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The "Colonial Wig" Pancreaticojejunostomy: Zero Leaks wtih A Novel Technique for Reconstruction after Pancreaticoduodenectomy
*Xihua Steve Yang1, *Pouya Aghajafari1, *Shirali Patel2, *Steven Cunningham2
1Saint Agnes Hospital, Ellicott City, MD;2Saint Agnes Hospital and Cancer Institute, Ellicott City, MD

OBJECTIVE: Despite extensive experience with pancreaticoduodenectomy (PD) postoperative pancreatic fistula (POPF) is common (>40% of soft-pancreas cases). We designed a novel approach. DESIGN: Retrospective. SETTING: High-pancreas-volume community-teaching hospital. PATIENTS: Fifty consecutive pancreatic head resections. INTERVENTIONS: Reasoning that leaks occur not only from the main pancreatic duct, but also from small ductules on the cut surface of the pancreas, that anastomotic corners are especially susceptible areas for leaking, and that two hermetic layers are optimal, we combined a compressive U-stitch invagination, a novel technique to bury the corners with the "curls" of the "Colonial Wig" (Figure), and finally hermetically sutured the outer layer. Patients having complications precluding assessment of POPF (eg, early postoperative mortality) were excluded. RESULTS: Of 50 consecutive pancreatic-head resections, 48 were PDs. Comorbidities existed in 96% of patients (median 5/patient). The morbidity rate was 49% (27% Clavien grade >2). The median length of stay was 11 days. In the first 26 PDs, the pancreaticojejunostomy (PJ) was performed with a duct-to-mucosa technique and the clinically relevant POPF (CR-POPF) rate was 15%. In the next 22 PJs, the "Colonial Wig" anastomosis was employed (Figure), with a CR-POPF rate 0% (P=0.066) among eligible cases. These groups had similar Fistula Risk Score (P=0.35). The observed CR-POPF rate of 0% was significantly lower than the predicted rate of 13% (P=0.049). CONCLUSIONS: High-volume pancreatic surgery is possible at a teaching community hospital, and morbidity is comparable with the literature. Our novel "Colonial Wig" anastomosis is an effective way to avoid POPF.


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