The pancreatogastrostomy (PG) represents an alternative anastomosis technique to the traditional pancreatojejunostomy or pancreaticojejunostomy (PJ) in the context of a pancreaticoduodenectomy.
Comparison of Pancreatic Anastomosis Techniques
For reconstruction after pancreaticoduodenectomy, two anastomosis techniques are fundamentally available:
The pancreato- or pancreaticojejunostomy (PJ) as the traditionally most widespread technique and the pancreatogastrostomy (PG).
The latter was introduced into clinical practice 50 years ago and is gaining importance again due to positive results in prospective randomized studies.
The reconstruction with a suture connection between the remaining pancreas and the stomach represents an alternative to the anastomosis between the remaining pancreas and the jejunum.
Terminologically, pancreat-o-gastrostomy means the omission of a duct-mucosa suture, which would be included in the term pancreat-iko-gastrostomy.
The pancreatic anastomosis practically represents the Achilles' heel of pancreatic surgery, as its insufficiency significantly determines postoperative morbidity and mortality.
Causes include aggressive pancreatic juice and local pancreatitis due to manipulation during anastomosis creation. Particularly, a soft pancreas is threatened by suture insufficiency.
Theoretical aspects that could make pancreatogastrostomy (PG) safer compared to pancreatojejunostomy (PJ) are:
- The direct anatomical proximity of the pancreas to the posterior stomach wall.
- The stomach wall offers a strong wall for deep invagination and good fixation of the pancreatic remnant.
- Pancreatic enzymes are not activated in the acidic gastric environment, unlike in the small intestine.
- The alkaline pancreatic juice neutralizes gastric acid to some extent and could thus prevent ulcerations at the gastroenterostomy.
- The separation of the pancreatic anastomosis from the hepaticojejunostomy is also discussed as an advantage.
A disadvantage is the need for further mobilization of the pancreatic stump compared to pancreatojejunostomy to achieve sufficient invagination. This can be technically challenging in the presence of chronic inflammatory adhesions in the retroperitoneal tissue.
For neither of the two anastomosis techniques has a clear clinical superiority been proven in terms of postoperative complications such as pancreatic fistula, insufficiency, bleeding, or gastric emptying disorder. However, pancreatogastrostomy seems to be a safe and simultaneously less demanding anastomosis, especially advantageous for high-risk patients. Individual studies show that with a soft, poorly suturable pancreas with a thin pancreatic duct, the invagination technique may reduce the fistula rate.
Overall, PG is the technically easier to learn and faster to perform procedure with at least equal safety.
Further Indications for PG
- After resection of intraductal papillary mucinous neoplasms (IPMN), PG offers the possibility of endoscopic surveillance with a high risk of recurrence in the remaining pancreas.
- PG is also proposed as a salvage procedure for a Grade C pancreatic fistula after PJ to avoid a remnant pancreatectomy.
Since PG is performed in the context of pancreaticoduodenectomy, we refer to our article "Duodenohemipancreatectomy with Blumgart Anastomosis and Biliopancreatic Separation (Merheim Method)" for the other sections of PM (postoperative management).