Distinguishing between parenchymal and anastomotic leakage at duct-to-mucosa pancreatic reconstruction in pancreaticoduodenectomy

Figure 1 PJ reconstruction of pancreatic remnant after pancreaticoduodenectomy. Posterior layer with interrupted 3-0 silk sutures approximating pancreatic parenchyma to jejunal serosa. Arrow shows ongoing duct-to-mucosa anastomosis with stent inside lumen. Once the duct-to-mucosa anastomosis is completed, anterior of parenchyma to jejunal serosa approximation is done.

Figure 2 Typical normal pancreatogram and cholangiogram. CJ indicates bilioenteric anastomosis, and PJ indicates PJ reconstruction.

Figure 3 Fluids collected from the peripancreatic drain are analyzed for amylase content and volumes at postoperative day (POD) 4 and 7. A: Amylase levels are not different among the 3 groups at POD 4 (P = 0.062); however, at POD 7, the anastomotic leak group has the significantly highest level, then the parenchymal leak group as compared to the normal group (P = 0.012). B: Volume of peripancreatic drain of the parenchymal leak group was significantly increased above the anastomotic leak and normal group at POD 4 (P = 0.022); on the other hand, there was no difference among the three groups at POD 7 (P = 0.477).

Figure 4 Parenchymal leaks due to a side branch in the pancreatic remnant surface. A: Normal pancreatogram shows intact PJ anastomosis (arrow); B: Sinogram shows a side-branch duct of the pancreas remnant (arrowhead).

Figure 5 Anastomotic leak is visualized at the initial diagnosis and its resolution is confirmed. A: Contrast extravasation into the surrounding (arrowhead) from the PJ anastomotic (arrow); B: Complete resolution of PJ anastomotic leak (arrow).

Figure 6 At completed PJ anastomosis, pancreatic leakage can occur either at anastomosis (dotted circle and arrow) or at a small peripheral duct opening or tear in the parenchyma (black circle and arrow).