Two-layered duct-to-mucosa end-to-side pancreatojejunostomy

Technique:

With resection of the seromuscular wall

An incision is made in the seromuscular layer of the jejunal wall, comparable with the size of the pancreatic stump.
Sutures are placed between the posterior edge of the seromuscular jejunal incision and the posterior pancreatic capsule to form the posterior part of the outer suture-row.
A small opening is made in the centre of the resected serosa, with a diameter that matches the diameter of the main pancreatic duct. Consequently, the jejunal mucosa is exposed at a point exactly opposite the main pancreatic duct.
The inner suture-row forms the actual duct-to-mucosa anastomosis: to this purpose, the pancreatic duct is sutured to the jejunal mucosa in all directions.
To complete the outer suture-row anteriorly, the anterior part of the seromuscular jejunal wall incision is anastomosed to the anterior pancreatic capsule.

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Without resection of the seromuscular wall: an alternative way to perform the two-layered duct-to-mucosa end-to-side pancreatojejunostomy is without seromuscular incision in the jejunal wall. As a result, the small opening opposite to the pancreatic duct is made in the full-thickness of the jejunal wall. Sutures from the inner, duct-to-mucosa suture-row are now circumferentially placed between the main pancreatic duct and the full-thickness of the bowel wall. The remaining aspects of the anastomosis are carried out in a same way as described above.

Modifications:

In case of a small pancreatic duct

A posterior outer suture-row is performed between the capsule of the pancreatic stump and the seromuscular layer of the jejunum posteriorly.
Opposite to the main pancreatic duct, a full-thickness incision with a length of 1 cm is made in the jejunal wall.
The cut surface of the pancreatic remnant is anastomosed to the seromuscular edges of the new-formed jejunal opening. The sutures are placed circumferentially and pass straight from the cut surface of the pancreatic parenchyma, 1 cm in diameter around the main pancreatic duct, via the incision on the jejunum through all jejunal layers. Consequently, a ‘duct-to-mucosa-like’ anastomosis of 1 cm in diameter is constructed between the pancreatic parenchyma and the jejunal mucosa, with the small pancreatic duct in the middle of the anastomosis.
The outer suture-row is completed between the capsule of the pancreatic stump and the seromuscular layer of the jejunum anteriorly.

True duct-to-mucosa anastomosis

An outer, posterior suture-row is performed between the outer 2/3rd of the radius of the cut pancreatic gland and the seromuscular layer of the jejunal wall posteriorly.
A small hole of 2-3 mm in diameter is made through the full-thickness of the jejunal wall, opposite the main pancreatic duct.
The jejunal mucosa is everted in all directions and anchored to the seromuscular wall around the new-formed opening in the jejunum, using four stitches.
An inner suture-row is circumferentially applied. Sutures are placed through the full-thickness of the jejunal wall, a few mm away from the jejunal opening and the everted mucosa, exciting the lumen of the jejunum via the small hole. Subsequently, the sutures penetrate the main pancreatic duct and periductal pancreatic parenchyma, including the inner 1/3rd of the radius of the cut pancreatic gland. The mucosal surfaces of the jejunum and main pancreatic duct are in close contact, featuring a ‘true duct-to-mucosa anastomosis’. Care is taken to avoid occlusion of the main pancreatic duct.
The outer suture-row is completed anteriorly in a same fashion as with the posterior outer suture-line.

Blumgart anastomosis & modifications

An opening is made in the seromuscular side wall of the jejunum, with a size similar to the diameter of the pancreas.
The Blumgart anastomosis is constructed by four to six transpancreatic U-sutures: two to three on each side of the main pancreatic duct. Suture-threads with a needle on both ends are used.
The suturing starts at the anterior side of the pancreatic stump, about 1 cm away from the cut end: the pancreatic gland is penetrated by each suture from anterior to posterior, after which a seromuscular bite of the posterior jejunal wall is taken. From posterior to anterior, each suture goes back again through the full-thickness of the pancreatic parenchyma. Herewith, the U-suture is completed and the posterior sides of the pancreatic remnant and jejunum are approximated. The U-sutures are kept separately for later completion of the anastomosis.
A small opening is created in the jejunum, through the full-thickness of the jejunal wall.
A duct-to-mucosa anastomosis is constructed circumferentially between the cutting edges of the new-made opening in the jejunal wall and the main pancreatic duct.
The previously held U-sutures are tied on the anterior capsule of the pancreas and placed through the seromuscular coat of the jejunum at the anterior edge of the seromuscular jejunal incision. Each suture is then stitched through the pancreatic capsule anteriorly, with the needle passing under the previously tied suture, so that the pancreas is covered by the anterior seromuscular wall of the jejunum. The anastomosis is completed by tying the U-sutures on the anterior capsule of the pancreatic stump.

Modifications of the Blumgart-technique have been described: suturing with the preserved U-sutures can be continued without first tying them on the anterior capsule of the pancreas. Also, the U-sutures can be tied on the anterior seromuscular jejunal wall after passing the needles through the anterior edge of the seromuscular incision; the anastomosis is hereby completed without penetrating the pancreatic gland ones more.

