The American Journal of Surgery (2011) 201, e29 e31

How I Do It

Telescopic technique associated with mucosectomy: a

simple and safe anastomosis in pancreaticoduodenectomy
Peng Li, M.D., Qinsheng Mao, M.D.*, Rui Li, M.D., Zhiwei Wang, M.D.,
Wanjiang Xue, M.D., Peng Wang, M.D., Jiangwei Zhu, M.D., Houxiang Li, M.D.
Department of Surgery, Affiliated Hospital of Nantong University, 20 Xisi Rd., Nantong 226001, China
KEYWORDS:
Pancreaticoduodenectomy;
Pancreatic leakage;
Pancreaticojejunal
anastomosis;
Mucosectomy

Abstract. Pancreatic fistula remains a common problem and a main cause of morbidity and mortality
after pancreaticoduodenectomy (PD). We have developed a safe and simple method of pancreaticojejunostomy in 33 patients, in whom approximately 3 cm of jejunal mucosa was cut to improve the
adhesion between the loop and pancreatic parenchyma after end-to-end invagination. Furthermore, we
have performed a purse-string procedure on 21 patients to secure the jejunum to the intussuscepted
pancreatic stump instead of continuous running fashion with double needles of 5-0 monofilament
synthetic absorbable sutures. This procedure was proved to be much more expeditious, and only 2 of
33 patients had pancreatic leakages. Therefore, the telescopic technique associated with mucosectomy
is an acceptable and safe surgery for pancreaticojejunal anastomosis.
2011 Elsevier Inc. All rights reserved.

Although the safety of pancreaticoduodenectomy (PD)

has been improved to a large extent during the past decades,
pancreatic fistulae remains a leading cause of morbidity and
mortality after PD.13 A variety of methods have been used
to reduce the postoperative pancreatic fistula rate to a minimum. In this study, we designed a modified one-layer
technique that invaginates the sheath of the jejunum with
the mucosa removed to the pancreatic remnant. It has been
proved to be effective in preventing the occurrence of pancreatic leakage, and to be clinically acceptable.

Technique
After PD, the neck of the pancreas was divided carefully
and clearly with a scalpel or electrocautery on the scheduled
The authors have no conflicts of interest to declare.
* Corresponding author: Tel.: 86-513-85052521; fax: 86-51385052432.
E-mail address: ntmqs@yahoo.com.cn
Manuscript received April 9, 2010; revised manuscript April 15, 2010

0002-9610/$ - see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2010.04.021

line. Hemostasis was sutured and ligated with 5-0 monofilament synthetic absorbable sutures by transfixion and these
sutures should not be cut because they are used later as
traction sutures. The pancreas remnant was dissected at a
distance of 3 cm away from its cut edge (Fig. 1). The jejunal
stump was everted for 3 cm by suturing the seromuscular
layer of the jejunal cut edge to a point at the jejunum 6 cm
from the edge. These 2 sutures were tied loosely, leaving 3
cm of the jejunum everted with its mucosa exposed for
excising (Figs. 2 and 3). Then, the main pancreatic duct was
identified and a stent was inserted for 3 to 5 cm, and sutured
twice at the 2 sides of the main duct with 5-0 monofilament
synthetic absorbable sutures. The traction suture was drawn
out through the cut for biliary anastomosis. Then, the pancreatic stump and free margin of jejunal limb were fixed
together as end-to-end invagination (Fig. 4). In the initial 12
cases, anterior and posterior rows of continuous running
sutures with 5-0 monofilament synthetic absorbable sutures
were placed between the cut edge of the jejunal stump and
pancreatic capsule. However, in the next 21 cases, a purse
string pliers was applied to the cut end of the proximal

e30

The American Journal of Surgery, Vol 201, No 3, March 2011

Figure 3
pared.
Figure 1 The pancreas remnant was dissected at a distance of 3
cm away from its cut edge.

jejunum (Fig. 5). Further, 6 fixation stitches with 5-0 PDS II

were used to incorporate the purse-string and the anterior
and posterior aspects of the pancreatic stump 3 cm from the
cut edge of the pancreas. The biliary anastomosis was constructed 10 cm distal to the pancreaticojejunostomy in an
end-to-end fashion. Then, 2 drainage tubes were placed near
the anastomoses. All patients recovered well in the 3- to
6-month follow-up period.

