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Indian Journal of Surgery, Vol. 68, No. 5, September-October, 2006, pp. 287 Letter To Editor Reply to: Technique of pancreaticogastric anastamosis without anterior gastrotomy Tewari Mallika, Shukla HariS Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, UP Code Number: is06085 Related Article: is05103 Sir, I read with interest the observations forwarded by Dr. Kannan[1] in response to a paper written by us, Dr. Mallika Tewari and Dr. HS Shukla,[2] published in the Indian Journal Surgery on the subject of restoration of Pancreatico-enteric continuity after pylorus preserving or standard pancreaticoduodenectomy. In this paper we had brought out a user-friendly method of completing posterior pancreatico- gastrostomy through anterior gastrotomy to give direct access to the posterior wall of the stomach from inside of the stomach. The common complication after pancreatico-duodenectomy is pancreatic leak and hemorrhage. Pancreatic fistula is the most important postoperative complication. The independent risk factors associated with high incidence of pancreatic leak are: 1) The type of pancreaticoenteric anastomosis, 2) A soft pancreas causes impaired healing, is difficult to suture as compared to hard and atrophic pancreas, 3) Duration of operation lasting for more than eight hours, 4) Intraoperative blood loss, 5) Ischemia of jejunal/pancreatic cut ends 6) Patient-related factors and 7) Surgeon volume. The possible explanation of postoperative gastrointestinal (GI) hemorrhage following pancreatoenteric anastomosis especially pancreaticogastrostomy (PG) is either from a stress ulcer or anastomotic suture line. As most patients routinely receive stress ulcer prophylaxis, suture line hemorrhage should still be considered as an important cause of GI hemorrhage in the immediate postoperative period and is seen in a significant number of patients having GI hemorrhage.[3],[4],[5],[6] Suture line hemorrhages can predispose to leak and erosive secondary hemorrhage. These hemorrhages have a high mortality even with aggressive management making prevention of this bleeding important. [3],[4],[5],[6] Authors using anterior gastrotomy technique of PG have not reported any case of GI hemorrhage which corroborates with our finding.[7],[8],[9] It can be understood that better hemostasis can be secured when one examines the PG from inside after construction rather than a blind invagination. Dr. Kannan and co-workers are suggesting that this can very well be done by the dunking procedure after making the gastrotomy on the posterior wall of the stomach and they claim that success is achieved in their hands. Difficult operations appear easy in the hands of experts. It is well recognized that one needs to do at least 10 pancreaticoduodenectomies per year to qualify as a pancreatic surgeon. In any case, the restoration of pancreatico-enteric continuity may be complicated by bleeding through the edges of the pancreas and direct vision while doing the pancreatic anastomosis may be far superior and technically easier than simply passing the stomach blindly from behind even if such modern gadgets like the harmonic scalpel etc. are available. We feel that a direct anastomosis of the pancreatic stump with the posterior wall of the stomach by doing anterior gastrotomy in patients undergoing pylorus-preserving pancreaticoduodenectomy is a fair procedure. References
Copyright 2006 - Indian Journal of Surgery |
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