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Kakita method (transfixing suturing technique) & modifications

A small incision in made through the full-thickness of the jejunal wall, with the same diameter as the main pancreatic duct.
An inner suture-row is circumferentially performed with 3-4 sutures, placed between the main pancreatic duct an the full-thickness of the jejunal wall.
For the outer layer, a so-called ‘transfixing suturing technique’ is used: from anterior to posterior, 6-8 sutures go straight through the pancreatic parenchyma. Each needle passes through the seromuscular layer of the jejunum superficially, widely enough the cover the pancreatic stump. Care is taken to achieve complete coverage of the pancreatic cut edge by the seromuscular jejunal wall.

Modifications of the Kakita method contain variations in the amount of sutures used for the inner and outer suture-rows.

Pair-watch suturing technique

The pair watch suturing technique contains a precise way of accomplishing a duct-to-mucosa pancreatojejunostomy, by imaging the faces of a pair of wristwatches on the jejunal hole and the main pancreatic duct during the anastomosis procedure.
A small opening is made through the full-thickness of the jejunal wall, opposite the main pancreatic duct, with a size that matches the diameter of the pancreatic duct.
The first suture is placed between 9 o’clock on the pancreatic ductal side and 3 o’clock on the jejunal side. Following this pattern, a total of seven and five sutures are placed in the posterior and anterior walls, respectively. Therewith, the inner anastomotic layer between the main pancreatic duct and the jejunal mucosa exists of twelve stitches, regardless of the calibre of the pancreatic duct.
A second, outer layer is performed between the pancreatic capsule and seromuscular coat of the jejunum, using 5-7 sutures on both the anterior and posterior sides.
The pancreatic anastomosis is completed by adding one backstopping stitch on both the caudal and cranial corners of the anastomosis.

Purse-string suturing technique

The seromuscular layer of the jejunum is incised with a width comparable to the diameter of the pancreatic remnant.
A purse-string suture is performed in the mucosa at the centre of the seromuscular incision.
A stent tube is placed in the main pancreatic duct and fixed with a stay suture; the other tip of the tube is introduced into the jejunal lumen through the mucosa in the middle of the preplaced mucosal purse-string suture and secured by ligating the purse-string. The ligated purse-string forms the second stay suture.
The posterior side of the pancreatic capsule is anastomosed to the posterior seromuscular layer of the jejunal wall.
The two stay sutures are tied together for approximating the ductal cut end and the jejunal mucosa. No further sutures are used for duct-to-mucosa contact.
The anastomosis is completed by suturing the pancreatic capsule to the seromuscular wall of the jejunum anteriorly.

Suspension pancreatic-duct-jejunum end-to-side continuous suture (SPDJCS)

The pancreatic capsule is anastomosed to the seromuscular layer of the jejunal wall posteriorly, 1-1.5 cm away from the pancreatic cut end.
A full-thickness incision is made in the wall of the jejunum, with a size comparable to the diameter of the main pancreatic duct or with a size that matches the diameter of the pancreatic stump.
The posterior cut end of the pancreas is continuously sutured to the posterior seromuscular layer (or seromuscular cut edge) of the jejunum. The posterior wall of the pancreatic duct and jejunal incision were included in the suture-row.
In a same fashion, an anterior suture-row is continuously performed between the cut end of the pancreas and the seromuscular layer (or seromuscular cut edge) of the jejunum, again including the anterior wall of the pancreatic duct. The two suture-threads of the anterior and posterior inner suture-lines are tied together.
The outer suture-row is completed anteriorly, by anastomosing the anterior pancreatic capsule to the anterior seromuscular layer of the jejunal wall, 1-1.5 cm away from the pancreatic cut margin.

Whole-layer tightly appressed anastomosis technique

The pancreatic capsule is sutured to the seromuscular wall of the jejunum posteriorly, about 1 cm away from the pancreatic cut end.
A small hole, with a diameter that matches the diameter of the main pancreatic duct, is made through the full-thickness of the jejunal wall, opposite to the pancreatic duct.
A posterior inner suture-row is carried out between the pancreatic duct, including the complete pancreatic parenchyma, and the new-formed opening in the jejunum, including the full-thickness of the bowel wall. Suture-threads with a needle on both ends were used. The first needle of each suture is placed via the lumen of the main pancreatic duct, through the complete layer of pancreatic parenchyma, exiting the pancreas posteriorly from the pancreatic capsule. The second needle of each suture goes into the jejunal lumen, via the incision, and is pulled out through the full-thickness of the posterior jejunal wall.
The inner suture-row is completed anteriorly in a same fashion as with the posterior inner suture-row.
The pancreatic anastomosis is completed with an anterior outer suture-line between the pancreatic capsule and seromuscular jejunal wall.

Stump-closed

Before the pancreatojejunal anastomosis is started, the pancreatic stump is ‘closed’. For this procedure, a stent tube is placed into the main pancreatic duct, and the cut surface of the pancreatic stump is shaped like a ‘fish-mouth’. The two lips of the fish-mouth are sutured together, closing the cut end of the pancreas, with exclusion of the pancreatic duct.
An incision is made in the seromuscular layer of the jejunal wall, matching the diameter of the pancreatic stump.
A small hole of 2-3 mm in diameter is made in the centre of the seromuscular incision, through which the pancreatic stent tube is inserted.
The posterior lip of the pancreatic capsule is sutured to the posterior seromuscular wall of the jejunum.
Periductal stitches are applied circumferentially around the pancreatic stent tube, between the periductal pancreatic parenchyma and the edge of the small, new-formed jejunal hole, to secure the stent tube firmly.
The anterior lip of the pancreas is anastomosed to the anterior seromuscular jejunal wall, finishing the stump-closed pancreatojejunostomy.