- Open Access
An end-to-end pancreatic anastomosis in robotic central pancreatectomy
- Zi-Zheng Wang†1,
- Guo-Dong Zhao†1,
- Zhi-Ming Zhao1,
- Yuan-Xing Gao1,
- Yong Xu1,
- Zhu-Zeng Yin1,
- Qu Liu1,
- Wan Yee Lau2Email author and
- Rong Liu1Email author
© The Author(s). 2019
- Received: 11 January 2019
- Accepted: 26 March 2019
- Published: 13 April 2019
Suturing the proximal pancreatic stump and performing pancreaticoenterostomy for the distal pancreatic stump following central pancreatectomy is a conventional procedure. This reconstruction after resection of the pathological pancreatic lesion brings changes in anatomy and physiology. In this study, an innovative one-stage robotic end-to-end pancreatic anastomosis was reported to replace the conventional pancreaticoenterostomy following central pancreatectomy.
Materials and methods
The clinical data of 11 consecutive patients who underwent robotic central pancreatectomy with end-to-end pancreatic anastomosis between August 2017 and December 2017 were analyzed retrospectively.
All operations were completed successfully without any conversion to open surgery. Nine patients had benign tumors, one had a mass-forming chronic pancreatitis, and one had an isolated pancreatic metastasis from a renal cancer. The mean gap left after central pancreatectomy was 4.3 ± 1.0 cm. The median operative time was 121 (range, 105 to 199) min. The median blood loss was 50 (range, 20 to 100) ml. Seven (63.6%) patients developed complications which included Clavien–Dindo Grade I complications in five patients, a Grade II complication in one patient, and a Grade IIIa complication in one patient. Seven patients developed a Grade B postoperative pancreatic fistula, and two patients a biochemical leak. There was no Grade C or worse pancreatic fistula. Magnetic resonance cholangiopancreatography at postoperative 6 months showed no stricture in any of the main pancreatic ducts. Three patients had an asymptomatic and small pancreatic pseudocyst.
Robotic central pancreatectomy with end-to-end pancreatic anastomosis was safe and feasible. It restores the normal anatomy of the pancreas. With its good short-and long-term outcomes, it could be an alternative reconstructive method to pancreaticoenterostomy following central pancreatectomy.
- Robotic surgery
- Central pancreatectomy
- End-to-end pancreatic anastomosis
Various operative approaches have been attempted to resect pathological lesions in the neck and body of the pancreas [1, 2]. For benign and low malignant potential lesions in these regions, central pancreatectomy is commonly used, whereas more aggressive resections, such as pancreaticoduodenectomy or distal pancreatectomy, are usually used for malignant lesions [3, 4]. As early as the 1900s, Ehrhardt and Finney reported on resection of the central portion of the pancreas, followed by reconstruction of the pancreas by direct suturing of the two pancreatic stumps . The medical literature became completely silent on central pancreatectomy followed by reconstruction of the pancreas for 70 or more years. In 1982, Dagradi and Serio reported on central pancreatectomy followed by reconstruction of the pancreas by oversewing the cephalic stump and performing an end-to-end pancreaticojejunostomy for the distal pancreatic stump . Since then, this method of reconstruction became the conventional procedure following open, laparoscopic, and robotic central pancreatectomy [7–9].
Central pancreatectomy is a parenchyma-sparing surgery which conserves the exocrine and endocrine functions of the pancreas. There are inherent defects in the conventional reconstructive procedure. For pancreaticojejunostomy of the distal pancreatic stump, a Roux-en-Y limb of jejunum should be created and then delivered through an incision in the transverse mesocolon for the anastomosis, thus affecting the continuity and integrity of the small intestine [10, 11]. The jejunal juice which contains bile can activate pancreatic enzymes from the distal pancreas, leading to erosion of the anastomosis, bleeding, and fistula . The use of pancreaticogastrostomy is an attractive alternative to pancreaticojejunostomy. This procedure is technically easy and safe, as the stomach is close to the pancreatic stump and it has an abundant blood supply [13, 14]. There is, however, a potential harmful effect on the exocrine function of the pancreas, as acid gastric juice inactivates pancreatic enzymes [15, 16].
