Lap. PD reconstruction?

Hong-Jin Kim M.D.,PhD.,FACS

Professor and Director
Department of HBP Surgery,
Yeungnam University Hospital, Daegu, Korea
 Introduction

1. First described in 1994 by Gagner and Pomp as a feasible procedure

Contributing factors for recent increase of Lap PD:

1. Successful application of laparoscopy to other complex abd . Op.
2. Availability of newer technologies, such as da Vinci surgical system
3. Surgeons motivation to pursue innovation

Postop. PF. is leading morbidity after Lap. PD.

Pancreatic anastomotic method is associated with postop. PF.
Pancreaticoduodenectomy

Walter Kausch (1867-1928); First performed the successful PD

Cholecystojejunostomy
Jejunojejunostomy
using Murphy button
June 15, 1909 Kausch, wife & his son
Kausch himself died from
Pulmonary embolism
2 months on the twelfth day
after appendectomy

Resection of the The patient died of

duodenum & adjacent pancreas 9
Pancreatoduodenostomy
mo
Gastrojejunostomy
August 21, 1909
jaundice and sepsis
secondary to stricture
of cholecystojejuno-
stomy site
Drainage Procedure

Pancreaticojejunostomy
Richard Bartley Cattell

In 1947,
First performed lateral PJ
For relief of pain Achilles of PD !!
Pancreas head cancer pt.
 Pancreaticojejunostomy
l most commonly used method
l End-to side Vs end-to-end
l Duct-to-mucosa Vs dunking

Important three conditions

for successful pancreaticojejunostomy
l Tension-free & secure anastomosis

l Adequate blood supply of the pancreas stump and the jejunal end

l An anobstructed passage of pancreatic secretions into the jejunum

Types of reconstruction in laparoscopic PD
Pancreatico-enteric anastomosis

Dunking method Duct to mucosa method

 Choledocho-enteric anastomosis

Interrupted method Continuous method

 Duodeno/gastro-jejunostomy

Intracorporeal Extra-tracorporeal
Management of gastric/duodenal stump in laparoscopic PD
Study characteristics
Surgical anastomosis technique and definition of pa
ncreatic fistula
The effects of P G vs P-J after PD
Postoperative pancreatic fistula rate of ISGPF definition
 Advantages of PG vs PJ

Gastric acid alone is unable to activate pancreatic zymogens

Absence of intestinal enterokinase and bile

The NG tube may drain the gastric and pancreatic secretions

Tension-free environment for the anastomosis to heal.

Anastomosis with the posterior wall of the proximal stomach. aw

ay from the skeletonized major blood vessels
Reducing the chances of vascular corrosion
BJS 2014; 101: 11961208
 Reconstruction Method of YUMC

1. Continuous suturing of pancreas posterior rim and jejunal s

erosa by 5-0 polypropylene
2. Duct to mucosa suture by 6-0 PDS
(4-6 interrupted sutures with external drain)
3. Continuous suturing of pancreas anterior rim and jejunal s
erosa by 5-0 plypropylene
4. External drainage by 3.5-5F infant feeding catheter
5. Fibrin glue application
 Conclusions

1. PG is better than PJ on RCT for PF.

but currently mostly PJ!

2. Enetric anastomosis: which you prefer?

3. Surgeons preference; Do you want to change?

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