Vol.2, No.3, 195-199 (2010)
Copyright © 2010 SciRes Openly accessible at http://www.scirp.org/journal/HEALTH/
The reconstruction after pylorus preserving
pancreatoduodenectomy: pancreatogastrostomy with
Roux-en-Y reconstruction versus conventional Traverso
type reconstruction
Joji Yamamoto, Yoshiaki Shimizu, Motoki Nagai, Harufumi Makino, Shigehiro Kojima, Yuuki Ozamoto
Department of Surgery, Kamagaya General Hospital, Chiba, Japan
Received 16 October 2009; revised 11 January 2010; accepted 15 January 2010.
Objective: To compare the result of pancreato-
gastrostomy (PG) with Roux-en-Y reconstruc-
tion versus pancreatojejunostomy (PJ) with
conventional Traverso-type reconstruction fol-
lowing pylorus-preserving pancreatectomy (PP-
PD) in a retrospective study. PPPD has been
accepted as a radical surgical treatment for ma-
lignant periampullary neoplasms. However, the
reconstruction of this surgery is technically
complicated. The leakage of pancreatic juice
and the delayed gastric emptying are the major
complications of PPPD and may be fatal. To
solve these problems, we have performed PG
with Roux-en-Y anastomosis. There are several
techniques proposed the reconstruction after
PPPD, however there have been no previous
study describing the result of PG with Roux-
en-Y anastomosis. Since 2002 we have perfor-
med 32 cases of PPPD. They were divided into
two groups according to the reconstruction
procedures: PG with Roux-en-Y reconstruction
(group PG-RY) (17 cases) and pancreatojeju-
nostomy with Traverso-type reconstruction
(group PJ-T) (15 cases). Results: Patient age,
gender, and underlying disease were compara-
ble among the groups. Two groups showed no
differences in intraoperative bleeding amount,
and the time of surgery. The occurrence of the
pancreatic leakage was significantly reduced in
the group PG-RY compared with the group PJ-T.
There was no case of the delayed gastric emp-
tying in the group PGRY. Conclusions: Pan-
creatogastrosotmy with Roux-en-Y anastomosis
can reduce the occurrence of the pancreatic
leakage and delayed gastric emptying following
pylorus-preserving pancreatoduodenectomy.
Keywords: Pancreatoduodenectomy;
Pancreatogastrostomy; Roux-en-Y Reconstruction;
Pancreatojejunostomy; Traverso-Type Reconstruction
Since Traverso and Longmire reported the validity of
pylorus-preserving pancreatoduodenectomy (PPPD) for
benign pariampullary disease in 1978, this procedure has
been practiced and accepted as a radical treatment for
periampullary neoplasm. The 1999 National Survey of
Pancreatic Cancer in Japan showed that PPPDs were
performed in 42.6% of the periampullary cancers [1].
Recent advantages in surgical technique has reduced
operative mortality after this procedure, however, the rate
of post-operative complications is still high. The most
frequent and severe complication is the leakage of pan-
creatic juice. The delayed gastric emptying (DGE) is a
unique and frequent complication of PPPD. In some
previous reports, the causes of this complication were
speculated to be either the interruption of gastrointestinal
continuity, angulation of the gastrointestinal tract, hor-
mone imbalance or abnormal gastric peristalsis [2].
In an attempt to reduce the frequency and severity of
post-operative complications in patients undergoing
PPPD, we performed PG with Roux-en-Y reconstruction
for the reconstruction. To date, we have performed this
procedure in 17 cases of periampullary neoplasms and
have not yet encountered fatal complications.
Since 2002, thirty two cases of PPPD were performed for
radical operations of periampullary neoplasms in our
institute. These surgical procedures were carried out by 4
surgeons with sufficient experience. Out of these 32 pa-
tients, 22 were male (67.8%) and 10 were female (31.2%)
with a median age of 66.0 ± 8.6 years (range 46-82 years).
