pancreatic leakage remains a common and serious complication after standard pancreaticoduodenectomy ( pd ) or pylorus - preserving pancreaticoduodenectomy ( pppd ) [ 13 ] . pancreatic fistula is occasionally followed by several other potentially life - threatening complications , such as massive haemorrhage of eroded vessels and peritonitis . to prevent these complications , two main anastomotic techniques for reconstruction after pd , pancreaticojejunostomy ( pj ) , and pancreaticogastrostomy ( pg ) , exist . according to four randomized trials comparing pj and pg , there is no difference regarding the prevalence of pancreatic fistula between these reconstruction techniques [ 47 ] . however , it has been suggested that pg is associated with fewer overall complications than pj [ 6 , 8 ] . several different methods of anastomosing the pancreas to the stomach have been employed , including pg using several mattress sutures   and the so - called binding pg using two purse - string sutures at the posterior gastric wall . here we report the early results of a new technique for pg , which combines one binding purse - string and two transfixing mattress sutures between the pancreatic stump and the posterior gastric wall . the study cohort includes 35 patients who underwent elective pd with pg at the department of visceral , thoracic and vascular surgery , philipps university of marburg , between june 2007 and february 2011 . patients data , including patients demographics ( age , sex , diagnosis ) , type of procedure performed ( standard pd or pppd ) , complications , hospital mortality , hospital stay , postoperative interventional procedures or reoperations were prospectively documented . all patients had two closed suction drains placed at the time of operation in close proximity to the pancreatic anastomosis . patients received octreotide ( 3 times 100  g / d ) until postoperative day 5 . the proton pump inhibitor omeprazole was given in a dosage two times 40  mg / day for 7 days . the nasogastric tube was left in place until postoperative day 5 to protect the pancreatogastrostomy . however , the patients were allowed to drink fluids as well as liquid meals at postoperative day 1 . the closed suction drains were removed on postoperative day 5 , when amylase was not more than three times higher than the serum amylase . the volume and amylase activity of the drainage fluid were measured on postoperative days 1 , 3 , 5 and thereafter , when a pancreatic fistula was present . pancreatic fistula was classified according to the strict criteria of the igspf . in brief , fistulas without clinical impact were therefore graded type a. fistulas with maintenance of the drains longer than 3 weeks postoperatively were graded type b , whereas a type c fistula leads to clinical interventions like reoperations and percutaneous drainage . delayed gastric empting ( dge ) was defined as intolerance of an unlimited intake of any diet after postoperative day 7 . pancreatic texture was classified as soft or hard based on intraoperative findings and pathological examination . after the pancreaticoduodenectomy , any bleedings from the cut surface of the pancreatic stump were stopped by bipolar electrical coagulation or absorbable sutures ( pds 5.0 , ethicon , johnson & johnson medical gmbh , norderstedt , germany ) . then the pancreatic remnant was mobilized 2 to 3  cm from the splenic vein and the surrounding tissues . a polyethylene 5  cm pancreatic tube , 5.0 or 7.5 french ( peter pflugbeil gmbh , zorneding , germany ) was introduced into the main pancreatic duct to insure its patency . this lost drain was fixed to the main pancreatic duct by a 5.0 absorbable suture ( vicryl rapide 5 - 0 p-3 , 45  cm ; ethicon , johnson & johnson medical gmbh , norderstedt , germany ) . two transient holding sutures ( vicryl plus 2.0  mh , 70  cm ; ethicon , johnson & johnson medical gmbh , norderstedt , germany ) were positioned at the cranial and caudal proximal end of the pancreatic remnant ( figure 1 ) . then a transverse full - thickness incision was made on the posterior wall of the stomach with a length of at most 2  cm , to ensure tight adherence of the gastric wall to the pancreatic remnant after completion of anastomosis ( figure 2 ) . the appropriate position of the incision was selected , so that the pancreatic stump could enter this hole without tension . then a 5-cm longitudinal incision was created in the anterior gastric wall opposite to the dorsal wall incision . through the incision of the anterior gastric wall , a full - thickness purse - string suture ( pds ii 2.0  mh plus , 70  cm ; ethicon , johnson & johnson medical gmbh , norderstedt , germany ) , taking about 1  cm of the whole posterior gastric wall , was preplaced ( figures 3(a ) and 3(b ) ) . the pancreatic remnant was then pulled with slide tension on the holding sutures through