The jejunal stump everted without mucosa is pre-

with double needles of 5-0 monofilament synthetic absorbable sutures to compare with continuous running fashion.
The procedure saved time and there was no surgical mortality. The volume and amylase contents of the drainage
were measured every other day postoperatively. Pancreatic
fistula was defined as a draining fluid amylase level that was
3 times the upper limit of the normal amylase level after the
third postoperative day when the drain output exceeds 50
mL.4 Prophylactic somatostatin was used as routine. Two
patients developed pancreatic leakage, and were treated
with drainage only. No hemorrhage or cholangitis was observed. The postoperative hospital stay was 9 to 26 days
(mean, 18 d). No postoperative mortality was observed.

Results
In our consecutive series of 33 cases between May 2007
and May 2009, 4 patients had pancreatic head malignancy
and 29 had periampullary malignancy. Telescopic technique
associated with mucosectomy was performed, in which the
purse-string technique with the jejunum intussuscepted to
the pancreatic stump was performed on 21 of 33 patients

Figure 2

Excising the mucosa of the jejunal stump.

Comments
PD has become the standard treatment for patients with
periampullary malignancy, including pancreatic carcinoma,
ampullary carcinoma, and distal cholangiocarcinoma. De-

Figure 4 The pancreatic stump and free margin of the jejunal

limb were fixed together as end-to-end invagination. The traction
sutures are drawn out through the cut where the biliary anastomosis will be performed.

P. Li et al.

Telescopic technique

Figure 5 A purse-string pliers was applied to the cut end of the

jejunal stump.

spite the recent advances in surgical techniques and perioperative management, the postoperative morbidity and mortality rates of PD surgeries still is high. Pancreaticojejunal
anastomotic fistula is still the most common and serious
complication. Some investigators prefer duct to mucosa
pancreaticojejunostomy if the pancreatic duct is 5 mm or
greater in diameter. Murr et al constructed the end-to-end
pancreaticojejunal anastomosis with the purse-string technique and the outcomes were encouraging.5 We used this
telescopic technique associated with mucosectomy in our
consecutive series of 33 cases between May 2007 and May
2009 and observed a pancreatic leakage rate of 6%. In
addition to adherence to basic principles of the pancreatic
anastomosis such as blood supply preservation and tensionfree fixation of the gastrointestinal tract to the pancreas, our
acceptable results might be attributed to several reasons.
First, the removal of the mucosa makes it easier and faster
to induce an inflammatory adhesion and thereby promotes

e31
the healing process of the seromuscular layer of the end of
the jejunum and the pancreatic stump capsule by a tight seal.
Second, fine, nonstrangulating suture placement produces a
watertight patent anastomosis. Third, removal of the mucosa of the jejunum makes the lumen of the jejunal limb
wide enough to accommodate any type of pancreatic stump,
which is a prerequisite for an ideal pancreaticojejunal anastomosis. Fourth, the mucosa of the jejunum is loose and
pachyntic and thus easier to cut, therefore, a shorter learning
curve is needed to master this technique even for an inexperienced pancreatic surgeon if compared with the technique of duct-to-mucosa pancreatico-enteric anastomosis.
Fifth, absorbable monofilament sutures instead of silk sutures mitigates the laceration of the pancreatic stump and
purse-string sutures reduces the stitches to a minimum. The
results of this modified pancreaticojejunostomy anastomotic
technique are encouraging.
In conclusion, this modified pancreaticojejunostomy
anastomotic technique can be considered as an alternative
treatment for PD, and can be applied easily in pancreatic
surgery. However, larger prospective cohort series and prospective randomized studies are needed to further validate
our preliminary outcome.

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4. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic
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