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  Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 1  |  Page : 48-52  

Binding pancreaticojejunostomy: Is it safe?


Department of Surgery, Government Medical College and Hospital, Chandigarh, India

Date of Submission13-Apr-2019
Date of Decision20-Jul-2019
Date of Acceptance14-Sep-2019
Date of Web Publication10-Feb-2020

Correspondence Address:
Dr. Sanjay Gupta
Department of Surgery, Government Medical College and Hospital, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njs.NJS_17_19

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  Abstract 


Background: Postoperative pancreatic fistula (POPF) or leak from pancreaticojejunostomy (PJ) is one of the most common complications after pancreaticoduodenectomy (PD), with an incidence of 5%–30%. Various techniques have been advocated to bring down the incidence of POPF, but there is still none that can be called the “gold standard”. Peng's binding PJ (BPJ) was proposed as a good method of performing PJ with low fistula rates; we present our results with BPJ. Methods: The data of all patients who underwent PD with BPJ between January 2016 and March 2018 were retrospectively analyzed for demographics, clinical features, type of procedure performed, complications (especially POPF), hospital stay, morbidity, and mortality. Results: A total of 24 patients (18 males and 6 females) were identified. The mean age at the diagnosis was 65.5 ± 6.4 years. Majority of the patients had ampullary carcinoma (62.5%). The most common postoperative complication was delayed gastric emptying seen in 10 patients, whereas only 2 (8.33%) had POPF and there was one mortality. Conclusion: BPJ is safe and is associated with a low incidence of POPF.

Keywords: Pancreatic fistula, pancreaticoduodenectomy, pancreaticojejunostomy


How to cite this article:
Gupta S, Attri AK, Sharma R, Gureh M, Nasir MI. Binding pancreaticojejunostomy: Is it safe?. Niger J Surg 2020;26:48-52

How to cite this URL:
Gupta S, Attri AK, Sharma R, Gureh M, Nasir MI. Binding pancreaticojejunostomy: Is it safe?. Niger J Surg [serial online] 2020 [cited 2020 Nov 27];26:48-52. Available from: https://www.nigerianjsurg.com/text.asp?2020/26/1/48/277958




  Introduction Top


Pancreaticoduodenectomy (PD) is still the best option for resectable carcinoma head of the pancreas or periampullary region and is also indicated for some benign lesions involving duodenum or pancreas. With improvement in surgical technique and better perioperative management, the procedure-related mortality has come down to <5%.[1] However, this procedure is often associated with complications such as pancreatic fistula (PF), delayed gastric emptying (DGE), pulmonary complications, intra-abdominal abscess, pancreatitis, and hemorrhage.[2] Of these, postoperative PF (POPF) or leak from pancreaticojejunostomy (PJ) is the most common and most feared complication. It is also considered the initial event that initiates a cascade, leading to other complications.[3] The incidence of POPF, as reported by various series ranges from 5% to 30%.[4] To minimize the incidence of POPF, various techniques using different segments of the gastrointestinal tract, fibrin glue, pancreatic duct stenting, and somatostatin analogs have been reported in the literature,[5] but an ideal technique to prevent PF is still not available.

Binding PJ (BPJ) as a technique for performing PJ was first described and published by Peng et al. in a series of 150 patients where they did not encounter even a single case of POPF.[6],[7] Going by their encouraging results, our unit also switched to BPJ from conventional two-layered PJ, and the present series reflects our experience with the same.


  Materials and Methods Top


The data of all patients who underwent PD between January 2016 and March 2018 were retrieved. These patients were assessed for demographics, complications (especially POPF), postoperative hospital stay, and mortality.

