Complications after pylorus-preserving pancreatoduodenectomy with gastrointestinal reconstruction by the Imanaga method

Background: Pylorus-preserving pancreatoduodenectomies (PPPDs) have been performed for disorders of the pancreatic head and periampullary region. The most commonly used reconstructive technique anastomoses the duodenum end-to-side to the jejunum, with pancreatic and biliary anastomoses placed proximally to the end-to-side duodenojejunostomy. In contrast, we ha ve favored PPPD with gastrointestinal reconstruction by the Imanaga method (PPPD-Imanaga), which consists of end-to-end duodenojejunostomy, end-to-side pancreatojejunostomy, and choledochojejunostomy, performed in that order, because the PPPD-Imanaga provides a physiologic mixture of food, pancreatic juice, and bile in the upper portion of the jejunum. Study Design: To identify their postoperative complications, we retrospectively reviewed the cases of 55 patients who underwent a PPPD-Imanaga between December 1986 and December 1996. In all cases, the right gastric artery was divided and the pancreatic duct was sewn directly to a small opening in the jejunal mucosa. Twenty patients with malignancy received adjuvant radiotherapy. Results: Five patients died without being discharged, including one who died of cancer progression, for a postoperative mortality rate of 9%. These deaths were limited to patients who had received adjuvant radiotherapy, with only two deaths being procedure related. Delayed gastric emptying, pancreatic leak, and marginal ulcer were observed in 25 (45%), 3 (5%), and 3 (5%) patients, respectively. The delay in gastric emptying was transient and resolved spontaneously, with no patients undergoing reoperation. Only one patient required a reoperation, for the control of intraabdominal bleeding. Conclusions: A PPPD-Imanaga can be performed with acceptable morbidity and mortality risks. We conclude that the Imanaga method is a favorable complement to PPPD. (C) 1998 by the American College of Surgeons.