The reconstruction after pylorus preserving pancreatoduodenectomy: pancreatogastrostomy with Roux-en-Y reconstruction versus conventional Traverso type reconstruction

doi:10.4236/health.2010.23028

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Vol.2, No.3, 195-199 (2010)

doi:10.4236/health.2010.23028

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.

ABSTRACT

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

1. INTRODUCTION

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.

2. PATIENTS AND METHODS

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

196

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.

3. SURGICAL TECHNIQUE

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.

PG-RY PJ-T

patients 17 15

gender (male/female) 11 6 10 5 NS

age (years) 70.1 ± 8.0 62.5 ± 8.4 p=0.013

disease

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

197

(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.

4. RESULTS

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.

5. DISCUSSIONS

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

198

Table 2. Operative and postoperative results.

PG-RY PJ-T

(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

Complications

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.

Complication

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

passage.

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

199

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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