Evidenz - Pankreatogastrostomie

Die Pankreatogastrostomie stellt eine häufig verwendete Alternative zur Pankreatojejunostomie dar [1, 2, 3, 4]. Erstmals beschrieben wurde die Anastomosierung des Pankreasrestes mit dem Magen 1946 [5] und in den 1980er Jahren weiterentwickelt.

Die Pankreatogastrostomie hat folgende Vorteile:

• enge anatomische Lage von Magenhinterwand und Pankreas
• geringes Ischämierisiko des Magens
• problemlose Zugänglichkeit der Anastomose mittels Gastroskopie
• problemlose Druckentlastung der Anastomose über eine Magensonde
• Anastomosierung auch großkalibriger Rest-Pankreata [6, 7]

Mit der Pankreatogastrostomie als Rekonstruktionsprozedur werden Pankreasfistelraten von unter 2,5 % erreicht [4, 7, 8, 9]. Zu den Komplikationen gehören ebenfalls  Blutungen im Anastomosenbereich, die durch ein adäquates postoperatives Komplikationsmanagement gut beherrschbar sind [4, 7, 8, 10]. Eine Überwucherung der Pankreatogastrostomie durch Magenmukosa mit resultierender Anastomosenstenose ist beschrieben worden [11, 12, 13].

Es existieren diverse technische Varianten für die Technik der Pankreatogastrostomie:

• Invagination oder „duct to mucosa“ [14]
• Nahttechnik – Tabaksbeutelnaht oder transpankreatische Matrazennaht [10, 15]
• Zugang zur Magenhinterwand via anteriorer Gastrotomie [16]

Zur Frage, welche Anastomosentechnik - Pankreatojejunostomie oder Pankreatogastrostomie - die bessere hinsichtlich Morbidität und Letalität ist, existieren zahlreiche Beobachtungsstudien, einige Metaanalysen und randomisiert kontrollierte Studien [17 – 31]. Fazit: Aktuell gibt es keine ausreichende Evidenz für die eindeutige Überlegenheit einer der beiden Anastomoentechniken.

z. Zt. keine

1. Hirner A, Haring R, Semsch B (1987) Pancreatogastrostomy in Whipple’s operation. Chirurg 58:431–434

2. Eggert A, Teichmann W (1982) Pancreatogastrostomy in papillary cancer. Chirurg 53:382–386

3. Flautner L, Tihanyi T, Szecseny A (1985) Pancreatogastrostomy: an ideal complement to pancreatic head resection with preservation of the pylorus in the treatment of chronic pancreatitis. Am J Surg 150:608–611

4. O’Neil S, Pickleman J, Aranha GV (2001) Pancreaticogastrostomy following pancreaticoduodenectomy: review of 102 consecutive cases. World J Surg 25:567–571

5. Waugh JM, Clagett OT (1946) Resection of the duodenum and head of the pancreas for carcinoma. Surgery 20:224–232

6. Standop J, Overhaus M, Schafer N et al (2009) Technique of pancreatogastrostomy after pancreaticoduodenectomy. Zentralbl Chir 134:113–119

7. Mason GR (1999) Pancreatogastrostomy as reconstruction for pancreatoduodenectomy: review. World J Surg 23:221–226

8. Fabre JM, Arnaud JP, Navarro F et al (1998) Results of pancreatogastrostomy after pancreatoduodenectomy in 160 consecutive patients. Br J Surg 85:751–754

9. Kapur BM, Misra MC, Seenu V et al (1998) Pancreaticogastrostomy for reconstruction of pancreatic stump after pancreaticoduodenectomy for ampullary carcinoma. Am J Surg 176:274–278

10. Standop J, Schafer N, Overhaus M et al (2009) Endoscopic management of anastomotic hemorrhage from pancreatogastrostomy. Surg Endosc 23:2005–2010

11. Pessaux P, Aube C, Lebigot J et al (2002) Permeability and functionality of pancreaticogastrostomy after pancreaticoduodenectomy with dynamic magnetic resonance pancreatography after secretin stimulation. J Am Coll Surg 194:454–462

12. Amano H, Takada T, Ammori BJ et al (1998) Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study. Hepatogastroenterology 45:2382–2387

13. Kurosaki I, Hatakeyama K, Kobayashi T et al (2003) Pancreaticogastrostomy: unreliable long-term pancreatic duct patency. Hepatogastroenterology 50:545–549

14. Shinchi H, Takao S, Maemura K et al (2006) A new technique for pancreaticogastrostomy for the soft pancreas: the transfixing suture method. J Hepatobiliary Pancreat Surg 13:212–217

