Perioperative management - Pancreatogastrostomy

  1. Indication

    Pancreatogastrostomy (PG) is an alternative anastomosis technique to traditional pancreatojejunostomy or pancreaticojejunostomy (PJ) as part of a pancreatoduodenectomy.

    Comparison of pancreatic anastomosis techniques

    In principle, anastomosis in reconstruction after pancreatoduodenectomy can be fashioned in one of two techniques:

    Pancreato- or pancreaticojejunostomy (PJ) as the traditional most widely used technique and pancreatogastrostomy (PG).

    The latter had already been introduced into clinical practice 50 years ago and is becoming more prominent once again due to positive outcomes in prospective randomized trials.

    Reconstruction with sutured anastomosis between the pancreatic remnant and the stomach is an alternative to anastomosis between the pancreatic remnant and the jejunum.

    By definition, pancreatico--gastrostomy implies that the duct is not sutured to the mucosa, which would otherwise be included in pancreatico-gastrostomy.

    Pancreatic anastomosis is the Achilles heel in pancreatic surgery, since anastomotic failure is a major factor in postoperative morbidity and mortality.

    Possible causes include aggressive pancreatic juice and local pancreatitis from manipulation while fashioning the anastomosis. A soft pancreas is particularly at risk of suture line failure.

    Theoretical aspects that could make pancreatogastrostomy (PG) safer than pancreatojejunostomy (PJ) include:

      • Direct anatomical relation of the pancreas with the posterior gastric wall.
      • The strong gastric wall lends itself to deep telescope-type invagination and good fixation of the pancreatic remnant.
      • Unlike in the small intestine, the acidic conditions in the stomach do not activate the pancreatic enzymes.
      • The alkaline pancreatic juice neutralizes gastric acid to a certain extent and can therefore prevent ulceration at the gastroenterostomy.
      • Another possible advantage discussed is the separation of the pancreatic anastomosis from the hepaticojejunostomy.

    The downside is the need for more extensive mobilization of the pancreatic remnant than with pancreatojejunostomy to achieve an adequate invaginating telescope-type of anastomosis. This may be technically challenging in the presence of chronic inflammatory adhesions with the retroperitoneal tissues.

    Neither anastomotic technique has yet been shown to be clinically superior in terms of postoperative complications such as pancreatic fistula, anastomotic failure, postoperative bleeding, or gastroparesis. However, pancreatogastrostomy appears to be advantageous as a safe, yet less challenging, anastomosis, especially in high-risk patients. Some trials have revealed that in a soft, difficult-to-suture pancreas with a slender pancreatic duct, the telescope-type invagination technique may reduce the fistula rate.

    In general, PG is technically easier to master and faster to perform while providing at least the same level of safety.

    Other indications for PG 

      • Following resection of intraductal papillary mucinous neoplasm (IPMN), PG allows for endoscopic follow-up when there is a high risk of recurrence in the pancreatic remnant.
      • In addition, PG is recommended as a salvage procedure in grade C pancreatic fistula post PJ to avoid completion pancreatectomy.

    Since PG is performed in the setting of pancreatoduodenectomy, for the other PM (postoperative management) sections, please refer to our article "Duodenohemipancreatectomy with Blumgard anastomosis and bilio-pancreatic separation (Merheim procedure)"