Updates in Surgery

, Volume 70, Issue 1, pp 137–141 | Cite as

Modified end-to-side double-layer open pancreaticogastrostomy after Whipple procedure: surgical tips for a safe anastomosis

  • Raffaele Dalla Valle
  • Matteo Rossini
  • Laura Lamecchi
  • Maurizio IariaEmail author
Technical Note


Pancreatic fistula (PF) remains the Achilles’ heel of pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) appears to be associated with a lower risk of postoperative leak according to recent evidence. We started to fashion PG, especially in soft pancreas, modifying the original technique described by Bassi. At our institution, 105 PD procedures were carried out from January 2011 to December 2016; pancreatic-enteric continuity was restored by PG in 35 cases. Superior mesenteric/portal vein resection/reconstruction was necessary in three patients. A total of 34/35 patients underwent PG with an open anterior gastrostomy approach. Briefly, our double-layer PG anastomosis (illustrated by a video) starts with a posterior row of interrupted absorbable 4/0 monofilament sutures including the gastric serosa and the pancreatic capsule. It is essential to mobilize the left pancreas for 4–5 cm and to shape the posterior gastrostomy shorter than the pancreatic stump. After a wide anterior auxiliary gastrostomy the pancreas is invaginated into the stomach and an interrupted row of sutures between the posterior gastric wall (full-thickness) and the body of the pancreatic stump is fashioned. The anterior gastrostomy is closed with an absorbable running suture. Finally, a further layer of sutures is applied over the posterior suture line between the gastric serosa and the pancreatic capsule. The 90-day postoperative mortality was nihil. No biliary leakage was detected and the overall PF rate was 11.4% (4/35) according to the ISGPF study group. Only one patient suffered a grade B PF (in this case, PG was carried out only through a posterior gastrostomy), whereas three patients had a minor (grade A) PF. Our modified PG proved to be safe and easy to perform, while it carried excellent outcomes even in the setting of soft pancreas. Despite the limited number of cases, such modified PG appears promising, particularly for pancreatic remnants at higher risk of PF.


Pancreaticoduodenectomy Pancreaticogastrostomy Pancreatic fistula Soft pancreas 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Research involving human participants and/or animals

No animals but only human participants were involved in our study protocol.

Informed consent

Informed consent was obtained from each patients before taking part in the study. Patient anonymity was maintained. The study was not advertised and no remuneration was offered.

Supplementary material

Supplementary material 1 (AVI 19337 kb)


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Copyright information

© Italian Society of Surgery (SIC) 2018

Authors and Affiliations

  1. 1.Department of SurgeryParma University HospitalParmaItaly

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