15. Ohigashi H, Ishikawa O, Eguchi H et al (2008) A simple and safe anastomosis in pancreaticogastrostomy using mattress sutures. Am J Surg 196:130–134

16. Bassi C, Butturini G, Salvia R et al (2006) Open pancreaticogastrostomy after pancreaticoduodenectomy: a pilot study. J Gastrointest Surg 10:1072–1080

17. Tewari M, Hazrah P, Kumar V et al (2010) Options of restorative pancreaticoenteric anastomosis following pancreaticoduodenectomy: a review. Surg Oncol 19:17–26

18. Lai EC, Lau SH, Lau WY (2009) Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review. Arch Surg 144:1074–1080

19. Adams DB (2009) The pancreatic anastomosis: the danger of a leak, which anastomotic technique is better? J Gastrointest Surg 13:1182–1183

20. Kleespies A, Albertsmeier M, Obeidat F et al (2008) The challenge of pancreatic anastomosis. Langenbecks Arch Surg 393:459–471

21. Shrikhande SV, Qureshi SS, Rajneesh N et al (2005) Pancreatic anastomoses after pancreaticoduodenectomy: do we need further studies? World J Surg 29:1642–1649

22. Kim JH, Yoo BM, Kim WH (2009) Which method should we select for pancreatic anastomosis after pancreaticoduodenectomy? World J Surg 33:326–332

23. Kim SW, Youk EG, Park YH (1997) Comparison of pancreatogastrostomy and pancreatojejunostomy after pancreatoduodenectomy performed by one surgeon. World J Surg 21:640–643

24. Takano S, Ito Y, Watanabe Y et al (2000) Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy. Br J Surg 87:423–427

25. Oussoultzoglou E, Bachellier P, Bigourdan JM et al (2004) Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy. Arch Surg 139:327–335

26. Hoshal VL Jr, Benedict MB, David LR et al (2004) Personal experience with the Whipple operation: outcomes and lessons learned. Am Surg 70:121–126

27. Duffas JP, Suc B, Msika S et al (2005) A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg 189:720–729

28. Bassi C, Falconi M, Molinari E et al (2005) Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg 242:767–771, discussion 771–763

29. Fernandez-Cruz L, Cosa R, Blanco L et al (2008) Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy: a prospective randomized study. Ann Surg 248:930–938

30. Mckay A, Mackenzie S, Sutherland FR et al (2006) Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy. Br J Surg 93:929–936

31. Wente MN, Shrikhande SV, Muller MW et al (2007) Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis. Am J Surg 193:171–183

Bauschke A, Deeb AA, Kissler H, Rohland O, Settmacher U. [Anastomotic techniques  in minimally invasive hepatobiliopancreatic surgery]. Chirurgie (Heidelb). 2023 Sep;94(9):775-779.

Chierici A, Frontali A, Granieri S, Facciorusso A, De' Angelis N, Cotsoglou C. Postoperative morbidity and mortality after pancreatoduodenectomy with pancreatic duct occlusion compared to pancreatic anastomosis: a systematic review and meta-analysis. HPB (Oxford). 2022 Sep;24(9):1395-1404.

Fiorentini G, Tamburrino D, Belfiori G, Crippa S, Partelli S, Falconi M. Which is the best pancreatic anastomosis? Minerva Chir. 2019 Jun;74(3):241-252.

Gai YW, Wang HT, Tan XD. Pancreaticojejunostomy Conducive to Biological Healing in Minimally Invasive Pancreaticoduodenectomy. J Gastrointest Surg. 2022 Sep;26(9):1967-1981.

Guo C, Xie B, Guo D. Does pancreatic duct stent placement lead to decreased postoperative pancreatic fistula rates after pancreaticoduodenectomy? A meta-analysis. Int J Surg. 2022 Jul;103:106707.

Kawaida H, Kono H, Hosomura N, Amemiya H, Itakura J, Fujii H, Ichikawa D. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol. 2019 Jul 28;25(28):3722-3737.

Perivoliotis K, Sioka E, Tatsioni A, Stefanidis I, Zintzaras E, Zacharoulis D. Pancreatogastrostomy versus Pancreatojejunostomy: An Up-to-Date Meta-Analysis of  RCTs. Int J Surg Oncol. 2017;2017:7526494.

Qin H, Luo L, Zhu Z, Huang J. Pancreaticogastrostomy has advantages over pancreaticojejunostomy on pancreatic fistula after pancreaticoduodenectomy. A meta-analysis of randomized controlled trials. Int J Surg. 2016 Dec;36(PtA):18-24.

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Wang XX, Yan YK, Dong BL, Li Y, Yang XJ. Pancreatic outflow tract reconstruction  after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. World J Surg Oncol. 2021 Jul 6;19(1):203.

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