MANAGING A SOFT PANCREATIC STUMP WITH END-TO-SIDE INTERRUPTED DOUBLE LAYER PANCREATOGASTROSTOMY: HOW I DO IT.

Pancreatic anastomotic failure is a main cause of significant morbidity and potential mortality after pancreaticoduodenectomy, especially in presence of a soft pancreatic stump. Pancreaticogastrostomy proved to be associated with a lower risk of pancreatic fistula in a recent metaanalysis. Since 2010, we have been refining our technique (illustrated by a videoclip), now routinely implemented with soft pancreas, without experiencing any clinically significant pancreatic fistula. Briefly, after the pancreaticoduodenectomy is completed, we identify and cannulate the Wirsung with a small Nelaton catheter. Then we pursue full hemostasis of the pancreatic stump by 4/0 and 5/0 prolene sutures. The next step consists in achieving extended mobilization of the left pancreas (almost 4cm). The double-layer anastomosis starts with a posterior row of interrupted absorbable 4/0 monofilament sutures including the gastric serosa and the pancreatic capsule. It is essential to shape the posterior gastrotomy shorter than the pancreatic stump to prevent excessive widening and to ease the anastomosis. The anterior auxiliary gastrotomy instead needs to be larger to facilitate the inner anastomosis. Then, we invaginate the pancreas into the stomach and we proceed with an interrupted row of sutures between the posterior gastric wall (full-thickness) and the body of the pancreatic stump, using retractors. HPB 2016, 18 (S1), e1ee384 Electronic Poster Abstracts e119 Accurate check of the inner sutures is mandatory and further stitches may be necessary to secure the anastomosis. The anterior gastrotomy is finally closed with an absorbable running suture. Finally, a further layer of sutures is applied over the posterior suture line between the gastric serosa and the pancreatic capsule.