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JVS-708; No. of Pages 9 ARTICLE IN PRESS

Journal of Visceral Surgery (2017) xxx, xxx—xxx

Available online at

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SURGICAL TECHNIQUE

Pancreatico-jejunal anastomoses after

pancreatoduodenectomy
A. Sauvanet

Pôle des maladies de l’appareil digestif, service de chirurgie hépatobiliaire et pancréatique,

hôpital Beaujon, université Paris VII, 100, boulevard Général-Leclerc, 92110 Clichy, France

Introduction
After pancreatoduodenectomy (PD), complications related to the remnant body and tail
of the pancreas occur frequently, particularly if the pancreatic parenchyma is healthy
and the caliber of the pancreatic duct is small. Complications (including pancreatic fis-
tula, fluid collections and/or abscesses, sepsis, and hemorrhage) not only prolong the
duration of hospitalization, but may become life-threatening. The technical superiority of
pancreatico-jejunal anastomosis (the ‘‘historical’’ approach) versus pancreatico-gastric
anastomosis (more recently introduced) remains an unresolved question despite twenty
years of debate [1]. The aim of this presentation is to describe pancreatico-jejunal anas-
tomosis along with several described technical variations that aim to improve its results.

E-mail address: alain.sauvanet@aphp.fr

http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
1878-7886/© 2017 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Sauvanet A. Pancreatico-jejunal anastomoses after pancreatoduodenectomy. Journal
of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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1 Direct end-to-side anastomosis (the Cattell—Warren technique)

This anastomosis is end-to-side rather than end-to-end so that the size of the jejunotomy and the diameter of the
divided pancreatic stump will be congruent in all cases. The pancreatic stump must be mobilized for about 2 cm to the left.
Hemostasis of the pancreatic stump is obtained by electrocoagulation or preferably by monofilament suture ligation, and
must be meticulous along the posterior surface and divided parenchyma of the gland before placement of the posterior row
of sutures. Division and suture ligation of the dorsal pancreatic artery and/or inferior pancreatic artery facilitate both the
mobilization and hemostasis.
The anastomosis is performed with monofilament polypropylene suture, which is less traumatizing to the pancreas than
braided suture; the suture caliber is 4-0 or 5-0 depending on the consistency of the pancreatic parenchyma. Suturing com-
mences with the posterior row [2]. If the parenchyma is firm and Wirsung’s duct is dilated, there is very little risk of stricture
of the anastomosis and it is then both safe and quicker to use a running suture. Placement of sutures from back to front
lessens the risk of venous injury during placement of the posterior row and of stricture during placement of the anterior
row. This simple technique is often useful when there is upstream pancreatitis above a tumor or chronic pancreatitis, which
entails very little risk of fistula. In such cases, placement of peri-pancreatic drains depends on the surgeon’s judgment.

Please cite this article in press as: Sauvanet A. Pancreatico-jejunal anastomoses after pancreatoduodenectomy. Journal
of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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Pancreatico-jejunal anastomoses after pancreatoduodenectomy 3

2 anastomosis
End-to-side duct-to-mucosa

The difficulty of performing a direct anastomosis when the

caliber of the pancreatic duct is small and the parenchyma
non-fibrotic has led to the development of a four-layer
anastomosis (anterior and posterior layers approximating
the seromuscular layer of the jejunum and the pancreatic
capsule, and anterior and posterior layers between the pan-
creatic duct and jejunal mucosa). For this technique, very
precise suture placement using fine monofilament is neces-
sary, and the use of simple interrupted sutures is preferable
to a running suture, at least for the mucosa-to-mucosa layer
[3]. The anastomosis begins with placement of the posterior
seromuscular-to-pancreatic capsular layer.
A small 2—3 mm jejunotomy is then made at a point where
the jejunum will lie easily against the pancreatic duct
without tension. The posterior mucosa-to-mucosa layer is
constructed with interrupted sutures with the knots tied on
the outside. A internal stenting drain (cf. Section 4) can
then be placed to facilitate the placement of the anterior
mucosa-to-mucosa layer.
The anterior inner row is performed placing all the sutures
first and tying them only after assuring that none of the
sutures transfix the drain. The anterior outer row between
the pancreatic capsule and the jejunal seromuscular layer
completes the anastomosis.
This technique is particularly useful when the parenchyma
of the pancreatic remnant is normal, which entails a high
risk of pancreatic fistula. In these cases, placement of
peri-pancreatic drains is indicated. The superiority of the
mucosa-to-mucosa anastomosis over direct anastomosis has
not been demonstrated [3].

