title: Double Purse-String Telescoped Pancreaticogastro stomy using an Atraumatic Self-retaining Ring Retractor in a Subtotal Stomach-Preserving Pancreaticoduodenectomy.
abstract: BACKGROUND
  Pancreatoenteric anastomotic failure is the main cause of pancreatic fistula after pancreaticoduodenectomy (PD). Double purse-string telescoped pancreaticogastrostomy, reported by Addeo et al., is an easy and safe procedure.1 The aim of this article was to introduce our technique of pancreaticogastrostomy using an atraumatic self-retaining ring retractor (Alexis Wound Retractor) in a patient undergoing subtotal stomach-preserving PD (SSPPD).
  
  
  METHODS
  An 82-year-old woman presented with pancreatic cancer located in the uncinate process of pancreas. She underwent SSPPD with resection of the superior mesenteric vein (SMV) and double purse-string telescoped pancreaticogastrostomy using an Alexis wound retractor.
  
  
  RESULTS
  The pancreas was transected on the portal vein and the remnant pancreas was separated from the splenic vein and artery. After extirpation of specimens and reconstruction of the SMV, two seromuscular purse-string sutures were placed on the posterior wall of the upper stomach. The anterior wall of the upper stomach was incised and opened using an Alexis wound retractor. The remnant pancreas was inserted into the gastric cavity through the posterior wall of the stomach and sutured circumferentially with running stitches to fix on the gastric muco-muscular layer. After closure of the anterior wall of the stomach, purse-string sutures were tightened and pancreaticogastrostomy was completed. The patient's postoperative course was uneventful and a computed tomography imaging study revealed no fluid collection around the pancreaticogastrostomy. This patient was discharged on the 14th postoperative day.
  
  
  CONCLUSIONS
  Use of an Alexis wound retractor makes it easier to perform a double purse-string telescoped pancreaticogastrostomy by a self-expanding property to allow a wide operative view.
authors.affiliation: Department of Surgery, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan. narinari@kuhp.kyoto-u.ac.jp.
authors.forename: Masato
authors.initials: M
authors.lastname: Narita
authors.affiliation: Department of Surgery, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan.
authors.forename: Ryo
authors.initials: R
authors.lastname: Matsusue
authors.affiliation: Department of Surgery, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Hata
authors.affiliation: Department of Surgery, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Yamaguchi
authors.affiliation: Department of Surgery, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan.
authors.forename: Tetsushi
authors.initials: T
authors.lastname: Otani
authors.affiliation: Department of Surgery, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan.
authors.forename: Iwao
authors.initials: I
authors.lastname: Ikai
mesh_terms: D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods*; D005260:Female; D005774:Gastrostomy / Q000379:methods*; D006801:Humans; D059351:Organ Sparing Treatments / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D011379:Prognosis; D013270:Stomach / Q000601:surgery*