Pancreaticoduodenectomy: Pancreaticogastrostomy
Laureano Fernández-Cruz
DEFINITION
Pancreaticogastrostomy (PG) is defined as the anastomosis of the remnant pancreas to the stomach rather than a limb of jejunum. This procedure is necessary following pancreaticoduodenectomy or central pancreatectomy.
DIFFERENTIAL DIAGNOSIS
PG is a viable option regardless of the indication for pancreatic resection requiring reconstruction.
PG may be a particularly attractive option for patients with intraductal papillary mucinous neoplasms (IPMN). In these patients, the rationale for surgical intervention is reduction of risk for malignant transformation. Many surgeons advocate partial pancreatectomy for IPMN, trading the risk of progression of disease in the remnant against the brittle diabetes associated with total pancreatectomy. However, this approach mandates surveillance of the pancreatic remnant. PG theoretically provides straightforward access to the remnant duct to facilitate this surveillance, but clinical benefit has not been proven.
PG should also be considered for reconstruction of the distal, remnant pancreas in the rare situation that central pancreatectomy is performed. PG avoids the need for creation of a Roux limb, and although complications of this component of intestinal reconstructions are rare, they do occur.
PATIENT HISTORY AND PHYSICAL FINDINGS
Pancreatic fistula has a central role in the development of other intraabdominal complications and occurs with a frequency of 5% to 30%.1,2 Risk factors for pancreatic fistula include a soft pancreas, a small pancreatic duct, the underlying pathology, reduced regional blood supply, and the surgeon’s experience.3,4 Thus, patient factors impact the risk of pancreatic fistula.
SURGICAL MANAGEMENT
Preoperative Planning
Efforts to reduce the rate of pancreatic fistula have encompassed the consideration of replacing the pancreaticojejunal (PJ) anastomosis with PG.
The lack of a uniform technique for performing PG has led to the same debate as that regarding the PJ anastomosis (duct-to-mucosa, invagination, or telescoping the pancreatic remnant into the gastric cavity).
At present, there is still no consensus on the choice of anastomotic technique (PJ vs. PG). There have been four prospective randomized controlled trials (RCTs) comparing PJ with PG.3,5, 6, 7 Three RCTs5, 6, 7 showed similar pancreatic fistula rates for the two types of pancreatic anastomosis: 12%, 16%, and 13% for PG and 11%, 21%, and 16%, respectively, for PJ. In one recent RCT,3 the pancreatic fistula rate was significantly lower after PG (4%) compared with that after PJ (18%).
PG has been gaining favor in recent years. Of historical interest, the clinical introduction of this procedure originated when Waugh and Claggett8 reported it in 1946.
TECHNIQUES
TELESCOPIC INVAGINATION
Delcore et al.2 reported a method of PG in which the pancreatic remnant was telescoped into the gastric lumen (a small gastrotomy is made in the posterior gastric wall) without any stenting of the main pancreatic duct.
PG is performed either through the transected gastric stump prior to gastrojejunostomy or through an anterior wall gastrotomy (in the case of a pylorus-preserving procedure) (FIG 1).
The most important technical aspect of this anastomosis is establishing adequate mobilization of the remnant pancreatic body and tail. At least 3 cm is required, but greater mobilization is not discouraged provided it does not compromise perfusion.
A posterior, transverse gastrotomy is created. Attention to the size of the gastrotomy is paramount and should take the elastic nature of the stomach into consideration. The need to dilate the gastrotomy to accommodate the pancreatic remnant is a welcome finding.
A generous longitudinal, anterior gastrotomy is performed directly opposite of the posterior gastrotomy to provide access to the lumen side of the PG. (Alternatively, the staple line from the antrectomy that will be used for a subsequent gastrojejunostomy is removed.)
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