Late Reoperative Surgery after Laparoscopic Pancreaticoduodenectomy: A Novel Pancreaticogastrostomy Based on the "Modified Blumgart" Philosophy (with video)

● Modified Blumgart pancreaticogastrostomy for recurrence or anastomotic stricture. ● avoidance of jejunal mobilization. ● Mucosa-to-mucosa pancreatic-gastric adaptation reduces hemorrhage. ● Locking mattress suture ensures hemostasis, eliminates dead space. ● Separate suturing of duct/gastric walls reduces pancreaticogastric anastomotic gap. Laparoscopic pancreaticoduodenectomy has become an established procedure for pancreatic head tumors. However, local recurrence or anastomotic stricture requiring reoperation is uncommon, and no standardized approach exists for re-anastomosis of the pancreatic remnant. This article demonstrates a novel modified locking technique of Blumgart pancreaticogastrostomy applied during re-laparoscopy. The locking Blumgart pancreaticogastrostomy was performed in four layers: the posterior pancreatic stump-to-stomach layer, the posterior and lateral pancreatic duct-to-gastric mucosa layer, the anterior pancreatic duct-to-gastric mucosa layer, and the anterior pancreatic stump-to-stomach layer. Three cases of the pancreatogastric anastomosis procedure were carried out by the authors. No postoperative pancreatic fistula occurred, with no incidence of pancreatogastric anastomotic stricture observed during follow-up to date. The technical rationale of this anastomotic approach include: 1) avoidance of resection of the original afferent jejunal limb, 2) a more physiological mucosa-to-mucosa adaptation between the pancreatic duct and gastric wall, and 3) use of a locking mattress suture to achieve more complete hemostasis, and 4) separate suturing of the anterior/posterior and lateral walls of both the pancreatic duct and gastric mucosa. The modified locking Blumgart pancreaticogastrostomy is technically feasible and demonstrates preliminary safety in reoperative surgery for late local tumor recurrence or anastomotic stricture at the pancreaticojejunal site following laparoscopic pancreaticoduodenectomy.