Omental Flap to Protect Gastro-Duodenal Artery Stump From Pancreatic Anastomotic Leak in Pancreato-Duodenectomy

Context Pancreatoduodenectomy continues to be associated with a high morbidity. Pancreaticojejunostomy leak is one of the major complications of pancreaticoduodenectomy. Pancreaticojejunostomy leak leads to collection and abscess which erodes into the stumps of divided vessels e.g. gastroduodenal artery, to cause delayed intra-abdominal bleed. Delayed intra-abdominal bleed due to pancreaticojejunostomy leak after pancreaticoduodenectomy is associated with high mortality. Omentum has been used to protect various anastomoses. Objective Use of an omental flap to protect the gastroduodenal artery stump from effects of pancreaticojejunostomy leak after pancreaticoduodenectomy. Patients Pancreaticoduodenectomy was performed in 784 patients between 1989 and 2015 omental flap was used in 132 patients who underwent pancreaticoduodenectomy between 2002 and 2015. Interventions A vascularized flap of greater omentum, based on epiploic branches of right gastro-epiploic vessels, was placed anterior to the gastroduodenal artery stump, fixed to the retroperitoneum and wrapped around the pancreaticojejunostomy like a carpet so as to separate the pancreatic anastomosis from the gastroduodenal artery stump. Results The two groups (omental flap n=132 and no omental flap n=652) were similar for preoperative parameters (hemoglobin and albumin) and operative findings (consistency of pancreas and main pancreatic duct diameter). Incidences of anastomotic leaks were similar in both groups. Post pancreaticoduodenectomy bleed and delayed intraabdominal bleeds occurred in equal proportions in two groups but omental flap group had less grade C bleeds and less delayed intraabdominal bleeds. No patient with pancreaticojejunostomy leak in the omental flap group had delayed intra-abdominal bleed from the gastroduodenal artery stump. Conclusion A vascularized omental flap wrapped around the pancreaticojejunostomy protected the gastroduodenal artery stump from ill effects of pancreaticojejunostomy leak and avoided the risk of delayed intra-abdominal bleed from the gastroduodenal artery stump after pancreaticoduodenectomy. Received November 13th, 2015-Accepted February 15th, 2016