Pancreaticoduodenectomy is the standard surgical method for benign and malignant tumors of the pancreatic head or periampullary region.¹ However, compared to the other abdominal surgeries, complications such as anastomotic leakage, stricture, bleeding, dumping syndrome, and delayed gastric emptying are more likely to occur in this surgery due to various anastomoses created for reconstruction after resection.^2,3 Patients with many underlying diseases might develop medical or systemic complications due to the long operation time.^4,5 With the development of surgical tools and surgical methods, stapling has been used for intestinal anastomosis in several surgeries to ease the complex surgical process and to reduce the time of surgery compared to that in manual anastomosis.^6-9 After pancreaticoduodenectomy, the stapler has also been used for duodenojejunostomy or gastrojejunostomy, and it has been reported that operation time was reduced. Moreover, the incidence of delayed gastric emptying (DGE) after surgery decreased in patients who underwent gastro/ duodenojejunostomy using stapling anastomosis after pylorus-preserving pancreticoduodenectomy (PPPD) and Whipple’s operation.¹⁰ However, some reports also mentioned that the decrease in the incidence of DGE was not significant.¹¹ The above studies analyzed several surgical methods such as Whipple’s op, PPPD, and pylorus-resecting pancreaticoduodenectomy (PrPD); therefore, factors other than the handsewn and stapled anastomosis might have influenced the outcomes. This study aimed to compare the postoperative results of stapled gastrojejunostomy and handsewn gastrojejunostomy in patients who undersent PrPD performed by a single surgeon.

A total of 131 patients underwent PrPD; 90 in the HGJ group and 41 in the SGJ group. The relevant patient characteristics and perioperative details are shown in Table 1. There were no significant differences in the age, sex, BMI, American Society of Anesthesiologists (ASA) score ≥3, underlying diseases such as hypertension and diabetes mellitus, previous operation history, preoperative total bilirubin or preoperative bile drainage between the groups. Histologically, bile duct carcinoma was the most common type of tumor in both groups (n=28 vs. n=17, p=0.338). Further, no significant difference in pancreatitis (n=26 vs. n=9, p=0.536), pancreas texture (soft n=60 vs. n=31, p=0.409), and vein resection including the portal vein, superior mesenteric vein, or inferior vena cava (n=11 vs. n=4, p=0.908) was noted between the two groups.

Table 2 shows the postoperative outcomes in both groups. The mean operative time was shorter in the SGJ than in the HGJ (450.4±75.4 min vs. 397.1±66.5 min, p<0.001). The incidence of DGE in HGJ and SGJ was 12.2% and 14.6%, respectively; however, there was no significant difference (n=11 vs. n=6, p=0.92). Additionally, there were no significant differences in postoperative length of hospital stay (22.7±24.7 day vs. 19.7±15.4 day, p=0.353), bile leak (n=1 vs. n=0, p=1), chyle leak (n=6 vs. n=0, p=0.214), intra-abdominal fluid collection (n=5 vs. n=6, p=0.162), postoperative bleeding (n=1 vs. n=1, p=1), ileus (n=2 vs. n=1, p=1), POPF (n=16 vs. n=8, p=1), Clavien-Dindo classification (Grade I-II n=83 vs. n=37, p=0.969, Grade IIIa-IIIb n=5 vs. n=4, p=0.611, Grade IV-V n=1 vs. n=0, p=1), reoperation (n=0 vs. n=2, p=0.179), or 30-day mortality (n=0 vs. n=2, p=0.179) between both groups.

In this study, we compared the clinical outcomes between the stapler and handsewn anastomosis for gastrojejunostomy in patients who underwent PrPD. The operative time was significantly shorter in stapler group, while post-operative morbidity and mortality were no significantly different between the stapler and handsewn group.

There have been some attempts to use a stapler in pancreticoduodenectomy, especially to reduce the incidence of DGE in duodenojejunal anastomosis using circular stapler in PPPD. Murata et al.¹⁴ reported that the incidence of primary DGE was significantly low in the stapled side-to-side gastrojejunostomy group for subtotal stomach-preserving pancreaticoduodenectomy. This was thought to be because the stapling anastomosis, prevented anastomotic edema or stenosis, and disruption in the blood supply, and allowed easier drainage of the food contents. According to a systematic review compared to conventional handsewn anastomosis, stapled anastomosis might be associated with a lower incidence of DGE after pancreaticoduodenectomy without increasing the risk of POPF or mortality.^10,15 However, in some cases, the decrease in the reconstruction time was the same. A few other studies showed no difference in the incidence of DGE.^11,16-18

In these studies, most of the results after gastrojejunostomy were in patients who underwent Whipple’s operation or PPPD, and there were few reports about the results after gastrojejunostomy using staples in PrPD. Moreover, in most studies, several surgical methods such as Whipple’s operation, PPPD, and PrPD were analyzed together. In some reports, duodenojejunostomy and gastrojejunostomy were included and analyzed together in the stapled group; hence, so there might have been some other factors influencing the DGE, such as pylorospasm. However, we analyzed only cases of PrPD for the following reasons. First, many reports have described that the rate of DGE is lower in PrPD than PPPD.^16,19-21 Second, the possibility of occurrence of DGE due to the spasm of the pyloric ring was excluded by excising the pyloric ring.²² Third, excision of the pyloric ring eases the linear stapled anastomotic procedure and enables a consistent surgical method. Furthermore, single surgical method was performed by a single surgeon in order to reduce the factors that might affect the results due to the differences in the surgical methods and to limit the technical variables. Therefore, it can be presumed that the outcomes of the two groups are highly reliable.

Although this result showed that there was no difference in the rate of DGE between the groups, the use of stapler has the advantage of reducing the operation time without any difference in the incidence of other complications. Moreover, the handsewn technique might differ between each surgeon. A stapler can ensure a more standardized anastomotic method with less variation between the surgeons.

Two patients in the stapled group required re-operation. The first patient was re-operated for pancreaticojejunostomy leakage, and the second patient was re-operated for postoperative bleeding. The bleeding was not at the staple line, and thus, it might not be associated with staple use. In the HGJ group, there were no cases that required re-operation; however, one patient died. The patient had an Eastern Cooperative Oncology Group (ECOG) score of 1 due to an underlying disease and died due to postoperative pneumonia.

Our study has several limitations. First, this study was a retrospective analysis; therefore, the possibility of selection bias cannot be eliminated. In order to minimize this bias, we analyzed data for one surgical method performed by a single surgeon. Second, the different number of patients between the two groups might have affected the power of statistical evaluation. Third, when randomly checking the time of gastrojejunostomy, handsewn took 23-25 minutes and stapled was 9-10 minutes. However, the procedure time was not recorded for all patients. Fourth, this study reported only the short-term outcomes, further analysis is necessary to determine if there is any difference in the long-term outcome.

In conclusion, this study suggest that stapled GJ shortens reconstruction time during PrPD without affecting the incidence of DGE. Therefore, using a stapler for the GJ is feasible and safe technique.