Please cite this article in press as: Sauvanet A. Pancreatico-jejunal anastomoses after pancreatoduodenectomy. Journal
of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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3 invagination
End-to-side anastomosis with
(‘‘Dunking’’)
The rationale of this technique is to limit the extension of
an eventual pancreatic fistula beyond the two anterior and
posterior capsular layers of the divided pancreas by con-
taining them with two supplementary anastomotic layers
(anterior and posterior) between the jejunal sero-muscular
layer and the pancreatic capsule [4]. At least 3 cm of the
pancreatic remnant must be mobilized, which sometimes
requires mobilization of the first portion of the splenic
artery; meticulous hemostasis of the posterior aspect of
the pancreatic remnant is essential. The anastomosis begins
with the most posterior layer approximating the pancre-
atic capsule 5—10 mm back from the transected edge to
the jejunum halfway between the mesenteric and anti-
mesenteric borders to avoid needle injury to the bowel vasa
recti. Interrupted sutures are necessary to guarantee good
positioning of the jejunum; completion of the posterior layer
should result in an invagination of the pancreas above and
below the isthmus.
The second anastomotic layer is made between the poste-
rior edge of the transected pancreas and the jejunum, which
is opened along a distance less than that of the pancreatic
stump. If possible, the sutures should encompass the full
thickness of the transected pancreas from capsule to duct,
although this may be difficult at the cranial and caudal bor-
ders, even with the use of 3/8 circle needles. In such cases,
the needle should encompass the capsule and as much of
the parenchyma as possible, counting on the posterior and
anterior suture layers that include the ductal wall to keep
the duct open. This anterior layer constitutes the third row.
The fourth row approximates the jejunal sero-muscular
layer to the pancreatic capsule 5—10 mm back from the pre-
vious layer, first at the cranial and caudal borders, and then
along the anterior face of the pancreas. It is safer to place
all the sutures before tying them down in order to avoid
creating a jejunal dog-ear. The sutures should purchase the
jejunum where it will come to lie easily against the pan-
creas with minimal tension; the sutures are tightened down
and knotted with care to avoid all tension on the pancreatic
capsule, particularly if the gland has a fatty consistency. A
randomized study has shown that invagination of the anasto-
mosis is superior to simple mucosa-to-mucosa approximation
[4].

Please cite this article in press as: Sauvanet A. Pancreatico-jejunal anastomoses after pancreatoduodenectomy. Journal
of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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Pancreatico-jejunal anastomoses after pancreatoduodenectomy 5

4 Intubated anastomosis with an internalized pancreatic drain

This technique consists of introducing a 5—10 cm long multi-perforated tube drain (a segment of a small caliber
catheter or ureteral catheter) into Wirsung’s duct over a distance of 2—3 cm, with suture fixation to the transected pancreas
with an absorbable suture; the other end of the tube lies free in the downstream jejunum below the anastomosis. This
technique can complement any of the previously described anastomoses. If the intra-pancreatic segment is too long, this
may increase the risk that the catheter does not migrate downstream with possible symptomatic obstruction of the drain.
While this type of stenting drain does not necessarily decrease the risk of fistula development, it certainly decreases the
risk of an anastomotic stenosis due to poor suture technique.

Please cite this article in press as: Sauvanet A. Pancreatico-jejunal anastomoses after pancreatoduodenectomy. Journal
of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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5 Intubated anastomosis with an externalized pancreatic drain

In this technique, Wirsung’s duct is intubated by a multi-perforated silicone drain affixed to both the pancreas and
to the jejunal wall. It is easier to insert this drain after completion of the posterior row of the anastomosis. The drain is
exteriorized through a downstream jejunal pursestring and transcutaneous stab wound according to the Völker technique or
through the blind end of the upstream jejunal segment if there is enough slack to bring this to the abdominal wall without
tension. This allows drainage of part or all of the pancreatic secretions while the anastomosis is healing, as long as the drain
is well fixed in place and is not kinked. Once anastomotic healing has taken place, the drain can be clamped, leaving the
option of re-opening the tube to drainage if a late fistula develops. Typically, the drain is removed 6—8 weeks after the PD;
several randomized studies and a meta-analysis [5,6] have demonstrated that externalized drainage of the pancreatic duct
is effective in decreasing the risk of pancreatic fistula.

