Surgical Morphology of the Pancreatic Isthmus

Background: Pancreatic isthmus method anastomosis following pancreatic resection is an important factor of postoperative fistula formation. While the anatomy and vascular supply of the pancreatic head have been studied in detail, little is known about the morphology of the pancreatic isthmus. The authors determine the anatomy and morphology of the pancreatic isthmus. Methods: 99 consecutive cadaveric pancreatic specimens were taken during standard autopsy. Organs were transected at the isthmus and pancreatograms and microscopic specimens of the transection plane were analyzed. Results: The mean size of the Wirsung duct at the isthmus was 2.89 mm (±0.87 mm, from 1.4 to 6 mm). The main pancreatic duct was located approximately in the middle of the pancreatic cross-section plane in almost all specimens. The total number of second-degree pancreatic ducts visible on pancreatograms within the isthmus was 1.77 (±1.00, from 0 to 4) and 1.83 (±1.4, from 0 to 5) on microscopic analysis. Conclusions: The presence of second-degree pancreatic ducts at the transection site might favor the use of a pancreaticoenteric anastomosis with stump invagination to reduce the risk of anastomotic leakage.

[1]  H. Friess,et al.  Pancreatic Duct Diversity , 2009, Pancreas.

[2]  K. Jaskiewicz,et al.  Pancreatic cross-section: an elliptical model. , 2007, JOP : Journal of the pancreas.

[3]  M. Zenker,et al.  Pancreatic development and disease. , 2007, Gastroenterology.

[4]  H. Friess,et al.  Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis. , 2007, American journal of surgery.

[5]  S. Takao,et al.  A new technique for pancreaticogastrostomy for the soft pancreas: the transfixing suture method. , 2006, Journal of hepato-biliary-pancreatic surgery.

[6]  T. Fujii,et al.  Is pancreaticogastrostomy safer than pancreaticojejunostomy? , 2006, Journal of hepato-biliary-pancreatic surgery.

[7]  Seung Woo Park,et al.  The Relationship of Anatomic Variation of Pancreatic Ductal System and Pancreaticobiliary Diseases , 2006, Yonsei medical journal.

[8]  S. Koizumi,et al.  A prospective analysis of the factors influencing pancreaticojejunostomy performed using a single method, in 100 consecutive pancreaticoduodenectomies , 1998, Surgery Today.

[9]  C. Bassi,et al.  Reconstruction by Pancreaticojejunostomy Versus Pancreaticogastrostomy Following Pancreatectomy: Results of a Comparative Study , 2005, Annals of surgery.

[10]  S. Msika,et al.  A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. , 2005, American journal of surgery.

[11]  H. Nakajima,et al.  Patency of the accessory pancreatic duct evaluated by dye‐injection endoscopic retrograde pancreatography: Methods and clinical implication , 2004 .

[12]  P. Schmittenbecher.  Anomalous pancreatic duct anatomy, ectopic distal location of the papilla of vater and congenital biliary dilatation a new developmental triad?: I. Li, A. Yamataka, Y-X. Wang, et al. Pediatr Surg Int 19:180–185, (May), 2003 , 2004 .

[13]  A. C. Rao,et al.  Inkwell pancreaticojejunal anastomosis after pancreaticoduodenectomy. , 2004, American journal of surgery.

[14]  T. Takada,et al.  Current pancreatogastrointestinal anastomotic methods: results of a Japanese survey of 3109 patients. , 2004, Journal of hepato-biliary-pancreatic surgery.

[15]  A. Gumbs,et al.  Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial. , 2003, Surgery.

[16]  A. Yamataka,et al.  Anomalous pancreatic duct anatomy, ectopic distal location of the papilla of Vater and congenital biliary dilatation: a new developmental triad? , 2003, Pediatric Surgery International.

[17]  Kaspar Z'graggen,et al.  How to do a safe pancreatic anastomosis. , 2002, Journal of hepato-biliary-pancreatic surgery.

[18]  Y. Ku,et al.  New Pancreatic Duct-Invagination Anastomosis Using UltrasonicDissection for Nonfibrotic Pancreas with a Nondilated Duct , 2002, World Journal of Surgery.

[19]  Y. Morishita,et al.  Results of duct-to-mucosa pancreaticojejunostomy for pancreaticoduodenectomy Billroth I type reconstruction in 100 consecutive patients. , 2001, Journal of the American College of Surgeons.

[20]  M. Makuuchi,et al.  Anatomical segmentectomy of the head of the pancreas along the embryological fusion plane: a feasible procedure? , 2000, Surgery.

[21]  W. Kimura.  Surgical anatomy of the pancreas for limited resection. , 2000, Journal of hepato-biliary-pancreatic surgery.

[22]  H. Nagai,et al.  Pancreatogastrostomy (PG) after pancreatoduodenectomy with or without duct-to-mucosa anastomosis for the small pancreatic duct: short- and long-term results. , 2000, Hepato-gastroenterology.

[23]  T. Takada,et al.  Three-dimensional reconstruction of the ventral and dorsal pancreas: a new insight into anatomy and embryonic development. , 1999, Journal of hepato-biliary-pancreatic surgery.

[24]  C. Wilasrusmee,et al.  Pancreaticobiliary ductal anatomy in Thai people. , 1999, Journal of hepato-biliary-pancreatic surgery.

[25]  Y. Yamada,et al.  Pancreatic division by electrocautery in pancreatoduodenectomy. , 1999, Journal of hepato-biliary-pancreatic surgery.

[26]  K. Inoue,et al.  Pathophysiology after pylorus-preserving pancreatoduodenectomy: a comparative study of pancreatogastrostomy and pancreatojejunostomy. , 1999, Hepato-gastroenterology.

[27]  M. Koike,et al.  Embryology of the Pancreatic Duct System , 1999, Digestion.

[28]  S. Strasberg,et al.  Results of a technique of pancreaticojejunostomy that optimizes blood supply to the pancreas. , 1998, Journal of the American College of Surgeons.

[29]  M. Talamini,et al.  Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. , 1997, Annals of surgery.

[30]  T. Tillmanns.  Novak’s gynecology, 12th edition. edited by jonathan s berek, md, mmsc, eli y adashi, md, and paula a. hillard, md 1,359 pages, illustrated. $95.00. baltimore: williams & wilkins, 1996. , 1997 .

[31]  Y. Morishita,et al.  Pancreaticojejunostomy-securing technique: duct-to-mucosa anastomosis by continuous running suture and parachuting using monofilament absorbable thread. , 1997, Journal of the American College of Surgeons.

[32]  G. Ravera,et al.  Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Review and statistical meta-analysis regarding 15 years of literature. , 1991, Anticancer research.

[33]  J. Peoples,et al.  Are pancreatoenteric anastomoses improved by duct-to-mucosa sutures? , 1991, American journal of surgery.

[34]  W. Kausch.  Das Carcinom der Papilla duodeni und seine radikale Entfernung , 1912 .