Stapled Cholecystojejunostomy and Gastrojejunostomy for the

Palliation of Unresectable Pancreatic Carcinoma

Eric Thg##wr, MD, Rochester, Minnesota David M. Nagomey, MD, Rochester, Minnesota

Two major problems posed by unresectable carcino- ma of the head of the pancreas are distal bile duct obstruction and potential or actual gastric outlet obstruction from tumor infiltration of the duode- num. The efficacy of both bilioenteric and gastroje- junal bypass for the palliation of patients with unre- sectable tumors of the head of the pancreas has been well established, and many effective techniques for both biliary and gastric bypass have been proposed [1,2]. Herein, we describe a simple, expeditious method of cholecystojejunostomy and gastrojejun- ostomy utilizing intestinal staplers.

Technique

If an unresectable pancreatic tumor is found intraoper- atively, both bilioenteric and gastroenteric bypass are undertaken. However, several points warrant emphasis before undertaking this technique of combined bypass with staplers. Importantly, the use of the gallbladder for biliary decompression is predicated upon a widely patent cystic duct. Thus, the junction of the cystic duct and common bile duct must be inspected carefully to confirm gross dilatation and patency. Cholangiography is advised to document a patent cystic duct entering the common bile duct a minimum of 1.5 to 2 cm proximal to the neoplastic obstruction. In addition, intraoperative gall- bladder decompression must result in simultaneous de- compression of the common bile duct. Finally, peritoneal metastases along the hepatoduodenal ligament must be excluded. If these criteria are met, effective biliary de- compression by cholecystojejunostomy can be antici- pated. Gastrojejunostomy is performed routinely.

Our stapled bypass technique is initiated with the gas- trojejunostomy. A loop of proximaljejunum is positioned

From the Depertment of Surgery. Mayo Clink, Rochester, Minnesota Requests for reprints should be addressed to David M. Negorney, MD,

Depertment of Surgery. Mayo Clink. 200 1st Street SW, Rochester, Minnesota 55905.

Ftgue 7. The comfhed bypeaa Is tnftlated by performIng the fht step of th9 atapted geetro/e/moatomy.

anterior to the colon. An anterior gastrotomy and an antimesenteric jejunotomy are made. The forks of the ILA (American V. Mueller, Minneapolis, MN) or GIA (United States Surgical Corp., Norwalk, CT) stapler are inserted into the lumina of the stomach and jejunum, the instrument is closed, and the staples are fired (Figure 1). The stapler is removed, the opposing staple lines are grasped individually with Allis clamps, and hemostasis is secured. The stomach and jejunum are approximated just distal to the staple line by a single suture to avoid undue tension during insertion of the EEA stapler (United States Surgical).

Next, the EEA stapler is loaded with a 25 or 28 mm cartridge; the choice of cartridge is dictated directly by the jejunal diameter. The cartridge-loaded EEA stapler is

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Thompson and Nagorney

Flgure 2. lhe EEA stapler Is passed through the part/ally completed gastro~ejunostomy into the efferent tlmb with the center rod traverslng theJeJunat wall. 7he anvil Is attached and Is postttoned wtthln the gallbladder for constructton of the choe cysto)e/lmostomy.

inserted through the partially completed gastrojejunos- tomy into the efferent jejunal limb. The center rod of the EEA stapler is advanced through the jejunal wall through a small antimesenteric jejunotomy. The anvil is then se- cured to the center rod. A purse&ring suture is placed around the cholecystotomy which is positioned at a de- pendent portion of the gallbladder fundus. Before insert- ing the anvil into the gallbladder, the jejunal mucosa overlying the base of the cartridge is flattened to minimize the tissue volume between the cartridge and anvil when the stapler is closed. A pursestring suture is not placed around the jejunotomy and the center rod unless the opening is inadvertently enlarged by excessive operative manipulation of the EEA instrument. The anvil is then inserted into the gallbladder, and the gallbladder purse- string suture is tied (Figure 2). The EEA instrument is closed, the staples are fired, and the instrument is with- drawn by the standard method. Tissue sections from the cartridge and anvil are removed and inspected. If the tissue rings are complete, the gastrojejunostomy is com- pleted by opposing the stapled gastrojejunal suture lines and by closure with a PI-55 (American V. Mueller) or TA- 55 (United States Surgical) stapler (Figure 3).

comments

We have employed this technique in five patients with unresectable ductal carcinoma of the head of the pancreas. Preoperatively, each patient had clin- ical, biochemical, and radiographic evidence of bil- iary obstruction, and one patient had clinical and radiographic evidence of gastric outlet obstruction.

Figure 3. The completed chotecystojejunostomy and gastro- jejunostomy. Note opposttton of the gastrojejunal staple lines.

Intraoperatively, a diffusely dilated extrahepatic biliary tree, including the gallbladder, was con- firmed in each patient. Postoperative convalescence was uncomplicated in all but one patient in whom jaundice persisted. Percutaneous transhepatic chol- angiography in this patient showed cystic duct ob- struction, emphasizing the need for cholangiogra- phy which was not performed in this patient. Despite appropriate placement of a percutaneous transhepatic biliary endoprosthesis, jaundice per- sisted until the patient’s death 7 months later. Rap- id clinical resolution of jaundice was confirmed bio- chemically in the other four patients. Neither cholangitis nor delayed gastric emptying were en- countered. The median duration of postoperative hospitalization was 9 days (range 7 to 10 days). Two patients died of metastatic disease 9 and 13 months postoperatively, and two were alive with disease at last follow-up 8 months postoperatively. These pa- tients remained anicteric and asymptomatic from gastric outlet obstruction until death or until the date of last follow-up.

Summary

This technique of combined gastrojejunostomy and cholecystojejunostomy utilizing gastrointesti- nal staplers provides a quick, simple, safe, and effec- tive means for palliation of biliary and duodenal obstruction occurring in patients with unresectable carcinoma of the head of the pancreas. Use of a

510 The American Journal of Surgery

Cholecystojejunostomy and Gashojejunostomy for Pancreatic Carcinoma

common loop of jejunum for both biliary and gastric bypass avoids the complexities of other reported methods.

Acknowledgment: We are indebted to Robert C. Ben- assi for providing the illustrations.

RefererKGes

1. Sarr MG, Cameron JL. Surgical management of unresectable carcinoma of the pancreas. Surgery 1982;9 1: 123-33.

2. Mullin TJ, Damazo F, Dawe EJ. Cholecystenteric anastomosis with the EEA stapler for cancer of the pancreas. Am J Surg 1983;145:338-42.

Volume 151, April 1988