In the recent one to two decades, only anecdotal reports were published on the end-to-end anastomosis of the pancreas following central pancreatectomy, even though this reconstructive technique is straightforward and accords with normal physiology and anatomy [17–19]. This can partly be explained by the suboptimal anastomotic techniques and the limited operative views in the past.
In the past one to two decades, minimally invasive pancreatic surgery has undergone fast development [20–23]. Minimally invasive equipment and instruments allow surgeons to perform operations with less trauma. The robotic surgical system overcomes several drawbacks of the laparoscopic system and allows more complex procedures to be carried out [24–26]. In this study, our initial clinical experience on robotic end-to-end pancreatic anastomosis following central pancreatectomy was reported .
The patients were closely monitored for vital signs for about 24 h postoperatively. Antibiotics, somatostatin, proton pump inhibitors, and parenteral nutrition were routinely given. The patients were prescribed adequate analgesia and they were encouraged to have early mobilization. The nasogastric tube was typically removed on postoperative day 1. The drain outputs were carefully monitored for the volumes and amylase levels. The drain amylase level and bacteria culture were routinely tested on postoperative day 3. The drains were removed if the drainage was less than 5 ml per day with a low amylase level.
The demographic data, clinicopathological characteristics, and perioperative outcomes were presented as frequency for categorical variables, and mean ± standard deviations or median (range), as appropriate, for continuous variables based on normality.
The clinicopathological characteristics of patients
Baseline and intraoperative data
Sex (female/male), n
Age, mean ± SD (years)
42.4 ± 14.3
BMI, mean ± SD (kg/m2)
24.1 ± 2.8
Tumor size, mean ± SD (cm)
3.4 ± 1.1
Pancreatic duct diameter, mean ± SD (mm)
2.4 ± 0.3
Defect of main pancreatic duct, mean ± SD (cm)
4.3 ± 1.0
Operative time, [median (range)] (min)
121 (105, 199)
Estimated blood loss, [median (range)] (ml)
50 (20, 100)
Open conversion, n (%)
Solid pseudopapillary tumor, n (%)
Serous cystadenoma, n (%)
Pancreatic metastasis from renal cancer, n (%)
Mass-forming chronic pancreatitis, n (%)
Negative margin in tumor (n)
The short-term and long-term outcomes of patients
Postoperative hospital stays, [median (range)] (day)
Complication, n (%) 
Clavien–DindoI/II/IIIa, n (%)
5 (45.5)/1 (9.1)/1 (9.1)
Grade B pancreatic fistula, n (%)a
Peripancreatic fluid collection, n (%)
Postoperative pancreatitis, n (%)
Drain removal time, mean ± SD (day)
36.3 ± 16.8
30-day readmission, n (%)
90-day mortality, n (%)
Follow-up period, [median (range)] (month)
Spontaneous detachment of pancreatic stent, n (%)
Pancreatic anastomosis stricture, n (%)
Pancreatic pseudocyst and discontinuous main pancreatic duct, n (%)
Postoperative diabetes, n (%)
The most commonly performed radical resections for pancreatic malignancies are pancreaticoduodenectomy and distal pancreatectomy +/− splenectomy . However, benign lesions and tumors of low malignant potential do not require extensive resections , and pancreatic enucleation and central pancreatectomy are adequate to treat these lesions [30, 31]. When these lesions are superficial in the pancreas, enucleation can achieve good outcomes. When these lesions are deeply situated in the pancreas or when they are close to the main pancreatic duct, enucleation may damage the duct. Even with successful repair of a damaged duct which technically is very difficult, POPF is likely to occur . In the past two decades, central pancreatectomy has been increasingly used to treat benign lesions and tumors with low malignant potentials in the central pancreas. This operation conserves more pancreatic parenchyma but the conventional reconstruction using pancreaticoenterostomy disrupts the continuity and integrity of the small intestine which can potentially lead to short- and long-term complications [7, 9].
