Introduction

The role of surgical resection in the treatment of pancreatic cancer was established in 1935 by Whipple and associates with the demonstration that resections of the head of the pancreas could be technically performed ₁,₂. Accumulated clinical experience with pancreatic resections has demonstrated that radical surgical treatment of pancreatic cancer results in significant morbidity and mortality and is applicable only to a small fraction of patients with pancreatic malignancies₃. International literature suggests that in most patients, pancreatic malignancies are diagnosed at late stages when surgical cure by any type of procedure is not possible₄.

Pancreaticoduodenectomy generally, is considered to be the standard operation for resection of carcinomas of the pancreas or periampullary region. The Whipple operation comprises an en bloc resection of the duodenum, the distal bile duct and the gastric antrum. Pancreaticoduodenectomy procedure has had many technical variations described, typically dealing with the extent of dissection or with the details of reconstructing the gastrointestinal tract after the resection.

Various series have appeared in the medical literature reporting the overall results of pancreaticoduodenal resections. Most series report operative mortality rates averaging 20% for pancreaticoduodenal resections for carcinoma of the pancreatic parenchyma with 3-year survivals averaging under 15% and 5-year survivals averaging 10% or less⁴. Pancreatico-duodenectomy series performed for peri-ampullary tumors show an average perioperative mortality of 15%, a 3-year survival of 30% and a 5-year survival approaching 20% range₅.

Complication rates are high in patients undergoing the Whipple procedure with complications of some type developing in more than 50% of patients₆. The most common complication after pancreaticoduodenectomy is fistula formation from the anastomoses at the sites of gastrointestinal tract reconstruction. The pancreaticojejunal anastomosis is technically difficult to perform and is the most frequent site of fistula formation. It is important that the pancreaticojejunostomy to be a secure anastomosis because the leakage of pancreatic secretions from the anastomosis can have potentially fatal consequences.

Many technical modifications have been proposed such as an end-to-end or an end-to-side anastomosis₇. Many other authors propose the avoidance of pancreaticojejunostomy (total pancreatectomy, oversewn of pancreatic remnant). In this paper an end-to-side anastomosis of the pancreatic stump to the jejunum is discussed.

Materials and Methods

Twenty seven patients (19 men and 8 women [mean age: 58,5 years]) with pancreatic or periampularry cancer, eligible for elective pancreatic resection were enrolled in this study (Table 1).

Figure 1

TABLE 1: Patients demographics and indication for pancreatic operations.

After pancreatic resection, the reconstruction of the alimentary tract has to be performed. Reconstruction involves gastro-jejunostomy, choledochojejunostomy and pancreaticojejunostomy. According to the method used in the 1^st Surgical-Oncological Department of Theagenion Cancer Hospital, gastrojejunostomy is placed distal to choledochojejunostomy and pancreaticojejunostomy to allow the gastrojejunostomy to be bathed in alkaline biliary and pancreatic secretions. Exposure of the gastrojejunostomy to alkaline resections minimizes the risk of marginal ulceration caused by the sensitivity of the jejunal mucosa to gastric acid. Pancreatico-jejunostomy is the most proximal anastomosis. For the pancreaticojejunostomy two steps have to be performed:

1. The traumatic surface of the pancreatic stump is ligated with locking sutures 3-0 silk (1st step).

2. A two-layers end-to-side anastomosis is performed (1st layer: jejunal mucosa-pancreas, 2nd layer: jejunal serosa-pancreas).

For this study protocol, eleven typical complications were defined (Table 2) and each patient was followed for 90 days postoperatively. All patients received octrotide at 3/100 µg/day subcutaneously to achieve the maximal inhibition of pancreatic enzyme secretion ₉.

Figure 2

TABLE 2: Definition of postoperative complications.

Results

The postoperative incidence of pancreaticojejunal fistula was zero. There were many other complications (Table 3) unrelated to the formation of pancreaticojejunal anastomosis. The most severe one, was a gastric marginal bleeding on the 9^th postoperative day and the patient needed relaparotomy.

Figure 3

TABLE 3: Mortality and complications

Figure 4

TABLE 4 : Number and type of complications

Discussion

The significant mortality and morbidity of pancreatic resection raises questions by surgeon oncologists of whether the small possibility of cure is justified by the price of possible death from surgery or of complications that can lead to prolonged hospitalization ₁₀. The most common complication is the pancreaticojejunal fistula formation. In a series reported by Pessaux and associates ₁₁, postoperative fistulas occured in 177 patients, for an overall fistula complication rate of 21,5%. Leakage from the pancreaticojejunal anastomosis occured in 114 patients (13,9%), biliary fistulas occured in 45 patiernts (5,4%) and gastric fistulas developed in 18 patients (2,2%).

Although Cameron and associates₁₂ reported 145 pancreaticoduodenectomies without death, mortality and morbidity rates are the main problem of pancreatic resection.

In the study presented here, despite the fact that mortality was zero, morbidity rate was significantly high (10/21 patients – 47,6%) but with no pancreaticojejunal fistula formation among the complications.

Formerly, total pancreatectomy was proposed as a more appropriate operation for pancreatic carcinoma. Support was based on a reported 30-40% incidence of multifocality of pancreatic cancer, a concern about tumor cell implantation into the remnant pancreatic duct at Whipple resection and the high mortality and morbidity associated with the pancreaticojejuno-stomy₁₃. As the literature has substantiated concerns about tumor seeding and multicentricity are not relevant, because the 5-year survival rate in patient who undergo the classic total pancreatectomy is equivalent to that in patients who undergo Whipple resection⁴. Also improved techniques and postoperative management have made pancreaticojejunostomy safer₁₄. Total pancreatectomy removes all exocrine and endocrine pancreatic function, requiring exogenous pancreatic enzyme and insulin administration₁₅.

An alternative method to avoid pancreaticojejunostomy is to ligate the remnant either with intraductal blocking or not and leave it free but well-drained in the abdominal cavity.

Despite the fact that ligation of the remnant causes more fistulas than pancreatico-jejunostomy, fistula formation after pancreatico-jejunostomy is more dangerous. Probably there is an activation of pancreatic enzymes caused by the enteric secretions. Activated pancreatic fluid is more corrosive compared to the fluid secreted by the isolated pancreatic remnant.

The modification described in this paper is simple. Excretion of pancreatic fluid inside jejunum is inhibited, in order to avoid mixing of pancreatic and enteric secretions and activation of pancreatic enzymes.

Even though, the number of treated cases was few, the early experience has indicated successful results in pancreaticojejunostomy formation.