Please cite this article in press as: Sauvanet A. Pancreatico-jejunal anastomoses after pancreatoduodenectomy. Journal
of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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Pancreatico-jejunal anastomoses after pancreatoduodenectomy 7

6 (Blumgart
Anastomosis with transfixing suture
technique)
This technique creates a duct-to-mucosal anastomosis in
association with a mattressed reinforcement of the jejunum
around the pancreatic body while completing hemostasis
of the pancreas by placement of transfixing sutures that
include the full thickness of the pancreatic parenchyma [7].
Three cm of the pancreatic body must be mobilized. Double-
armed 3/8 circle needles are required. The anastomosis
begins with U-shaped mattress sutures that transfix the
full thickness of the pancreatic parenchyma, purchase the
jejunal wall between the mesenteric and anti-mesenteric
borders (taking care to avoid occluding the lumen of the
duct) and then return through the full thickness of the pan-
creas. The sutures are not tied immediately but are retained
in order on hemostats. After the jejunum and the pancreatic
body have been approximated, a small 2—3 mm enterotomy
is made in the jejunal wall at a point that can be brought to
Wirsung’s duct without tension. The duct-to-mucosal anas-
tomosis is then performed with interrupted sutures that are
then tied down while assuring that the permeability of the
duct is not compromised.
The transfixing sutures that encompassed the full thickness
of the pancreatic parenchyma are then tied down in contact
with the anterior capsule. They are then passed as mattress
sutures through the jejunal wall and tied to approximate
the jejunum to the anterior capsule of the pancreas. All
sutures are placed before they are tied down against the full
thickness of the pancreas. This mattressing effect can then
be completed by several simple sutures along the cranial
and caudal borders of the anastomosis. The effectiveness
of this technique has been suggested by comparative non-
randomized studies [7].

Please cite this article in press as: Sauvanet A. Pancreatico-jejunal anastomoses after pancreatoduodenectomy. Journal
of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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8 A. Sauvanet

7 (Peng
Anastomosis with intussusception
technique)
The aim of this technique is to minimize the risk of fistula by
limiting capsular trauma due to passage of sutures in combi-
nation and by invagination of 3 cm of the pancreatic stump
within the jejunal lumen.
The water-tightness of the anastomosis is ensured by delib-
erate injuries to the jejunal mucosa to stimulate rapid
adherence to the pancreatic capsule followed by circumfer-
ential suturing [8]. The pancreatic stump is mobilized for a
distance of 4 cm with meticulous hemostasis. A 3 cm length
of the jejunal wall is everted and the exposed mucosa is
destroyed using phenol, absolute alcohol or bipolar electro-
cautery.
An anastomosis is performed between the pancreatic cap-
sule and the jejunal mucosa beyond the area of mucosal
destruction at the apex of the invagination. The pancreatic
capsule is also abraded in order to favor the formation of
adhesive scarring.
The everted jejunal wall is then ‘‘dis-invaginated’’ allowing
it to cover the pancreatic capsule over a distance of 3 cm;
the free edge of the jejunum is then affixed to the pan-
creatic capsule with several interrupted superficial sutures.
Good results with this technique have been reported only by
the surgical team that originally described it [8].

8 Roux-en-Y
Pancreatic anastomosis to a
jejunal limb
The Roux-en-Y montage isolates the pancreatic anastomosis
from the other anastomoses in order to avoid any biliary
component and to decrease the volume of flow in case a
fistula develops. The bile duct and stomach are anastomosed
into a separate jejunal limb. The efficacy of this montage
has not been demonstrated [9].

Please cite this article in press as: Sauvanet A. Pancreatico-jejunal anastomoses after pancreatoduodenectomy. Journal
of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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JVS-708; No. of Pages 9 ARTICLE IN PRESS
Pancreatico-jejunal anastomoses after pancreatoduodenectomy
Disclosure of interest
The author declare that he has no competing interest.
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of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.06.003
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