The end-to-end anastomosis of the pancreatic stumps after central pancreatectomy has all along been considered by mainstream pancreatic surgeons to be unreliable , and prone to result in severe POPF, especially when the texture of pancreas is normal and the main pancreatic duct is not dilated. In the past, the end-to-end anastomosis of the pancreas has been used to repair traumatic pancreatic neck transections. For the various techniques which have been reported, one technique was to use a pancreatic stent and to perform an end-to-end anastomosis of the pancreatic duct and parenchyma . Another technique was to do the pancreatic anastomosis using a stent put into the pancreatic duct which was then brought through the ampulla of Vater, through the duodenum into the stomach, and then exteriorized through a gastrostomy . Other techniques include pancreatic duct opposition with or without ductal anastomosis, and with or without pancreatic parenchymal anastomosis . The postoperative complications and long-term follow-up of these reported cases were favorable. In pancreatic trauma, unlike in central pancreatectomy, the gap left between the two pancreatic stumps is much less. The earliest report on the use of the end-to-end anastomosis following central pancreatectomy was in the 1900s. This operation was seldom used subsequently . An experimental study in dogs using an end-to-end anastomosis with or without stenting following central pancreatectomy suggested that this reconstructive technique was practicable . Subsequently, only occasional case reports on one to three patients using this technique for pancreatic reconstruction after central pancreatectomy were reported [17–19]. These reports routinely exteriorized a stent through the ampulla of Vater for internal-or-external drainage. Ramesh  added a serosal patch from a Roux-en-Y limb of the jejunum to the anterior suture line to buttress the anastomosis.
The robotic surgical system is an upgraded surgical platform of the traditional laparoscopic system over which it has several virtues which include the flexible Endo-wrist instruments, tremor elimination, 3D magnified view, as well as persistent and stable traction by the robotic arm. These advantages of the robotic surgical system enable operative procedures to become more delicate and precise, particularly for dissection and anastomosis of tiny vasculatures. The key technique in the end-to-end anastomosis in our operation is the need to fully mobilize the distal pancreatic stump by transecting the peripancreatic ligaments. The main pancreatic duct of most patients is not dilated and too thin to perform a precise duct-to-duct anastomosis. The parenchyma of the pancreatic head and tail are then pulled together to approximate the two pancreatic duct stumps. MRCP at postoperative 6 months indicated that the “pull-together” approach had good effect and no stricture of the main pancreatic duct happened. The limitations of this study are the small case number and the inherent defects of its retrospective study nature. In the future research, studies such as randomized controlled trial, propensity score matching study to compare this technique to conventional technique with larger cohort are needed to further define the efficacy of this technique.
In this cohort, 65.6% (7/11) of the patients developed Grade B pancreatic fistula because of a persistent drainage > 3 weeks, including a patient with a peripancreatic fluid collection and a patient with postoperative acute pancreatitis. We think the high postoperative pancreatic fistula rate might be associated with the soft texture of the pancreas without malignancy in this cohort. It also may be attributed to our preliminary experience. Despite the POPF rate is high, most of the patients with POPF only have a prolonged drainage without and recovered uneventfully without other complications.
Robotic central pancreatectomy with end-to-end pancreatic anastomosis allowed resection of lesions with the least injury, maximized preservation of pancreatic parenchyma, and maintained normal anatomy and physiology after surgery. Our preliminary clinical experience suggested that this end-to-end anastomosis following robotic central pancreatectomy was safe and feasible. Although the POPF rate is high, most of the patients with POPF only have a prolonged drainage without clinical relevant change in the management of POPF. It could be used as an alternative to pancreaticoenterostomy following central pancreatectomy. Comparative study with larger cohort and further modification of the technique are needed to define the efficacy of this technique.
This work was supported by the National Key Research and Development Program of China (grand number 2017YFC0110405) and the National Natural Science Foundation of China (grant number 81500499).
Availability of data and materials
All data generated or analyzed during this article are included in this published article.
Conception and design: Z Wang, G Zhao, R Liu. Acquisition of the data: Z Wang, G Zhao, Y Xu, Z Yin, Q Liu. Analysis and interpretation of the data: Z Zhao, Y Gao, Y Xu, Z Yin, Q Liu. Drafting of the article: Z Wang, G Zhao, R Liu, W Lau. Critical revision of the article: Z Zhao, Y Gao, R Liu, W Lau. All authors have viewed and approved the final version of the manuscript.
Ethics approval and consent to participate
The study was conducted in accordance with the ethical principles of the Helsinki Declaration for research on humans. The study was approved by the Ethical Committee of the PLA Central Hospital. Written informed consent was obtained from the all individual participants included in the study.
Consent for publication
Informed consent was obtained from the patient for publication and accompanying images.
All authors declare that they have no conflict of interest or financial ties to disclose.
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