Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 68, Num. 4, 2006, pp. 233-233

Indian Journal of Surgery, Vol. 68, No. 4, July-August, 2006, pp. 233

Letter To Editor

Technique of pancreaticogastric anastamosis without anterior gastrotomy: A point of view

Kannan N, Gupta S, Kapoor S, Rajagopal G

Oncology Center, Army Hospital (Research and Referral), New Delhi

Correspondence Address:Oncology Center, Army Hospital (Research and Referral), New Delhi Email: majkannan@rediffmail.com

Code Number: is06067

Sir,
We read with interest the article by Tewari and Shukla - ′Anterior gastrotomy technique of fashioning pancreaticogastrostomy following pancreatico-duodenectomy for pancreatic head and periampullary cancer′.[1] We commend the excellent outcome of the procedure of the reported by the group.

At the Oncology Center at Army Hospital (Research and Referral), New Delhi, the standard procedure of reconstruction after a pancreaticoduodectomy has been a posterior pancreaticogastrostomy. Our technique uses a single posterior gastrotomy on the upturned stomach, irrespective of whether or not the pylorus has been spared. The anastomosis is done in two layers with interrupted nonabsorbable sutures. We aim to achieve a duct-to-mucosa anastomosis with 3-4 fine 5′0′ vicryl or PDS suture in addition. We place a simple PVC feeding tube through the duct and anchor the same to the gastric wall before starting the posterior layer of the pancreatic anastomosis, which is done with a parachute technique. Though widely considered ineffective in reducing pancreatic leak, this method of stenting has aided us in performing a better anastomosis without accidental occlusion of the duct. The entire anastomosis is done under direct vision.

Surgical concerns in whipples pancreatico-duodenectomy relates to the various anastomoses needed to be done for restoration of GI continuity. Pancreatic anastomosis has obsessed surgeons for decades and various successful modifications have been described. The success of a pancreatico-intestinal anastomosis is dependent on a duct-to-mucosa, tension-free, well-vascularized suturing technique. The authors rightly point out that most surgeons perform the procedure that does best in their hands.

The addition of a fourth anastomosis in a procedure that already has three major anastomoses seems, in our mind, unnecessary and not without adding risk of early and late problems. The role of a gastrotomy for the sole purpose of better visualization of an anastomotic line seems excessive, as surgically speaking, no anastomosis can be constructed without adequate exposure.

References

Copyright 2006 - Indian Journal of Surgery