Original Article  / Pancreas
Prevention of pancreatic leakage after
pancreaticoduodenectomy by modified
Child pancreaticojejunostomy
Yan-Ling Yang, Xiao-Ping Xu, Guo-Qiang Wu, Shu-Qiang Yue and Ke-Feng Dou
Xi'an, China
BACKGROUND: Pancreatic leakage after pancreaticoduo-
denectomy is associated with a morbidity and mortality.
Different techniques have been used to make a safe
anastomosis to the left pancreatic remnant.
METHODS: We performed "modified Child pancreatico-
jejunostomy" for 31 patients, by which end-to-end
pancreaticojejunal anastomosis was made with a two-layer
polypropylene continuous running suture.
RESULTS:  In the patients who underwent pancreatico-
jejunostomy, the average operative time was 14.2 minutes.
There was no pancreaticoenterostomy leakage in all
patients, and no deaths occurred.
CONCLUSIONS:  In pancreaticojejunostomy, pancreatic
anastomosis is time-saving and free from complications.
Thus it is an improvement of pancreaticojejunostomy.
(Hepatobiliary Pancreat Dis Int 2008; 7: 426-429)
KEY WORDS: pancreaticojejunostomy;
pancreaticoduodenectomy;
pancreatic leakage
Author  Affiliations:  Department of Hepatobiliary Surgery, Xijing
Hospital, Fourth Military Medical University, Xi'an 710032, China (Yang
YL, Yue SQ and Dou KF); Department of General Surgery, Zhujiang
Hospital, South Medical University, Guangzhou 510282, China (Xu
XP); and Department of General Surgery, General Hospital of Shenyang
Military Area of PLA, Shenyang 110016, China (Wu GQ)
Corresponding  Author:  Yan-Ling Yang, MD, Department of
Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical
University, Xi'an 710032, China (Tel: 86-29-84775259; Fax: 86-29-
84775561; Email: yangylfmmu@yahoo.com.cn)
© 2008, Hepatobiliary Pancreat Dis Int. All rights reserved.
426 • Hepatobiliary Pancreat Dis Int，Vol 7，No 4 • August 15，2008 • www.hbpdint.com
Introduction
P
ancreaticoduodenectomy has been used
increasingly in recent years as a safe method
of resection in selected patients with
malignant and benign disorders of the pancreas and
periampullary region.[1, 2] Although the mortality
from pancreaticoduodenectomy has decreased, there
is still a potential risk of developing a pancreatic
fistula after anastomosis.[3,  4] Different surgical
techniques for anastomosis have been attempted to
decrease the incidence of pancreatic fistula.[5,  6] Fibrin
glue and octreotide have been used with no marked
improvement in the morbidity from pancreatic
fistulas.[7, 8] We designed a technique termed "modified
Child pancreaticojejunostomy", by which the jejunum
is anastomosed to the pancreatic remnant in the order
from the posterior wall to the anterior wall, with a
continuous prolene suture.
Methods
The pancreas was clearly transected with a
ultrasonically activated scalpel on the scheduled
line. Hemostasis was secured by 4-0 prolene suturing
(Ethicon, Somerville, NJ). The main pancreatic duct
was identified, and a stent tube was inserted into
the main pancreatic duct and fixed with a suturing
thread. The cut end of the pancreatic remnant was
isolated for 3.0 cm. The jejunal limb was brought
to the supramesocolic region through an opening
in the transverse mesocolon to the right of the
midcolic vessels. Then, the pancreatic stump and the
free margin of the jejunum were brought together.
The detailed procedures of the "modified Child
pancreaticojejunostomy" are outlined below (Figs. 1-6).
A posterior row of continuous running parachute
sutures using 4-0 prolene were made between the
posterior surface of the pancreas and the seromuscular
Prevention of pancreatic leakage after pancreaticoduodenectomy

Fig. 1. Parachute continuous suturing made between the posterior surface of the pancreas and the seromuscular portion of the
jejunum. The posterior surface of the jejunum was 5 cm away from the posterior surface of the pancreas during this procedure.
Fig. 2. Prolene stitches were gently pulled one by one with a small right-angled nerve hook to push the jejunum close to the
pancreatic stump, to anastomose the jejunal posterior seromuscular layer with the posterior surface of the pancreas.