Operative technique

BPG was done according to the technique described by Peng et al.[8] – after resection, the proximal portion of the remnant pancreas was mobilized for at least 3 cm off the splenic vessels [Figure 1]. The cut end of the jejunum was everted using three 2-0 silk sutures taken approximately 6 cm from the cut end to have 3 cm of the everted jejunal mucosa. The everted jejunum was isolated from the rest of the abdominal viscera using surgical pads, and its mucosa was fulgurated using a swab soaked in 10% carbolic acid until it was whitish and discolored. The jejunal stump was then cleansed with normal saline and brought close to the mobilized pancreatic stump. Using 3-0 polydioxanone, the mucosa of jejunum was sutured to the posterior margin of the pancreatic stump in a continuous manner, with a few sutures passing through the lumen of the duct posteriorly [Figure 2]. After the completion of this layer, the everted jejunum was rolled over the pancreatic stump all around, and the margins of the everted jejunum were sutured to the pancreas using 3-0 polyglactin suture. A silk suture was then passed through the mesentery of the small bowel leaving distal 1–2 vessels and tied around the anastomosis gently just to approximate the jejunal mucosa with the pancreatic surface [Figure 3]. Hepaticojejunostomy and gastrojejunostomy were done to the same jejunal loop distal to PJ. Tube drain was placed in all cases near the PJ site.
Figure 1: Mobilized pancreatic stump

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Figure 2: Approximation of the jejunal loop to pancreatic stump

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Figure 3: Completed binding pancreaticojejunostomy

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Postoperative management

Oral intake was allowed on the 3rd postoperative day. As per our protocol, drain fluid amylase was assessed only if drain output was more than 50 ml after the 3rd postoperative day. Somatostatin or analogs were not administered, either preoperatively or postoperatively. Complications such as POPF and DGE were defined as per the criteria laid down by the International Study Group on Pancreatic Fistula.[9],[10]


  Results Top


A total of 24 patients (18 males and 6 females) underwent BPJ, with a mean age of 65.5 ± 6.4 years at the diagnosis. Most of our patients who underwent PD had ampullary carcinoma (62.5%), probably due to high unresectability rate associated with pancreatic head carcinoma on presentation.[11] The overall morbidity and mortality associated with PD were 41.6% and 4.1% in our hands, respectively [Table 1] and [Table 2]. The average duration of postoperative stay was 15 ± 3 days.
Table 1: Patients characteristics

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Table 2: Postoperative outcome

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The most common complication encountered was DGE (41.6%), with most patients having Grade A DGE (8 patients). All patients with DGE responded to conservative treatment (nasogastric tube insertion and prokinetics). POPF was seen in only two patients (8.3%). Both of these patients had Grade B POPF, drain output more than 100 ml after the 3rd postoperative day, and their drain fluid amylase level was found to be more than three times the normal serum amylase level – none of these patients required any intervention and drain was removed on the 8–10th POD. One of these had a pus collection in the lesser sac (probably due to contained leak from PJ) which was drained under ultrasound guidance.

Other complications that were documented included wound infection (3), pancreatitis (2), and pulmonary infection (3). One patient died of multi-organ failure on the 7th postoperative day, the exact cause of which could not be ascertained. Postoperative CT did not show any collection, and drain output was also <50 ml/day with amylase level 30 IU/l (normal serum level 23–125 IU/L).


  Discussion Top


POPF contributes significantly to postoperative morbidity and mortality after PD.[12] To reduce the rate of POPF, various techniques have been developed and compared from time to time, such as invagination versus duct to mucosa anastomosis, PJ versus pancreaticogastrostomy, dual-loop with isolated PJ, gastric partition technique, pancreatic duct stenting, fibrin glue, and use of somatostatin analogs.[3],[5] Among the various available pancreatic-enteric anastomotic techniques, PJ is the most commonly practiced, usually performed as duct to mucosa or end-to-side invagination in single or two layers but is still associated with a POPF rate of 6%–24%.[13],[14] However, to date, no technique has been found to be superior over another, and it is difficult to recommend any specific technique in a given situation to decrease the incidence of POPF.[3] In addition to operative technique, the risk of developing POPF is related to various patient-related perioperative and intraoperative factors and is significantly dependent on texture of the pancreatic parenchyma, type of pathology (pancreatic adenocarcinoma/pancreatitis or other), duct diameter, and intraoperative blood loss.[15]

