TWO LAYER OPEN PANCREATOGASTROSTOMY. TOWARD AN EASY AND SAFE ANASTOMOSIS? PRELIMINARY EXPERIENCE.

Introduction: Pancreatic fi stula (PF) is the main cause of morbidity and mortality after pancreaticoduodenectomy (PD). It mostly occurs when anastomosis is performed in soft pancreatic tissue. Pancreaticogastrostomy (PG) seems actually to be preferred to Pancreaticojejunostomy (PJ) in presence of soft residual parenchyma. The aim of the study is to compare the PG and PJ in a consecutive series of patients submitted to PD. Methods: From January 2009 to September 2011 61 patients were submitted to two different surgical reconstructive technique, PG and PJ. 31 patients received PJ (duct to mucosa pancreaticojejunostomy) and 30 PG (two layer open pancreaticogastrostomy). All the procedures were performed by the same surgeon. PF was defi ned in according to the International Study Group on Pancreatic Fistula Classifi cation. 53 patients underwent a Whipple procedure whereas 7 patients were submitted to a pylorus-preserving operation. Results: In the PJ group (18 male/13 female, average age 69 years) we observed 5 PF (16.1%), 3 grade A, 1 grade B and 1 grade C. This latter case required a relaparotomy for completion pancreatectomy. In all these 5 PF the residual parenchyma was soft. In the PG group (14 male/16 female, average age 68 years) we registered 4 grade A PF (13.3%) all in presence of soft pancreatic tissue. In this group of patients we observed also 1 bleeding from the pancreatic anastomosis and 1 postoperative pancreatitis with a minimal leak of the gastrojejuneal anastomosis. All complications were treated conservatively. In the two groups mortality were 0%. The mean hospitalization time was 15.6 days in PJ group and 12.2 days in PG group. Histological examination led to the diagnosis of 36 ductal adenocarcinomas, 15 carcinomas of the papilla, 6 duodenal carcinoma, 3 chronic pancreatitis and 1 duodenal polyposis (Spigelmann stage IV). Conclusion: In our experience the incidence of PF seems to be lower in the PG group especially in presence of soft pancreatic tissue. The anterior gastrotomy makes easier the anastomosis whereas the two layer technique increases its safety. These initial results appear encouraging but must be confi rmed in a larger group of patients.