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

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 pancreaticoduodenectomy 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, wellvascularized suturing technique. The authors rightly point out that most surgeons perform the procedure that does best in their hands.