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Abstract

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Medicine

Colonial Wig Pancreaticojejunostomy

Published: March 12th, 2019

DOI:

10.3791/58142

1Department of Surgery, Saint Agnes Hospital

We describe a new technique for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy that is associated with a very low rate of postoperative pancreatic fistula.

Postoperative pancreatic fistula (POPF) is one of the most problematic complications after pancreaticoduodenectomy (PD). We describe a series of 48 pancreatic-head resections from our institution, in which we compare a new technique to create the pancreaticojejunostomy (PJ) reconstruction with standard techniques. The goal is to achieve a lower rate of POPF. This new PJ is termed the "Colonial Wig" (CW) PJ due to the novel appearance of the jejunum wrapping around the pancreas, resembling a Colonial wig wrapping around the head of a Colonial Whig (e.g., George Washington). In our consecutive series, 22 cases were performed using the new CW technique to perform the PJ and were compared to 26 traditional PDs with traditional reconstruction. There was an incidence of clinically relevant POPF of 0% in the CW group, compared to 15% in 26 conventional PJs. Our proposed CW PJ reconstruction is associated with a lower the incidence of POPF following PD, and hence may be a way to improve outcomes after PD.

Postoperative pancreatic fistula (POPF) is described as the Achilles' heel of pancreaticoduodenectomy (PD) with an incidence rate ranging between 4–36%1,2,3. The goal of the presently described method of pancreaticojejunostomy (PJ), termed the "Colonial Wig" (CW), is to lower the rate of POPF following PD.

The morbidity of POPF is variable and it can range from being asymptomatic (Grade A, or clinically insignificant biochemical leak) to being symptomatic, causing deviation in the postoperative management, requiring percutaneous, ....

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This study was approved by the Ethics Committee (Institutional Review Board) of Saint Agnes Hospital (No. 2016-020).

1. Preparations

  1. Preoperatively, give 5,000 units of heparin subcutaneously to prevent deep venous thrombosis prophylaxis, and give antibiotics per the hospital's surgical care improvement project (SCIP) policy, such as 2 g of cefazolin and 500 mg of metronidazole.
  2. Place an epidural as discussed with the anesthesia team for optimal postoperativ.......

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Perioperative data are found in our original publication on this procedure.9 Briefly, the POPF rate for the first 26 (control) PDs was 27%. There were 3 (12%) grade-A (clinically insignificant) fistulas, 4 (15%) grade-B, and 0 grade-C fistulas. This clinically relevant POPF (CR-POPF) rate (grade B + grade C) was 15%. In the next 22 CW PJs, however, the CR-POPF rate was 0 (P = 0.052, by Chi-square test) among eligible cases. There was one grade-A POPF in the CW.......

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There are many descriptions of novel PJs reported in the literature. It is generally true that the more ways that exist to perform a given task, the less likely there is a single perfect way to do it. This is likely accurate for PJ reconstruction as well. Each of the multiple different PJ techniques reported reports a low incidence of POPF. Nevertheless, POPF continues to be considered the "Achilles heel" of PD and more work is therefore needed to find a better way to construct this anastomosis.

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We thank Anne M Sill, MSHS, GME Research Coordinator and Department Statistician for careful review of the statistics, and acknowledge Xihua Yang, MD, Pouya Aghajafari, MD, and Pouya Aghajafari, MD, for their contributions as co-authors on the original paper reporting this technique9.

....

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Name Company Catalog Number Comments
French eye needle, tapered Anchor Products Co Inc, Addison, IL 1861-2dc 
Garrett dilator Medline, Northfield, IL MDS2040030
Octreotide Sagent, Schaumburg, IL 2055879
Pasireotide Curascript SD, Grove City , OH 246492

  1. DeOliveira, M. L., et al. Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Annals of Surgery. 244, 931-939 (2006).
  2. Grobmyer, S. R., Kooby, D., Blumgart, L. H., Hochwald, S. N. Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications. Journal of the American College of Surgeons. 210, 54-59 (2010).
  3. Fuji, T., et al. Modified Blumgart anastomosis for pancreaticojejunostomy: Technical improvement in matched historical control study. Journal of Gastrointestinal Surgery. 18, 1108-1115 (2014).
  4. 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. 161, 584-591 (2016).
  5. Callery, M. P., Pratt, W. B., Kent, T. S., Chaikof, E. L., Vollmer, C. M. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. Journal of the American College of Surgeons. 216, 1-14 (2013).
  6. Miller, B. C., et al. A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy. Journal of Gastrointestinal Surgery. 18, 172-179 (2014).
  7. Goussous, N., Patel, S. T., Cunningham, S. C., Cameron, J. L., Cameron, A. Bile-Duct Cancer. Current Surgical Therapy, 12th ed. , (2016).
  8. Cho, A., et al. Performing simple and safe dunking pancreaticojejunostomy using mattress sutures in pure laparoscopic pancreaticoduodenectomy. Surgical Endoscopy. 28, 315-318 (2014).
  9. Yang, X., Aghajafari, P., Goussous, N., Patel, S. T., Cunningham, S. C. The "Colonial Wig" pancreaticojejunostomy: zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy. Hepatobiliary and Pancreatic Disease International. 16 (5), 545-551 (2017).
  10. Cameron, J. L., Sandone, C. . Atlas of Gastrointestinal Surgery, Vol 2/Edition 2. , (2014).
  11. Grobmyer, S. R., Kooby, D., Blumgart, L. H., Hochwald, S. N. Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications. Journal of the American College of Surgeons. 210 (1), 54-59 (2010).

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