Binding type of PJ was first described by Peng et al. when they reported a remarkable nil PF rate in 150 consecutive patients who underwent BPJ.[7] This was further substantiated with a randomized controlled study on 217 patients, comparing conventional PJ (end-to-end two-layered anastomosis) with BPJ.[16] To explain their low leak rate after BPJ, they hypothesized that their technique caused less injury to the pancreatic parenchyma and ductules, thereby leading to less leak of pancreatic juice and autodigestion around the anastomosis.[16] In addition, chemical cauterization of the jejunal mucosa with carbolic acid promotes adhesion between the jejunal mucosa and pancreatic surface leading to a more secure PJ.[16] Since then, a number of studies have been done to study the efficacy of BPJ [Table 3];[8],[12],[16],[17],[18],[19],[20],[21],[22] none except for Kim et al. could reproduce similar results.[17] However, the majority of studies (except for Morggiori)[19] observed that the incidence of POPF was either less or comparable to conventional PJ. Buc et al. found that BPJ is safe and better technique even in high-risk patients, i.e., in the presence of nondilated duct and soft pancreatic remnant.[18] It was only the series by Morggiori et al. that reported a contrary opinion that BPJ was associated with higher leak rate (36% vs. 28%) and a high incidence of postpancreatectomy hemorrhage (27% vs. 0%) as compared to conventional PJ.[19] Difference in the definition of POPF as adopted by various authors and exposure of large pancreatic surface to the jejunal lumen were given as plausible reasons for increased incidence of POPF and PPH in this series.
Table 3: Outcome of various studies after binding pancreaticojejunostomy

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Although ours is a small series, we found our results to be comparable to most of the reported series; of the 24 patients who underwent BPJ, there were only two cases of POPF (8.33%). Other complications after PD with BPJ were also comparable to conventional PD with PJ, similar to the results published in a recent meta-analysis by Zhang et al. who also found that BPG is comparable to conventional PJ in terms of incidence of POPF, DGE, postpancreatectomy hemorrhage, morbidity, mortality, operation time, blood loss, blood transfusions, and hospital stay.[5]

Although BPJ appears to be promising, the procedure has its own limitations. It is technically more demanding – the pancreatic stump needs to be mobilized further after resection of the specimen, and it can be difficult to perform if there is a significant discrepancy between the size of the pancreas stump and the jejunal lumen. Correct placement, as well as tightening of the binding ligature, is also very important – if it is too tight, it can compromise duct lumen as well as the vascularity of the pancreatic stump, whereas if it is loosely kept, it can compromise anastomotic integrity; incorrect placement of the binding suture can lead to mesenteric ischemia.[16] Thus, the outcome with BPJ can vary depending on the experience of the surgeon and the intraoperative scenario.

A number of other variants of classical invaginating PJ such as “colonial wig” and “serous touch” have been described in the literature. The reported incidence of POPF with these techniques varies from 0% to 15%.[23],[24] Despite multiple randomized studies and meta-analyses, there are still no clear guidelines on how to construct an ideal pancreatico-enteric anastomosis. No technique has been found to be superior to the other, and ISGPS in its position statement on pancreatic anastomosis concluded that it is not the technique, but the practice of a standardized technique that can decrease the rate of clinically relevant POPF.[3] The same holds true for BPJ – though our initial results with BPJ are comparable to other techniques, we believe that consistent practice can further bring down the incidence of POPF in our hands.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yoshioka R, Yasunaga H, Hasegawa K, Horiguchi H, Fushimi K, Aoki T, et al. Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy. Br J Surg 2014;101:523-9.  Back to cited text no. 1
    
2.
Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience. J Gastrointest Surg 2006;10:1199-210.  Back to cited text no. 2
    
3.
Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, et al. Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the international study group of pancreatic surgery (ISGPS). Surgery 2017;161:1221-34.  Back to cited text no. 3
    
4.
Hackert T, Werner J, Büchler MW. Postoperative pancreatic fistula. Surgeon 2011;9:211-7.  Back to cited text no. 4
    
5.
Zhang X, Dong X, Liu P, Yan Y, Wei Y, Zechner D, et al. Binding versus conventional pancreaticojejunostomy in preventing postoperative pancreatic fistula: A systematic review and meta-analysis. Dig Surg 2017;34:265-80.  Back to cited text no. 5
    
