History of pancreaticojejunostomy in pancreaticoduodenectomy: development of a more reliable anastomosis technique
Executive Summary
The history of pancreatic surgery, particularly the reconstruction following pancreaticoduodenectomy (PD), is defined by a persistent struggle against postoperative complications, most notably anastomotic failure. While pioneers in the late 19th and early 20th centuries initially avoided pancreaticoenteric anastomosis, by the 1940s, the procedure became recognized as indispensable for preventing fatal leaks of pancreatic juice.
Current surgical practice generally employs two methods: invaginating end-to-end or end-to-side anastomosis. However, both techniques carry risks of ischemia, necrosis, or the creation of "dead spaces" that lead to pancreatitis. A refined surgical technique, developed and utilized in clinical practice since 1990, emphasizes a "less is more" approach. By utilizing a limited number of interrupted sutures (six to eight) and ensuring the jejunal wall completely covers the pancreatic cut surface without excessive tension, surgeons have achieved a remarkably low pancreatic fistula rate of 1.2% and zero anastomotic-related deaths in a series of 162 consecutive patients.
Historical Evolution of Pancreaticoduodenectomy
The development of pancreatic surgery has transitioned from simple excision and suture closure to complex ductal reconstruction.
Early Pioneers (1898–1912)
Codivilla (1898): Credited as the pioneer of partial resection of the pancreatic head and duodenum. However, he did not perform an anastomosis; the pancreatic cut surface was merely closed by suture.
Halsted (1899): Successfully performed a transduodenal resection where the common bile duct and pancreatic duct were reimplanted into the posterior wall of the duodenum.
Desjardins (1907): Conducted the first complete pancreaticoduodenectomy in a human cadaver, utilizing the "Button of Boari" to bridge the pancreatic duct and jejunal wall.
Coffey (1909): Advocated for a technique where the pancreatic stump was implanted into a jejunal loop.
The Shift to Reconstruction (1935–1946)
Initial resistance to anastomosis was based on the belief that pancreatic enzymes would inevitably cause failure. In 1935, Whipple, Parsons, and Mullins argued against anastomosis, suggesting that one could live without pancreatic juice and that any made anastomosis would eventually obstruct.
By 1943, Cattell challenged this view, asserting that pancreaticoenteric anastomosis was essential because the leakage of pancreatic juice from a ligated duct accounted for the majority of postoperative deaths. This led to the development of several foundational methods:
Child (1941): Attempted to invaginate the pancreatic stump into the jejunal stump.
Whipple (1946): Introduced the one-stage reconstruction now known as "Whipple’s method," which used a rubber tube to fix the pancreatic parenchyma to the jejunum.
Analysis of Current Anastomotic Techniques
Modern pancreaticojejunostomies are categorized by the direction of the anastomosis and the suturing method used.
Physiological Principles for Successful Anastomosis
To mitigate the risk of failure, surgeons must account for the specific organ characteristics of the pancreas. The normal parenchyma is "soft and fragile," making it susceptible to tearing if ligated too tightly.
Requirements for an Ideal Anastomosis
Maintenance of Blood Flow: Avoiding ischemia and necrosis in the pancreatic stump.
Secure Fixation: Ensuring the intestinal tract and the cut surface of the pancreas are firmly approximated.
Complete Coverage: The jejunal wall must fully cover the cut surface to prevent juice leakage from small ductules.
Complete Drainage: Ensuring pancreatic juice is successfully diverted into the intestinal tract via a tube or direct ductal connection.
A Refined Surgical Technique: The Kakita Method
Introduced to address the complications of existing methods, this technique simplifies the procedure while prioritizing tissue viability.
Procedural Steps
Isolation and Intubation: The pancreatic parenchyma is divided with a scalpel back until the main duct is visible. A drainage tube is inserted and tied firmly into the duct with an absorbable tie.
Ductal Fixation: The pancreatic duct and jejunal mucosa are fixed with three to four absorbable 5-0 sutures to secure the duct within the jejunal wall.
Approximation of the Stump: This is the unique aspect of the method. The stump and jejunal wall are joined in a single layer using only six to eight interrupted sutures (3-0 monofilament).
Sutures are inserted 5mm distal to the cut edge.
They pass straight through the parenchyma from the anterior to the posterior wall.
The sutures lift the seromuscular layer of the jejunum to ensure the wall fully covers the cut surface.
Theoretical Substantiation
The primary cause of failure in other methods is often over-suturing. Densely placed sutures or ties that are too tight restrict tissue blood flow, causing ischemia, necrosis, and subsequent autolysis triggered by the proteolytic action of pancreatic juice. By reducing the number of sutures and avoiding tight ligation, the Kakita method preserves the microcirculation of the pancreatic stump.
Clinical Performance and Outcomes
A study of 162 consecutive patients (127 malignant, 35 benign) treated with this refined technique demonstrated high reliability and safety.
Postoperative Complications
Delayed Gastric Emptying: 25.9% (42 patients).
Intra-abdominal Bleeding: 3.0% (5 patients).
Marginal Ulcer: 3.0% (5 patients).
Pancreatic Fistula: 1.2% (2 patients).
Key Findings
Mortality: There were no deaths caused by complications of the pancreaticoenteric anastomosis.
Anastomotic Integrity: In the two cases of fistula, no radiographic evidence of total breakdown was found; leakage was attributed to insufficient coverage of the cut surface or restricted blood flow from tension.
Long-term Function: In a follow-up of 104 patients (median 28 months), pancreatic duct patency was confirmed in 44 patients via MRCP. Fifty patients showed preserved exocrine and endocrine functions, while 10 showed ductal dilatation and functional decline.
Conclusion
The evolution of pancreaticojejunostomy highlights that technical simplicity and physiological awareness are superior to complex, high-tension maneuvers. By ensuring complete coverage of the pancreatic stump and prioritizing the preservation of blood flow through limited suturing, the risk of fatal anastomotic failure can be significantly minimized.
