested that it is a
cost-effective strategy, 17 two North American studies have
shown no effect, and in fact one showed an increase (albeit
insignificant) in the rate of complications. 18'19 We do not
use somatostatin analogues prophylactically, and use them
only rarely in the management of established fistulae.
We routinely use a #5 pediatric feeding tube as a stent
for the pancreaticojejunostomy. This tube is brought out
through a separate stab w o u n d in the j e j u n u m and then
through the abdominal wall. We remove the stent in the
office during the first postoperative visit, usually two to
three weeks after surgery. The stent facilitates suture
placement of the anastomosis, particularly the anterior
wall, w h e n the duct is small. It also diverts pancreatic
juice away from the anastomosis, and thus perhaps con-
tributes to a decreased fistula rate.
Long-term complications following pancreaticojeju-
nostomy are rare. We have seen three cases of pancreatitis
occurring between eight months and two years after the
pancreatoduodenectomy, all of which had evidence of an
obstructed anastomosis. One was treated endoscopically,
one required surgical revision, and the other is being
managed expectantly.
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53
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