Fig. 3. The free edge of the jejunum was sutured to the posterior surface of the lining of the section of the pancreas by 4-0 prolene
continuous sutures.
Fig. 4. The free edge of the anterior jejunal wall was sutured to the anterior surface of the lining of the section of the pancreas by 4-0
prolene continuous sutures.
Fig. 5. Continuous sutures were made between the anterior surface of the pancreas and the seromuscular portion of the jejunum,
2.5 cm from the transected ends of both organs. The continuous suture stitches were not tightened during this procedure.
Fig. 6. The anterior surface of the jejunum was pushed close to the pancreatic surface, the prolene stitches were gently pulled one
by one, with a small right-angle nerve hook to complete the pancreaticojejunostomy.

portion of the jejunum, 2.5 cm away from the
transected end of both organs. The continuous suture
was not tightened so as to keep the posterior surface
of the jejunum 5 cm away from the posterior surface
of the pancreas. The needle distance was about 0.3 cm.
The continuous suturing began at the superior point
on the side of the pancreatic stump and ended at the
inferior point on the same side with 6 to 8 sutures
(Fig. 1). After the sutures were completed, the prolene
stitches were gently pulled one by one with a small
right-angled nerve hook to push the jejunum close to
the pancreatic stump (parachute technique), then the
jejunal posterior seromuscular layer was anastomosed
to pancreatic posterior surface (Fig. 2).
The posterior plane of pancreaticojejunostomy
was completed by 4-0 prolene continuous suturing of
the free edge of the jejunum with the posterior surface
of the lining of the section of the pancreas. The suture
included the entire jejunal wall and the capsule, as
well as some of the parenchyma of the pancreas (Fig. 3).
Anterior 4-0 prolene suturing was made
continuously between the free edge of the entire
jejunal anterior wall and the anterior surface of the
lining of the section of the pancreas (Fig. 4).
An anterior row of continuous running sutures
was made by 4-0 prolene between the anterior surface
of the pancreas and the seromuscular portion of
the jejunum, 2.5 cm away from the transected ends
of both organs. The continuous sutures were not
tightened during this procedure (Fig. 5). After the
sutures were completed, the anterior jejunal surface
was pushed close to the pancreatic surface, and the
prolene stitches were gently pulled one by one with
a small right-angled nerve hook. Then the jejunal
anterior seromuscular layer was anastomosed to the
pancreatic anterior surface (Fig. 6).
A stent tube was inserted into the main pancreatic
duct and traversed through the position of the
bilioenteric anastomosis during the operation. A tube
was inserted and 0.1% methylene blue saline was
injected to test for a water-tight closure. A drainage
tube was placed around the anastomosis. The amount
and amylase content from the drainage tube were
measured every day. It was indicative of developing
pancreatic leakage when the amount was more than 50
ml each day and the amylase content more than 1000
IU/L. The tubes were removed when the volume was
less than 20 ml each day. Prophylactic octreotide was
not used.
Results
In our consecutive series of 31 patients treated from

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June 2004 to November 2007, 11 patients had pancreatic
head malignancy, 10 had ampullary carcinoma, 7 had
cancer of the bile duct, and 3 had duodenal cancer.
Pancreaticoduodenectomy with "modified Child
pancreaticojejunostomy" by prolene continuous
suturing was done in all patients. Pancreaticojejunal
anastomoses were all watertight during the surgical
procedure, and the mean operative time was 14.2
minutes (range 10-21 minutes). None of the patients
had a high content of amylase in the peripancreatic
peritoneal drainage. Two patients with upper
gastrointestinal bleeding caused by stress ulcers were
cured conservatively. One patient with bile leakage was
cured conservativly for three weeks. Two patients with
abdominal infection and four patients with pulmonary
infection recovered after anti-infection therapy.
Neither hemorrhage nor cholangitis occurred. The
postoperative hospital stay was 9 to 28 days (mean 15.3
days). There was no postoperative mortality.
Discussion
The Whipple procedure has been the standard
treatment for periampullary and pancreatic
carcinoma since its introduction by Allen Whipple in
1935. The mortality after pancreaticoduodenectomy
has decreased considerably over the past 3 decades.