J. Yamamoto et al. / HEALTH 2 (2010) 195-199
Copyright © 2010 SciRes Openly accessible at http://www.scirp.org/journal/HEALTH/
We divided these patients into two groups according to
the reconstruction procedures: 17 cases of PG-RY, 15
cases of PJ-T. Clinical factors of these patients were
shown in the Table 1. We analyzed the postoperative
course in these 32 patients and compared the results be-
tween these two groups.
Delayed gastric emptying is defined as the nasogastric
tube placement for more than 10 days postoperatively or
the output of gastric aspiration from gastrostomy tube
more than 200 ml. Pancreatic leakage is defined as an
external discharge greater than 50 ml obtained through
drain or percutaneous aspiration, containing at least three
times normal serum value of amylase, as described by
Yeo et al. [3]. Major leakage of pancreatic juice was
defined as a leakage with peripancreatic abscess forma-
tion. Biliary fistula was diagnosed by the distinctive color
of discharge containing bilirubin. Postoperative mortality
was defined as death occurring in the first 30 postopera-
tive days or before discharge from the hospital.
In PG with Roux-en-Y reconstruction, surgical proce-
dures are following:
Pancreatogastrostomy: After all standard resections are
completed, pancreatogastrostomy (PG) is performed. The
cut end of the pancreas is reapproximated and closed for
hemostasis. A short stenting tube is placed in the pancre-
atic duct and secured loosely with one absorbable surgical
suture. A horizontal incision is made in the posterior wall
of the stomach, followed by the invagination of the pan-
creatic remnant. A vertical incision is then made in the
anterior wall of the stomach. Interrupted sutures are
placed between the full thickness of the gastric wall and
the pancreas parenchyma through the interior of the
stomach. This anastomosis is secured with approximately
16 absorbable surgical sutures. A stenting tube is intro-
duced into the stomach, which allows for free drainage of
the pancreatic juices into the stomach. A gastrostomy
tube is inserted into the stomach to reduce the internal
pressure of the stomach.
Hepaticojejunostomy: Approximately 30 cm of the je-
junum is separated with its pedicle. The jejunal limb is
approximated and sutured to the proximal hepatic duct.
A stenting tube is not inserted when the hepatic duct is
dilated over 1 cm in diameter to reduce the incidence of
retrograde infection. A continuous running suture using
one absorbable suture line achieves speed. A drainage
tube is not placed beside this anastomosis.
Duodenojejunostomy: An end-to-end anastomosis is
made between the remnant jejunum and the pylorus.
Jejunojejunostomy: An end-to-end anastomosis is ma-
de between the separated and the remnant jejunum. The
remnant jejunum is brought up on the anterior side of the
transverse colon, so that we can avoid bowel stenosis in
case of intraabdominal recurrence. The right gastric ar-
tery is not preserved in our method. The position of this
anastomosis is approximately 20 cm downstream from
the duodenojejunostomy. The importance of this recon-
struction is to avoid the kink or torsion of the stomach and
the anastomosed jejunum. This may help the transport of
digestive contents (Figure 1(a)).
In Traverso-type reconstruction, the end-to-side pan-
creatojejunostomy was performed in two layers: a pan-
Table 1. Clinical factors in patients who underwent pylorus-preserving pancreatoduodenectomy.
patients 17 15
gender (male/female) 11 6 10 5 NS
age (years) 70.1 ± 8.0 62.5 ± 8.4 p=0.013
pancreas cancer 9 (52.9%) 7 (46.7%)
bile duct cancer 6 (35.3%) 2 (13.3%)
duodenal cancer 1 (5.9%) 3 (20.0%)
IPMT 1 (5.9%) 0
Vater cancer 0 3 (20.0%)
preoperative jaundice * 13 (76.5%) 5 (33.3%) p=0.266
PG-RY: Pancreatogastrostomy with Roux-en-Y reconstruction;
PJ-T: Pancreatojejunostomy with Traverso type reconstruction;
IPMT : intrapancreatic papillary mucinous tumor;
NS: not significant.
* All the patients with obstructive jaundice underwent biliary drainage before the surgery.
