Abstract: Objective:To explore the application value of endtoside closed in situ pancreaticojejunostomy in pancreaticoduodenectomy.
Methods:The clinical data of 22 patients with obstructive jaundice who were admitted to the Second Affiliated Hospital of Harbin Medical University from January to March 2014 were retrospectively analyzed. All the patients were explored whether tumors invaded inferior vena cava, superior mesenteric vein and portal vein after gallbladder decompression under general anesthesia by tracheal intubation. The standard or extended pancreaticoduodenectomy was applied according to the intraoperative results. The method of pancreaticojejunostomy was endtoside closed in situ anastomosis of pancreatic duct and jejunal seromuscular layer. The operation time, intraoperative blood loss, postoperative gastrointestinal function recovery time, amylase concentration of drainage at postoperative day 1, 3, 5, postoperative complication, pathological classification and duration of hospital stay  were observed. Patients were followed up by outpatient examination and telephone interview till May 2014. The outpatient followup included color Doppler ultrasound examination of effusion near the pancreatic stump, and the telephone interview included whether there were diarrhea of exocrine pancreatic insufficiency. Measurement data with normal distribution were presented as ±s (range), and measurement data with skewed distribution as M(range).
Results:All the 22 patients underwent successfully the operation, including 17 undergoing standard pancreaticoduodenectomy and 5 undergoing extended pancreaticoduodenectomy, with endtoside closed in situ anastomosis of pancreatic duct and jejuna seromuscular layer. The operation time of pancreaticoduodenectomy and endtoside closed in situ pancreaticojejunostomy were (313±37)minutes (range, 228-360 minutes) and(13±4)minutes (7-22 minutes), respectively. The intraoperative blood loss was (400±207)mL (range, 100-800 mL). The mean tumor size was 3.69 cm2 (range, 0.7²-1.68 cm2). The recovery time of gastrointestinal function was (5±2)days (range, 4-7 days). The serum amylase at postoperative day 1, 3, 5 in the 21 patients was (145±30)U/L (range, 116-180 U/L), (136±40)U/L (range, 105-176 U/L), (147±38)U/L (range, 110-175 U/L), and the drainage amylase was (220±56)U/L (range, 17²-289 U/L), (240±54)U/L (range,19²-300 U/L), (245±52)U/L (range, 190-298 U/L), respectively. The serum amylase at postoperative day 1, 3, 5 in the patient with pancreatic fistula was 156 U/L, 178 U/L and 177 U/L, and the drainage fluid amylase was 500 U/L, 620 U/L and 605 U/L, respectively. There was 1 patient in the 22 patients with pancreatic duct stent and without death. Among the 4 patients with postoperative complications, 1 patient with grade A postoperative pancreatic fistula recovered after continuous external drainage, the other 3 including 1 case of infection, 1 case of pneumonia and 1 of stress ulcer bleeding also recovered after symptomatic and supportive treatment. Postoperative pathological examinations of the 22 patients showed 12 cases of ductal adenocarcinoma, 2 of neuroendocine tumors, 1 of simple cyst, 1 of cystadenocarcinoma, 1 of squamous carcinoma, 1 of adenocarcinoma, 1 of ampullary carcinoma, 1 of tubular adenoma, 1 of leiomyoma and 1 of atypical intraductal hyperplasia. The average length of hospital stay was (11±3)days (range, ²-15 days). There were no effusion near the pancreatic stump showed in color Doppler ultrasound examination and diarrhea of exocrine pancreatic insufficiency.Conclusion:Endtoside closed in situ pancreaticojejunostomy is safe and feasible, and can be applied to any pancreatic duct size and texture.