6.
Peng S, Mou Y, Cai X, Peng C. Binding pancreaticojejunostomy is a new technique to minimize leakage. Am J Surg 2002;183:283-5.  Back to cited text no. 6
    
7.
Peng SY, Mou YP, Liu YB, Su Y, Peng CH, Cai XJ, et al. Binding pancreaticojejunostomy: 150 consecutive cases without leakage. J Gastrointest Surg 2003;7:898-901.  Back to cited text no. 7
    
8.
Peng SY, Wang JW, Li JT, Mou YP, Liu YB, Cai XJ. Binding pancreaticojejunostomy – A safe and reliable anastomosis procedure. HPB (Oxford) 2004;6:154-60.  Back to cited text no. 8
    
9.
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005;138:8-13.  Back to cited text no. 9
    
10.
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the international study group of pancreatic surgery (ISGPS). Surgery 2007;142:761-8.  Back to cited text no. 10
    
11.
Denbo JW, Fleming JB. Definition and management of borderline resectable pancreatic cancer. Surg Clin North Am 2016;96:1337-50.  Back to cited text no. 11
    
12.
Casadei R, Ricci C, Silvestri S, Campra D, Ercolani G, D'Ambra M, et al. Peng's binding pancreaticojejunostomy after pancreaticoduodenectomy. An Italian, prospective, dual-institution study. Pancreatology 2013;13:305-9.  Back to cited text no. 12
    
13.
Yang YM, Tian XD, Zhuang Y, Wang WM, Wan YL, Huang YT. Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenterol 2005;11:2456-61.  Back to cited text no. 13
    
14.
Bassi C, Falconi M, Molinari E, Mantovani W, Butturini G, Gumbs AA, et al. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: Results of a prospective randomized trial. Surgery 2003;134:766-71.  Back to cited text no. 14
    
15.
Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2013;216:1-4.  Back to cited text no. 15
    
16.
Peng SY, Wang JW, Lau WY, Cai XJ, Mou YP, Liu YB, et al. Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized trial. Ann Surg 2007;245:692-8.  Back to cited text no. 16
    
17.
Kim SJ, Lee DH, Kim JG, Lee KJ. Binding pancreaticojejunostomy compared with dunking pancreaticojejunostomy. Korean J Hepatobiliary Pancreat Surg 2009;13:286-94.  Back to cited text no. 17
    
18.
Buc E, Flamein R, Golffier C, Dubois A, Nagarajan G, Futier E, et al. Peng's binding pancreaticojejunostomy after pancreaticoduodenectomy: A French prospective study. J Gastrointest Surg 2010;14:705-10.  Back to cited text no. 18
    
19.
Maggiori L, Sauvanet A, Nagarajan G, Dokmak S, Aussilhou B, Belghiti J. Binding versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: A case-matched study. J Gastrointest Surg 2010;14:1395-400.  Back to cited text no. 19
    
20.
Silvestri S, Garino M, Campra M, Cassine D, Franchello A, Gennaro C, et al. Preliminary experience with binding pancreaticojejunostomy. Eur J Surg Oncol 2010;36:1031.  Back to cited text no. 20
    
21.
Targarona J, Barreda L, Pando E, Barreda C. Is peng's pancreaticojejunal anastomosis more effective than mucosa-mucosa anastomosis in duodenopancreatectomy for pancreatic and peri-ampullary tumours? Cir Esp 2013;91:163-8.  Back to cited text no. 21
    
22.
Kim JM, Hong JB, Shin WY, Choe YM, Lee GY, Ahn SI. Preliminary results of binding pancreaticojejunostomy. Korean J Hepatobiliary Pancreat Surg 2014;18:21-5.  Back to cited text no. 22
    
23.
Yang X, Aghajafari P, Goussous N, Patel ST, Cunningham SC. The “Colonial wig” pancreaticojejunostomy: Zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2017;16:545-51.  Back to cited text no. 23
    
24.
Watanobe I, Kawai M, Miyano S, Kosaka T, Machida M, Kitabatake T, et al. Pancreaticojejunostomy using a technique of invagination anastomosis (end-to-side anastomosis) without stenting for soft pancreas. HPB 2014;18:428.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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