Comparison between pancreatojejunostomy and pancreaticogastrostomy in pancreaticoduodenectomy in a gastroenterology and hepatology teaching hospital
Authors: Hamood Osama Hamid , Abdulhassan Bashar A. , Alturfi Raaft Raoof , Nile Anees K. , Hussein Shareef Mohammed 
Published: November 2024

Background: Pancreatoduodenectomy (PD) is a surgical procedure used to treat diseases of the pancreatic Head, the distal common bile duct (CBD), and the duodenum, as well as trauma to the head of the pancreas. Once the pancreatic head and the duodenum are resected, the surgeon needs to reconnect the stomach, the biliary tract, and the pancreatic stump. The technique for reconstructing the biliary tract is fairly standard, represented by the anastomosis of the CBD to the jejunum, but the reconstruction of the pancreatic stump is a matter of debate. In general, two procedures can be used: pancreaticojejunostomy (PJ), which is an anastomosis between the pancreatic stump and the jejunum, and pancreaticogastrostomy (PG), which is an anastomosis between the pancreatic stump and the stomach.

Aim: The objective of this study was to compare the impact of PJ and PG on the occurrence of postoperative pancreatic fistula (POPF), morbidity, and mortality following PD.

Patients and Methods: This study took place between April 1, 2021 and April 1, 2023 at Gastroenterology and Hepatology Teaching Hospital in Baghdad Medical City. The cases in the study were designed prospectively. It is a comparison between PG and PJ after undergoing Whipple surgery. A total of 30 patients were selected and divided into two groups. The first group consisted of 16 patients who underwent PJ, while the second group consisted of 14 patients who underwent PG. The cases were prepared in the surgical consultation clinic. On the one hand, through PG, it was determined whether the texture of the pancreas was soft and the size of the main pancreatic duct (MPD) was less than 3 mm. On the other hand, through PJ, it was determined whether the texture of the pancreas was firm or hard and the size of the MPD was more than 3 mm.

Results: The age group of males and females ranged from 11 to 68 (median 57) years. There were a total of 16 males and 14 females. The ampullary tumor was present in 11 patients of the PJ group and 7 patients of the PG group. Histopathology of tumors showed adenocarcinoma in 13 patients of the PJ group and in 6 patients of the PG group. POPF occurred in 3 patients of the PJ group, type A in 1 patient and type B in 2 patients, and no POPF was observed in the PG group. Hemorrhage occurred in 1 patient of the PG group and 2 patients of the PJ group. Delayed gastric emptying occurred in 5 patients: 3 patients of the PJ group (type A) and 2 patients of the PG group. SSI (surgical site infection) occurred in 7 patients: 5 patients of the PJ and 2 patients of the PG group. Finally, mortality occurred in 3 patients of the PJ group.

Conclusion: Pancreatic intestinal anastomosis must be tailored to the surgeon's preferences and experience level, and any innovative technique that reduces the prevalence of POPF is welcome in pancreatic surgery. PG seems to be associated with less POPF, morbidity, and mortality than PJ after undergoing Whipple surgery, especially given the soft texture of the pancreas and the size of the MPD < 3 mm.

Recommendations: 1. Because our study included a limited number of samples, further prospective randomized studies with larger samples are required to confirm that PG had fewer complications. 2 Surgeons should be encouraged to use PG more frequently in the future.