J. Yamamoto et al. / HEALTH 2 (2010) 195-199
Copyright © 2010 SciRes Openly accessible at http://www.scirp.org/journal/HEALTH/
(a) (b)
Figure 1. (a) Pancreatogastrostomy with Roux-en-Y reconstruction; (b) Pancreatojejunostomy with Traverso type reconstruction.
creatic duct and enteric mucosa interrupted suture and a
pancreatic tissue to jejunal seromuscular layer using ab-
sorbable interrupted suture. Choledochojejunostomy was
performed by the same technique introduced in Roux-
en-Y anastomosis technique (Figure 1(b)).
Closed suction drain tubes were placed at the site of
pancreatoenteric anastomosis in both procedures.
Statistical analysis:
Data are reported as mean ± SEM. Statistical analysis
was performed using the paired Student’s t-test and
Fisher’s exact test for comparison between preoperative
and postoperative status. Differences were considered as
significant if p<0.05.
Of the 32 patients analyzed, 17 patients received PG with
Roux-en-Y reconstruction (group PG-RY) and 15 patients
received PJ with Traverso-type reconstruction. (group PJ-
T). Operative and postoperative results were described in
Table 2.
In PGRY group, there were 12 male and 5 female with
mean age of 70.1 ± 8.0 years (56-82). The average op-
erative time was 430.3 ± 71.0 minutes. The average in-
traoperative bleeding amount was 988.2 ± 498.9 ml.
In PJ goup, there were 10 male and 5 female with a
mean age of 62.5 ± 8.6 years (46-78). The average op-
erative time was 430.3 ± 152.1 minutes. The average in-
traoperative bleeding amount was 1076.0 ± 670.9 ml.
Two groups showed no significant differences in gen-
der, preoperative jaundice, the time of the surgery, and
intraoperative bleeding amount.
As far as the pancreatic leakage is concerned, this
complication rate is significantly reduced in PG-RY
group compared with PJ-T group (p = 0.015). There was
no case of delayed gastric emptying in PG-RY group.
26.7% of the patients (4/15) in PJ-T group were suffered
from DGE in our study. Two groups showed significant
difference (p = 0.038). There was one case of mortality
(3.1%) in PJ-T group. The patient had liver cirrhosis as a
preoperative complication, and died of liver failure 60
days postoperatively.
The postoperative complications in the patient with
Roux-en Y with PG reconstruction were shown in Table 3.
Pancreatoduodenectomy (PD) has been considered as the
only radical operative treatmetent for patients with ma-
lignant periampullary neoplasms. Recently pylorus-
preserving PD (PPPD) is also accepted as a radical sur-
gical treatment. However, the reconstruction after PPPD
is technically complicated and the postoperative morbid-
ity is still high. There are two major complications in this
procedure, the one is the leakage of pancreatic juice and
the other is the delayed gastric emptying.
The pancreatic leakage or fistula sometimes leads to
fatal complications, including intraabdominal bleeding
and sepsis. The rate of pancreatic leakage is reported to be
5 % to 30% with a mortality rate of 6.5% to 8.4%, and up
to 50% of all death following pancreatoduodenectomy
are results of the pancreatic anastomosis leakage [4].
Several techniques have been proposed for reducing the
rate of pancreatic leakage and related complications. To
avoid the risk of this occurrence, the administration of
octreotide, which reduces the secretion of pancreatic
juice, can be an option for preventing the leakage. How-
ever the use of octreotide is still controversial. Yeo etc.
reported that the use of prophylactic octreotide does not
reduce the incidence of pancreatic fistula after PD [5].
The pancreatic duct ligation without anastomosis or duct
occlusion with fibrin glue can also be an option in select
circumstances [6]. Several retrospective studies have
reported low rates of pancreatic leakage and mortality
J. Yamamoto et al. / HEALTH 2 (2010) 195-199
Copyright © 2010 SciRes Openly accessible at http://www.scirp.org/journal/HEALTH/
Table 2. Operative and postoperative results.
