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Outcome of 150 Consecutive Blumgart’s Pancreaticojejunostomy After Pancreaticoduodenectomy

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Abstract

Postoperative pancreatic fistula (POPF) is the most feared complication after pancreaticoduodenectomy (PD) that leads to intra-abdominal abscess, sepsis, or bleeding and remains the single most important source of morbidity and mortality after PD. To minimize this dreaded complication, various surgical techniques and modifications of pancreaticoenteric reconstruction have been proposed. However, still POPF does occur even in experienced hands. We herein describe the outcome of 150 post PD patients who underwent duct-to-mucosa (DM) pancreaticojejunostomy (PJ) using a special technique, Blumgart’s “through & through” U transpancreatic sutures. The technique is described in detail. Postoperative octreotide and metoclopramide were used in all patients for 3 days. An enhanced recovery (ERAS) protocol was followed in a subset of patients. All patients were ASA grade 1 and had adenocarcinoma of the periampullary region/pancreatic head and underwent standard pylorus resecting PD after due optimization. Eighty-eight (58.7%) patients had pancreatic duct < 3 mm and pancreatic texture was soft to very soft in 112 (74.6%) patients. There was only one International Study Group of Pancreatic Surgery (ISGPS) grade C POPF with concomitant hemorrhage. Five patients developed ISGPS grade B and two grade C, delayed gastric emptying (DGE). There was no 30-day mortality. The average length of hospital stay was 7.3 ± 4.2 days with a median of 6 days in the ERAS subset of patients. Blumgart’s “through & through” DMPJ technique is very helpful in reducing the POPF and other complications even in high-risk pancreas (i.e., soft with a small pancreatic duct) and is easy to learn and perform.

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Fig. 1: Placement of transpancreatic "through and through" U sutures.
Fig. 2: Placement of Duct-to-mucosa stitches.
Fig. 3: Placement of anterior layer of stitches.
Fig. 4: Upon completion of Pancreaticojejunostomy, the jejunum is completely wrapped around the pancreatic stump.

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Acknowledgements

I am thankful to Dr. Jarnagin WR, MD, FACS, Chief, Hepatopancreatobiliary Service and Benno C. Schmidt, Chair in Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, for his guidance while I was in his unit as a UICC fellow and learnt the above discussed Blumgart’s DMPJ technique.

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Authors and Affiliations

  1. Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., 221005, India

    Mallika Tewari, R. Mahendran, T. Kiran & H. S. Shukla

  2. Department of Radiodiagnosis, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., 221005, India

    A. Verma

  3. Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, U.P., 221005, India

    V. K. Dixit & S. Shukla

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  1. Mallika Tewari
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Correspondence to Mallika Tewari.

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Tewari, M., Mahendran, R., Kiran, T. et al. Outcome of 150 Consecutive Blumgart’s Pancreaticojejunostomy After Pancreaticoduodenectomy. Indian J Surg Oncol 10, 65–71 (2019). https://doi.org/10.1007/s13193-018-0821-z

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  • DOI: https://doi.org/10.1007/s13193-018-0821-z

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