However, pancreatic fistula is still the most important
determinant of morbidity and carries a mortality of
28%.[9, 10]
The frequency with which pancreatic fistula
develops depends to some extent on the anatomy and
physiology of the pancreas.[11-13] Any incision of injury
to the pancreas transects both cells that normally
secrete proteolytic enzymes as well as pancreatic
ducts draining these cells.[14] So the primary approach
to pancreatic fistula should be an emphasis on its
prevention. A careful and meticulous anastomosis
must be constructed when pancreatojejunostomy
is accomplished. It is known that the incidence
of pancreatic fistula is high in patients with
deeper anatomic location of the pancreas because
anastomosis of the posterior pancreatic surface
becomes very difficult.[15] And it is well known that
the incidence of pancreatic leak is high in patients
with a soft or dropsical pancreatic parenchyma,[16,  17]
because the traditional interrupted silk suture and
ligation easily lead to incision of the pancreatic
parenchyma.[18] Some retrospective or prospective
studies have suggested the need for technical
modifications to reduce the pancreatic fistula rate.[19]
Our technique of "modified Child pancreatico-
428 • Hepatobiliary Pancreat Dis Int，Vol 7，No 4 • August 15，2008 • www.hbpdint.com
Hepatobiliary & Pancreatic Diseases International
jejunostomy" is derived from the traditional Child
procedure.[20] Different from the interrupted silk
suture and repeated ligation of traditional Child
pancreaticojejunostomy, our method has the following
advantages: Firstly, the parachute continuous suturing
facilitates the anastomosis of the posterior surface of
the pancreas to the posterior seromuscular portion of
the jejunum. The stumps of both the pancreas and the
jejunum are placed separately with an interval of about
5 cm and the prolene sutures are not tightened (Fig. 1).
In such conditions, the exposure of the anastomosis
position becomes clear, which ensures reliable
adjustment of every needle distance and reduces the
probability of inaccurate anastomotic sutures in deeper
anatomical locations.[21, 22] Secondly, the interrupted
suture and ligation generally results in unevenly
distributed tissue traction. The present approach
of parachute anastomosis allows the adjustment of
the tension for each suture, because no sutures are
tightened until all of them are completed. When
the anterior surface of the pancreas and the anterior
seromuscular portion of the jejunum are anastomosed,
the continuous suture stitches also not tightened.
Pushing the anterior surface of the jejunum close to
the pancreatic surface and gently pulling the prolene
stitches one by one with a small right-angled nerve
hook completes the pancreaticojejunostomy (Figs. 5
and 6). This method avoids insufficient interrupted
sutures and repetitive ligation,[23] and appears to be
much more important when the pancreas stump is
soft or dropsical. Compared with the traditional silk
suture, prolene stitches are smooth and less traumatic,
and are currently used in vascular anastomosis.
Prolene continuous suturing decreases the incision of
the pancreatic parenchyma caused by interrupted silk
suture and ligation.[1, 24] Thirdly, prolene stitches play
a binding role when making double-layer anastomosis
of pancreatic and jejunum stumps because of their
unabsorbed characteristics. Hence, the chance of
bleeding and leakage from the small pancreatic duct
via the exposed pancreatic stump is minimized.
In conclusion, the "modified Child pancreatico-
jejunostomy" is a safe, simple, and efficient technique
that avoids the primary complication of anastomotic
fista. Although it seems reasonable that this procedure
can be applied to all kinds of pancreatic remnants, we
think this "modified Child pancreaticojejunostomy"
has unique advantages for the operation in a deep
position and/or with a soft pancreas.
Funding: None.
Ethical approval: Not needed.
Prevention of pancreatic leakage after pancreaticoduodenectomy

Contributors: YYL proposed the study and wrote the first draft. Tonelli F. Comparison of Wirsung-jejunal duct-to-mucosa
YSQ analyzed the data. All authors contributed to the design and dunking technique for pancreatojejunostomy after
and interpretation of the study and to further drafts. DKF is pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int
the guarantor. 2005;4:450-455.
Competing interest: No benefits in any form have been received 12 Li B, Chen FZ, Ge XH, Cai MZ, Jiang JS, Li JP, et al.
or will be received from a commercial party related directly or Pancreatoduodenectomy with vascular reconstruction in
indirectly to the subject of this article. treating carcinoma of the pancreatic head. Hepatobiliary
Pancreat Dis Int 2004;3:612-615.
13 L  iu ZM, Yang WJ, Feng YC. One-layer pancreatico-
jejunostomy for prevention of pancreatic fistulae.
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