Clinical Challenges in Hepatobiliary Surgery: Pancreatic Anastomoses in Whipples

Behind The Knife: The Surgery Podcast

Medicine, Health & Fitness, Education, Science

4.8 • 1.4K Ratings

🗓️ 14 November 2024

⏱️ 21 minutes

🔗️ Recording | iTunes | RSS

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Summary

The pancreatic anastomosis is often regarded as the “Achilles Heel” of the Whipple operation, as technical failure and leakage is a significant source of perioperative morbidity and mortality. In this episode from the HPB team at Behind the Knife listen in as we discuss the standard techniques for the anastomosis, alternative techniques for the pancreatic anastomosis in patients with aberrant anatomy and/or physiology, key factors to consider when selecting the ideal approach/technique for the anastomosis, and mitigation strategies for leaks.

Hosts
Anish J. Jain MD (@anishjayjain) is a current PGY3 General Surgery Resident at Stanford University and a former T32 Research Fellow at the University of Texas MD Anderson Cancer Center.

Jon M. Harrison is a 2nd year HPB Surgery Fellow at Stanford University. He previously completed his general surgery residency at Massachusetts General Hospital, and will be returning to MGH as faculty at the conclusion of his fellowship.

Monica M. Dua (@MonicaDuaMD) is a Clinical Professor of Surgery and the Associate Program Director of the HPB Surgery Fellowship at Stanford University. She also serves as also serves as the regional HPB Surgeon at the VA Palo Alto Health Care System.

Learning Objectives
· Develop an understanding of the standard technical approaches to the pancreatic anastomosis during a Whipple (pancreatoduodenectomy) operation
· Develop an understanding of the alternative technical approaches to the pancreatic anastomosis during the Whipple when the standard approaches may not be feasible
· Develop an understanding of the key anatomic and physiologic factors in the decision making when selecting the optimal approach for the pancreatic anastomosis
· Develop an understanding of possible mitigation strategies in the event of a pancreatic anastomotic leak.

Suggested Reading
Jon Harrison, Monica M. Dua, William V. Kastrinakis, Peter J. Fagenholz, Carlos Fernandez-del Castillo, Keith D. Lillemoe, George A. Poultsides, Brendan C. Visser, Motaz Qadan. “Duct tape:” Management strategies for the pancreatic anastomosis during pancreatoduodenectomy. Surgery. Volume 176, Issue 4, 2024, Pages 1308-1311,
https://pubmed.ncbi.nlm.nih.gov/38796390/

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Transcript

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0:00.0	Behind the Night, the Surgery podcast, relevant and engaging content designed to help you
0:11.6	dominate the day.
0:26.8	Greetings, everyone. Welcome to another HPB episode on Behind the Knife. This is your HPB team coming to you from Stanford University in California. I'm Anish, a PGY3 general
0:32.5	surgery resident here at Stanford, and I'm excited to be joined by some great mentors in Dr. Monica
0:37.3	Dua, the associate PD of our HPB fellowship, and I'm excited to be joined by some great mentors in Dr. Monica Dua,
0:38.1	the associate PD of our HPB Fellowship, and Dr. John Harrison, our second-year HPB fellow
0:43.3	and soon-to-be HPB faculty at MGH. Today, we'll be discussing the pancreatic anastomosis
0:49.3	during pancreato duodenectomies or the Whipple procedure. Specifically, we'll discuss the standard reconstructive
0:55.2	options as well as alternative approaches when patients have unfavorable and or abhorrant
1:00.8	anatomy or physiology. A lot of the concepts that we'll discuss in today's episodes can be found in a
1:06.9	recent invited commentary in surgery that was written by the HV faculty here at Stanford
1:11.9	and the HV faculty at MGH. And we'll include that article in the show notes. So, Dr. Dua,
1:19.9	could you just kind of talk to us about the standard Blumgard style and Asthmosa that most people
1:24.2	are familiar with and most residents should be familiar with? Thank you. I think it's really an important topic because the pancreaticodeginostomy
1:32.3	is a really critical part of the reconstruction and it's really important to pay attention to technique.
1:40.3	And even though you have a favorite type of endastomosis, it's good to have different options available.
1:47.0	So for me, I preferably do the Blumgart anastomosis.
1:51.0	In this particular anastomosis, it involves three silk sutures, which are trans-pancreatic.
1:58.0	And they basically approximate the parankham to the dejunum using seromuscular
2:04.3	u stitches and then once these are placed we do a duct tube mucosa anostomosis using 6-0 PDS suture
2:13.2	okay awesome and john sometimes when we're around you talk to me about this end-to-side
2:18.2	dunking technique. Can you describe that for our listeners? Right. So this whole paper was inspired
	...

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