Pancreatojejunal sutural insufficiency occurring after pancreatoduodenectomy and countermeasures

Pancreatojejunal sutural insufficiency occurring after pancreatoduodenectomy and countermeasures are discussed. In the Department of Surgery at Kurume University School of Medicine, 318 patients underwent pancreatoduodenectomies. The present study includes 15 of these patients, all of whom had pancreatojejunal sutural insufficiency. The frequency of sutural insufficiency was 4.7%. Five patients had bile duct cancer, 5 had cancer of the papilla of Vater, 2 had a carcinoma of the pancreatic head, 1 each had gallbladder cancer, chronic pancreatitis, and papillitis. Six (40%) of the 15 patients died during hospitalization. The presence or absence of sutural insufficiency was confirmed mainly by radiography and determining the properties and amylase levels of the drainage fluid. There was no significant difference due to the method of anastomosis. End-to-side anastomosis had a rate of 5 (5.9%) of 85 patients, while end-to-end had 10 (4.3%) of 233 patients. The sutural insufficiency was manifested as a major leakage in 6 patients and a minor leakage in 9. The degree of lymph node dissection was D0 in 6.1%, D1 in 1.4%, D2 in 4.8% and D3 in 10.8%, with a high incidence of sutural insufficiency in D3 patients. The pancreatic duct diameter was smaller than 4 mm in 10, 5-7 mm in 4 and over 8 mm in 1 patient. The intraoperative pancreatic findings were a soft pancreas in 8, slightly hard in 3, and hard in 4 patients. Fibrosis of the pancreas was normal to slight in 11 and moderate in 4 patients. Drainage by relaparotomy was performed in 4 of the 6 patients with major leakages to control sutural insufficiency, and the other 2 underwent continuous aspiration with an intraperitoneal drain inserted during the operation. The 9 patients with minor leakage underwent conservative treatment including continuous aspiration via an intraperitoneal drain inserted during surgery, fasting, intravenous hyperalimentation, and antibiotic administration. All of the patients with major leakage died from an associated occurrence of hepatic insufficiency, renal insufficiency, intraperitoneal hemorrhage or diffuse peritonitis during hospitalization. However, 8 of the 9 patients with minor leakage had some healing, and the 1 remaining patient developed a pancreatic fistula. The frequency of pancreatojejunal sutural insufficiency was high in patients with minimal pancreatic fibrosis, with soft pancreatic tissue without dilatation of the pancreatic duct, and with relatively good pancreatic function.