the whole in the posterior gastric wall into the stomach . this manoeuvre was performed very gently to ensure tight wrapping of the posterior gastric wall around the pancreatic remnant and to avoid laceration of the pancreas . ideally , the pancreatic remnant should protrude above the posterior gastric wall by 2  cm . afterwards mattress sutures were preplaced through the posterior gastric wall and the pancreas , one cranial and one caudal of the main pancreatic duct . these sutures were carried out with double - armed straight needles ( pds ii 4.0  mh , 70  cm ; ethicon , johnson & johnson medical gmbh , norderstedt , germany ) passing in an u - like fashion . each u - like suture runs from the mucosal surface to the serosal surface of the caudal posterior gastric wall , just above the preplaced purse - string suture , then straight through the ventral to the dorsal surface of the pancreas , and finally from the serosal surface to the mucosal surface of the cranial posterior gastric wall ( figure 4 ) . the threads near the centre of the pancreatic stump were placed carefully to avoid passing through the main pancreatic duct containing the catheter . first the u - like mattress sutures and then the purse - string suture were ligated ( figure 5 ) . a nasogastric tube was positioned just above the pg before closure of the anterior gastric wall . the gastrostomy on the anterior gastric wall was closed with all layer single sutures ( pds ii 2 - 0 jb , 70  cm ; ethicon , johnson & johnson medical gmbh , norderstedt , germany ) . an end - to - side hepaticojejunostomy and antecolic end - to - side gastrojejunostomy in case of standard pd or antecolic duodenojejunostomy in case of pppd were performed to complete the reconstruction . there were 21 men and 14 women with a median age of 61.9 ( range 2584 ) years . thirty ( 85.7% ) patients underwent pppd and 5 ( 14.3% ) patients had standard pd . in 5 ( 14.3% ) the indications for pd were as follows : 24 pancreatic adenocarcinomas , 6 neuroendocrine tumors of the pancreatic head or duodenum , 1 cancer of the papilla vateri , 2 distal bile duct cancers , one ipmn and one chronic pancreatitis . twenty - five patients ( 71.4% ) had a firm pancreatic remnant , and 10 ( 28.6% ) patients had a soft pancreatic remnant . the median time for conduction of the pg ( incision of the posterior gastric wall to finishing the closure of the anterior gastric wall ) was 18 ( range 1228 ) minutes . the most frequent complication was dge , which occurred in 7 ( 20% ) patients . pancreatic fistulas occurred in 3 ( 8.6% ) patients ( 2x type a ; 1x type b ) . the type a fistulas occurred in patients with a firm pancreas , the type b fistula in a patient with men1-zes and a soft pancreas . thus , a clinically relevant pancreatic fistula occurred in 1 ( 2.9% ) of all or in 1 ( 10% ) of 10 patients with a soft pancreatic remnant . all three pancreatic fistulas could be managed non - operatively by maintaining the closed suction drains ( 14 , 15 and 30 days ) . pancreaticogastrostomy ( pg ) is the favoured reconstruction procedure of several surgeons after pancreaticoduodenectomy , although 4 prospective randomised trials showed no difference regarding pancreatic fistula or overall complication rates compared to pancreaticojejunostomy ( pj ) [ 46 ] . first , the anastomosis can be created easily because of the proximity of the stomach and the pancreas remnant . second , the thick posterior gastric wall is an excellent suture bed with an excellent blood supply . third , the pancreatic juice is not activated because of the acid milieu and lack of enterokinases in the stomach . fourth , if a minor dehiscence of the pg occurs , it can be managed in many cases via endoscopic interventions , for instance , fibrin sealing .   since the first clinical application of pg performed by waugh and clagett in 1946 , a large variety of modifications of the technique has been published in the literature ( table 2 ) . these modifications include invagination or duct - to - mucosa anastomosis , use of transanastomotic tubes for internal - external drainage of pancreatic juice , use of fibrin sealant , use of multiple transfixing mattress sutures   or 2 purse - string binding sutures , respectively . recently published studies on pg had shown that the prevalence of pancreatic fistula ranged from 0 to 16% , and the mortality rate varied from 0 to 12.3% in studies with 41 up to 250 patients ( table 2 ) [ 7 , 1423 ] . however , in these studies , the definition of pancreatic fistula was very heterogeneous and mostly not well defined . the prevalence of pancreatic fistula , as determined by the strict criteria of the igspf , with the modified technique described here , was 8.6% ( 3 of 35 patients ) . there occurred two type a and one type b fistula , which all three resolved without any radiological intervention or