(n=17) (n=15)
Operation time (min.) 430 ± 71.0 430.3 ± 152.1 NS
Blood loss (ml) 988.2 ± 498.9 1076.0 ± 670.9 NS
Portal vein reconstruction 2 (11.8%) 3 (20.0%) NS
pancreatic leakage 2 (11.8%) 5 (33.3%) p=0.015
delayed gastric emptying 0 4 (26.7%) p=0.038
biliary leakage 1 (5.9%) 0 NS
liver failure 0 1 (6.7%) NS
Mortality 0 1 (6.7%) NS
NS: not significant.
Table 3. Postoperative complication in the patient with Roux-en
Y with PG reconstruction.
Surgical wound infection 3
Pneumonia 1
Small bowel obsrtuction 1
Pancreatic leakage 2
Reflux esophagitis 1
Bileperitoneum 0
Delayed gastric emptying 0
Death None
after performing PG [7]. This procedure has several ad-
vantages over pancreatojejunostomy. Delcore et al. de-
scribed several theoretic physiologic and technical ad-
vantages of performing pancreatogastrostomy [8]. First,
the activation of the proteolytic enzymes can be avoided
by this anastomosis. Enterokinase, which converts
trypsinogen to its activated form trypsin, is present in
small intestinal mucosa and it does not exist in gastric
mucosa. The activation of trypin also depends on the
presence of a neutral pH. Second, the anatomical rela-
tionship between the remnant pancreas and the stomach is
the advantageous for a tension-free anastomosis. The
pancreas lies adjacent to the posterior gastric wall. At our
institute, we invaginate the remnant pancreas into the
stomach, and suture the pancreatic parenchyma and the
full thickness of gastric wall inside of the stomach [9].
This is a simple and safe method for pancreatogastric
anastomosis. A short stenting tube is used as a pancreatic
duct that spontaneously falls out within a few months. We
do not employ the long external drainage tube, because it
often becomes twisted which produces high internal
pressures within the pancreatic duct. In our 17 cases of
PG-RY, 2 cases showed minor leakage of pancreatic
juices, however, both cases resolved only by using
drainage and discontinuation of oral feeding within 2
weeks. We have never used octreotide prophylactically in
any patient.
The delayed gastric emptying (DGE) is a unique
complication after PPPD. DGE is defined as the output of
gastric aspiration from nasogastric tube or gastrostomy
tube more than 200 ml. PPPD has a risk of 37.5% to 50 %
for developing DGE in the early postoperative course
[10]. There is a report describing a higher rate of DGE
with PG [11]. The causes of DGE are not clear and might
be multifactorial. The low concentration of plasma mo-
tilin, leakage, cholangitis or bowel edema, are major
factors contributing to the development of this complica-
tion [2]. Furthermore, recent studies show that a strong
angulation or torsion at the site of duodenojejunostomy
plays a role for this unique complication. To address this
issue we compared PG with Roux-en-Y anastomosis to PJ
with conventional Traverso-type reconstruction. Roux-
en-Y anastomosis is a means by which this problem may
be avoided. By implementing PG-RY procedure, we can
prevent a strong angle and torsion between the pylorus
and the jejunum. A gastrostomy tube placed for the re-
duction of the internal gastric pressure can also straighten
the angle of this anastomosis. Our results suggest the
advantage of PG-RY regarding the smoothness of gastric
It is also important to avoid intraabdominal infection.
The infection in the abdominal cavity results in the de-
crease in peristalsis of digestive tract movement. When
constructing the anastomosis, care must be taken to re-
J. Yamamoto et al. / HEALTH 2 (2010) 195-199
Copyright © 2010 SciRes Openly accessible at http://www.scirp.org/journal/HEALTH/
duce the incidence of postoperative complication. Usual-
ly we place a closed suction drain tube only at the site of
pancreatogastric anastomosis. In pancreatic surgery, mul-
tiple suction catheters are placed in relation to the biliary
and pancreatic anastomoses. However, in doing this we
must realize that drainage tubes are associated with the
reflux infection in the abdominal cavity [12]. Therefore,
at our institution we employ the use of few drainage and
stenting tubes.
There is no agreement as to the best reconstruction
method after PPPD [13]. With our experience, PG with
Roux-en-Y reconstruction can reduce the rate of these
two major complications as least as possible.
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