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Brief Report | Resident's Forum

Minimizing Shear and Compressive Stress During Pancreaticojejunostomy:  Rationale of a New Technical Modification

Vladimir K. Neychev, MD, PhD1,2; Pierre F. Saldinger, MD3
[+] Author Affiliations
1Department of Surgery, Danbury Hospital Medical Arts Center, Danbury, Connecticut
2currently with the Surgical Endocrine Oncology Branch, National Cancer Institute, Bethesda, Maryland
3Department of Surgery, New York Hospital Queens, Flushing, New York
JAMA Surg. 2014;149(2):203-207. doi:10.1001/jamasurg.2013.2256.
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The failure of the pancreaticojejunal anastomosis remains an important and potentially lethal postoperative complication after pancreaticoduodenectomy. During the pancreaticojejunostomy, creation of compressive and shear forces during suture placement and knot tying may cause deformation of and cutting through the fragile pancreatic parenchyma. We sought to understand the mechanics of needle-pancreas interaction and make adjustments to our pancreaticojejunostomy technique so that the creation of shear and compressive stress could be minimized. We provide a detailed description, a mathematical model, and analysis of the outcomes of our new technical modifications.

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Figure 1.
Schematic of Outer-Row Pancreaticojejunal Anastomosis

A, Full-thickness outer-row U sutures with the needle straightened by the surgeon. B, The force (Fτ) applied by the surgeon at an application point (A) with its shear (Ft) and compressive (Fr) components, the center of the needle (C), the shear and compressive forces inversely proportional to the radius of the needle (r), and the angle (θ) between the radius and force vectors are depicted. C, The same section depicts the needle straightened with a bigger radius (r) and application angle (θ) and less shear (Ft) and compressive (Fr) forces. Calculations are given in the Supplement (eAppendix).

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Figure 2.
Schematic of the Duct-to-Mucosa Anastomosis

The duct-to-mucosa sutures are tied such that the knots are on the outside (the anterior row is not shown for clarity).

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Figure 3.
Schematic of Tying Outer-Row Sutures

A, The double-armed sutures tied on the jejunum. B, The shear (horizontal) component (Fh) of the force (Fs) created during double-armed suture tying redirected from the pancreas to the bowel wall. Fv indicates the nonshear (vertical) component. C, Single-needle suture technique not allowing for complete redistribution of shear component (Fh) to the forces (Fs) from the pancreas to the bowel. D, Tying sutures on the anterior surface of the pancreas before placing them through the jejunum changes the direction of the force vectors from vertical (Fv) to horizontal (Fh) and results in redistributing the shear forces (Fs) from the bowel back to the pancreas. Calculations are given in the Supplement (eAppendix).

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