reoperation . a soft consistency of the pancreatic remnant in ampullary , duodenal , and especially neuroendocrine diseases provide a significantly higher risk of pancreatic fistula [ 24 , 25 ] . several groups showed that the rate of pancreatic fistula in high - risk patients with a small fragile soft pancreatic remnant and a non - dilatated pancreatic duct was as high as 36% compared to only 24% in low - risk patients with a fibrotic pancreatic remnant composed of dense tissue [ 2629 ] . in the presented series , 10 patients ( 28.6% ) were high - risk patients with soft pancreas texture and only 1 ( 10% ) of them developed a clinically relevant type b pancreatic fistula . however , our technique has to be evaluated in a larger series of patients with this condition to determine its safety . until today the new modified technique described here combines the theoretical advantages of the binding and transfixing modifications , recently reported by ohigashi et al . and peng et al . only two transfixing mattress sutures are required in our technique , whereas in the techniques of ohigashi 4 to 6 mattress sutures are placed . every suture carries the risk for pancreatic laceration resulting in pancreatic leakage , especially in a fragile and soft pancreatic remnant . we also suggest that straight and parallel sutures through the pancreas minimize the trauma to the pancreatic parenchyma and that the gastric wall protects the ligature , similar to felt pledgets in mattress sutures for vascular or heart surgery . the additional purse - string suture in the posterior gastric wall , used in our modification , minimizes any potential space between the gastric wall and the pancreatic remnant . therefore , two mattress sutures combined with a purse - string suture in the gastric wall eventually prevent damage even to the very fragile parenchyma of a soft pancreas . our technique provides a theoretical risk of ischemic tissue injury due to the u - sutures . , due to the good perfusion of the stomach wall , the possibility of an ischemic injury at the pancreatic tissue or gastric wall seems rather low to us . since the transfixing mattress sutures are placed just above the purse - string suture , leakage from the pancreatic stitch holes will drain into the gastric lumen and not outside the anastomosis . the double - armed straight needles , used in our modification , allow an easier handling compared to curved needles . this advantage is clearly apparent , especially when the anastomosis must be performed in unfavourable conditions , such as in the case of an anastomosis of the pancreatic tail into the fundus of the stomach . the placement of a lost drain in the main pancreatic duct will drain the majority of pancreatic fluid in the distal stomach away from the anastomosis , which also might reduce the risk for anastomotic leakage . this is very similar to the modification of pg described by ohigashi , who needed 20 minutes for placing four transfixing mattress sutures [ 9 , 30 ] . the simplicity of our technique might be an important argument for surgical departments with training programs . in case of pj , langrehr et al . suggested that the mattress suture technique does not require special training and avoids tangential sheer forces during tightening of the suture thread . one theoretical disadvantage of our modified pg is that a gastrostomy on the anterior gastric wall is required to insure an optimal overview during conduction of this anastomosis . another potential disadvantage of pg compared to pj is bleeding from small vessels of the pancreatic stump , which was invaginated into the stomach . the bleeding required transfusion of 2 units of red blood cells and could be stopped endoscopically . the described modification of pg with two transfixing mattress sutures and one binding purse - string suture at the posterior gastric wall appears to be simple , safe and reliable . because this paper is preliminary
pancreatic anastomotic leakage remains a persistent problem after pancreaticoduodenectomy ( pd ) , especially in the presence of a soft , nonfibrotic pancreas . 
 a modified technique for pancreatogastrostomy was devised , which combines one binding purse - string and two transfixing mattress sutures between the pancreatic stump and the posterior gastric wall . 
 this technique was applied in 35 patients after pd for malignant and benign diseases of whom 10 ( 28.6% ) had a soft pancreas . 
 median time for the anastomosis was 18  minutes . 
 operative mortality was zero , and morbidity was 34.3% . 
 three ( 8.6% ) patients developed a pancreatic fistula ( 2 type a , 1 type b ) as classified according to the international study group on pancreatic fistula . 
 all fistulas resolved without further intervention . 
 the described technique is a simple and safe reconstruction procedure after pd that warrants further evaluation .