Evidence - Pancreatogastrostomy

Pancreatogastrostomy is a common alternative to pancreatojejunostomy [1, 2, 3, 4]. Anastomosis of the pancreatic remnant with the stomach was first described in 1946 [5] and refined in the 1980s.

Pancreatogastrostomy offers the following benefits:

• Close anatomical relation of the posterior gastric wall with the pancreas
• low risk of gastric ischemia
• easy access to the anastomosis by gastroscopy
• Easy decompression of the anastomosis via the gastric tube
• Anastomosis of even large-caliber pancreatic remnants [6, 7].

As a reconstruction procedure, pancreatogastrostomy results in pancreatic fistula rates of less than 2.5% [4, 7, 8, 9]. Complications also include bleeding at the anastomosis, which can be well controlled by adequate management of postoperative complications [4, 7, 8, 10]. Overgrowth of the pancreatogastrostomy by gastric mucosa resulting in anastomotic stenosis has been described [11, 12, 13].

A number of variant techniques have been published for pancreatogastrostomy:

• Invagination or "duct to mucosa" [14].
• Suture technique - purse-string suture or transpancreatic mattress suture [10, 15].
• Access to the posterior gastric wall via anterior gastrotomy [16].

There are numerous observational studies, some meta-analyses, and randomized controlled trials [17-31] addressing the issue which anastomosis technique – pancreatojejunostomy or pancreatogastrostomy – is better in terms of morbidity and mortality. Conclusion: At present, there is insufficient evidence for clear superiority of either anastomosis technique.

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2. Eggert A, Teichmann W (1982) Pancreatogastrostomy in papillary cancer. Chirurg 53:382–386

3. Flautner L, Tihanyi T, Szecseny A (1985) Pancreatogastrostomy: an ideal complement to pancreatic head resection with preservation of the pylorus in the treatment of chronic pancreatitis. Am J Surg 150:608–611

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5. Waugh JM, Clagett OT (1946) Resection of the duodenum and head of the pancreas for carcinoma. Surgery 20:224–232

6. Standop J, Overhaus M, Schafer N et al (2009) Technique of pancreatogastrostomy after pancreaticoduodenectomy. Zentralbl Chir 134:113–119

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8. Fabre JM, Arnaud JP, Navarro F et al (1998) Results of pancreatogastrostomy after pancreatoduodenectomy in 160 consecutive patients. Br J Surg 85:751–754

9. Kapur BM, Misra MC, Seenu V et al (1998) Pancreaticogastrostomy for reconstruction of pancreatic stump after pancreaticoduodenectomy for ampullary carcinoma. Am J Surg 176:274–278

10. Standop J, Schafer N, Overhaus M et al (2009) Endoscopic management of anastomotic hemorrhage from pancreatogastrostomy. Surg Endosc 23:2005–2010

11. Pessaux P, Aube C, Lebigot J et al (2002) Permeability and functionality of pancreaticogastrostomy after pancreaticoduodenectomy with dynamic magnetic resonance pancreatography after secretin stimulation. J Am Coll Surg 194:454–462

12. Amano H, Takada T, Ammori BJ et al (1998) Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study. Hepatogastroenterology 45:2382–2387

13. Kurosaki I, Hatakeyama K, Kobayashi T et al (2003) Pancreaticogastrostomy: unreliable long-term pancreatic duct patency. Hepatogastroenterology 50:545–549

14. Shinchi H, Takao S, Maemura K et al (2006) A new technique for pancreaticogastrostomy for the soft pancreas: the transfixing suture method. J Hepatobiliary Pancreat Surg 13:212–217

15. Ohigashi H, Ishikawa O, Eguchi H et al (2008) A simple and safe anastomosis in pancreaticogastrostomy using mattress sutures. Am J Surg 196:130–134

16. Bassi C, Butturini G, Salvia R et al (2006) Open pancreaticogastrostomy after pancreaticoduodenectomy: a pilot study. J Gastrointest Surg 10:1072–1080

17. Tewari M, Hazrah P, Kumar V et al (2010) Options of restorative pancreaticoenteric anastomosis following pancreaticoduodenectomy: a review. Surg Oncol 19:17–26

18. Lai EC, Lau SH, Lau WY (2009) Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review. Arch Surg 144:1074–1080

19. Adams DB (2009) The pancreatic anastomosis: the danger of a leak, which anastomotic technique is better? J Gastrointest Surg 13:1182–1183

20. Kleespies A, Albertsmeier M, Obeidat F et al (2008) The challenge of pancreatic anastomosis. Langenbecks Arch Surg 393:459–471

21. Shrikhande SV, Qureshi SS, Rajneesh N et al (2005) Pancreatic anastomoses after pancreaticoduodenectomy: do we need further studies? World J Surg 29:1642–1649

22. Kim JH, Yoo BM, Kim WH (2009) Which method should we select for pancreatic anastomosis after pancreaticoduodenectomy? World J Surg 33:326–332

23. Kim SW, Youk EG, Park YH (1997) Comparison of pancreatogastrostomy and pancreatojejunostomy after pancreatoduodenectomy performed by one surgeon. World J Surg 21:640–643

24. Takano S, Ito Y, Watanabe Y et al (2000) Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy. Br J Surg 87:423–427

25. Oussoultzoglou E, Bachellier P, Bigourdan JM et al (2004) Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy. Arch Surg 139:327–335

26. Hoshal VL Jr, Benedict MB, David LR et al (2004) Personal experience with the Whipple operation: outcomes and lessons learned. Am Surg 70:121–126

27. Duffas JP, Suc B, Msika S et al (2005) A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg 189:720–729

28. Bassi C, Falconi M, Molinari E et al (2005) Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg 242:767–771, discussion 771–763

29. Fernandez-Cruz L, Cosa R, Blanco L et al (2008) Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy: a prospective randomized study. Ann Surg 248:930–938

30. Mckay A, Mackenzie S, Sutherland FR et al (2006) Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy. Br J Surg 93:929–936

31. Wente MN, Shrikhande SV, Muller MW et al (2007) Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis. Am J Surg 193:171–183