A new modification of pancreaticogastrostomy after pancreaticoduodenectomy for patients with cancer head pancreas with possible less formation of post operative pancreatic fistula formation.

A new modification of pancreaticogastrostomy after pancreaticoduodenectomy: anastomosis of the pancreatic duct to the gastric mucosa with invaginatation of the pancreatic remnant end into the posterior gastric wall. Operative technique: Pancreaticoduodenectomy was performed in a classical technique using (linear cutter TRT75 , green, Ethicon (Registered Trademark)) to cut at the neck of the pancreas. Very few cases required further hemostasis as using the linear cutter was very effective to control bleeding from the pancreatic edge. The pancreatic remnant was mobilized 2 to 3 cm from the splenic vein and the surrounding tissues. After removal of one or two staples and identification of the pancreatic duct, a 10 or 12 Fr. polyethylene catheter passed into the main pancreatic duct to ensure its patency. The catheter was cut 1 cm. from the pancreatic edge. Then a stab 5mm. transverse full thickness incision was made on the posterior wall of the stomach opposite to the pancreatic duct end . A purse string suture was made in the posterior gastric wall around the opening in the posterior gastric wall using 2-0 polypropylene sutures, with a distance between the purse suture and the opening 1.5 times the distance between the pancreatic duct and the upper edge of the pancreas. The purse string suture was left loose. Next, anastomosis between the pancreatic duct and the gastric mucosa was done using four 4-0 polypropylene sutures at the four quarters. The polyethylene catheter passes into the stomach through the pancreaticogastrostomy and left to be dropped spontaneously. Four 3-0 polyglactin sutures were secured between the capsule of the pancreas (1 cm. from the edge) and the seromascular layer of the posterior wall of the stomach. In cases of soft pancreas, the pancreatic sutures were taken a little bit deeper. Care must be taken that the posterior suture must be done and kept loose before the anastomosis between the pancreatic duct and the gastric mucosa as the field will be blocked by the anastomosis and will make taking this suture very difficult and hazardous. Then, the posterior wall of the stomach is wrapped around the pancreatic remnant while the purse string is tightened to ensure invagination of the pancreatic remnant. This maneuver should be performed very gently to ensure tight wrapping of the posterior gastric wall around the pancreatic remnant and to avoid any tension over the anastomosis between the pancreatic duct and the gastric mucosa. Further reconstruction of digestive continuity was obtained by end-to-side hepaticojejunostomy, and side-to-side stapled gastrojejonostomy. All patients had two closed suction drains placed at the time of operation, one in close proximity to the pancreatic anastomosis and the other in the pelvis. duration of the procedure is from 3 - 6 hours.