Two‐in‐one method: Novel pancreaticojejunostomy technique for the bifid pancreas

Abstract The bifid pancreas is a rare anatomical variation of the pancreatic duct in which double main pancreatic ducts in the body and tail of the pancreas join at the pancreas head and drain through the major papilla. When pancreaticoduodenectomies are carried out on bifid pancreases, close attention must be paid to the reconstruction because of the possibility that there may be two pancreatic ducts that need to be reconstructed. We present a case of pancreaticoduodenectomy for the bifid pancreas and a novel technique named the ‘two‐in‐one’ method for double pancreatic duct to jejunum anastomosis. Using the two‐in‐one method, we anastomosed one jejunal hole to a double pancreatic duct. Pancreatic texture was normal and postoperative volumes of pancreatic juice from the two external pancreatic duct stents were 250 mL and 100 mL/day, respectively. Postoperative recovery went well although the patient needed a slightly longer hospital stay as a result of surgical site infection. This novel anastomotic technique was as simple to carry out as a normal pancreaticojejunostomy and may be useful for reconstruction of the bifid pancreas.

carried out on bifid pancreases, close attention must be paid to the reconstruction because of the possibility that there may be two pancreatic ducts that need to be reconstructed. We present a case of pancreaticoduodenectomy for the bifid pancreas and a novel technique named the 'two-in-one' method for double pancreatic duct to jejunum anastomosis. Using the two-in-one method, we anastomosed one jejunal hole to a double pancreatic duct. Pancreatic texture was normal and postoperative volumes of pancreatic juice from the two external pancreatic duct stents were 250 mL and 100 mL/day, respectively. Postoperative recovery went well although the patient needed a slightly longer hospital stay as a result of surgical site infection.
This novel anastomotic technique was as simple to carry out as a normal pancreaticojejunostomy and may be useful for reconstruction of the bifid pancreas.

K E Y W O R D S
bifid pancreas, pancreaticoduodenectomy, pancreaticojejunostomy around the inferior vena cava behind the liver and the head of the pancreas ( Figure 1). Blood test showed no evidence of elevated serum tumor markers. We diagnosed her with a recurrence of the liposarcoma and planned tumor resection with a PD if needed. The patient did not undergo MRCP because she did not have a primary pancreatic tumor.
Because the operative findings showed strong adhesion between the recurrent tumor and the pancreas, we decided to carry out PD. We transected the pancreas upon the portal vein. Following transection, subsequent operative exploration of the cut surface of the residual pancreas identified a double pancreatic duct orifice (approximately 3 and 2 mm in diameter, respectively). A bifid pancreatic duct was subsequently confirmed by intraoperative probing using blunt-tipped probes, which could be inserted deep into the cranial duct and 3 cm into the caudal duct of the residual pancreas (Figure 2A,B). The double pancreatic ducts joined near the cut surface of the resected head of the pancreas. Distance between the two ducts on the cut surface was 3 mm ( Figure 2C). Preoperative multi-detector computed tomography (MDCT) showed a bifurcated double main pancreatic duct, which we had not noticed before the operation ( Figure 3).

| Surgical techniques of the two-in-one method
We carried out a double pancreatic duct to jejunum anastomosis with transpancreatic jejunal sutures (a modification of the Blumgart mattress suture technique). 10

| RE SULTS
After the operation, volumes of pancreatic juice from the two external pancreatic duct stents were 250 and 100 mL/day, respectively. Although amylase level in the drainage fluid was high

| D ISCUSS I ON
The bifid pancreas is a rare anatomical variation which is reported to be present in the population at a rate of 0.9%-2.7%. 11 In the two-in-one method, two pancreatic ducts are anastomosed to one jejunal hole. We carried out this method because of the short distance between the two ducts on the cut surface of the pancreas. In hepaticojejunostomy, multiple bile ducts can be anastomosed to one jejunal hole by plasty of neighboring ducts. In addition, the Glissonean sheath, including multiple bile ducts, could be treated as a single duct by regarding the septa as a thick wall of the duct. 13  should carry out the reconstruction method deemed most appropriate for each patient. When the distance between the two ducts on the cut surface of the pancreas is short, because we cannot place two jejunal holes too close together, the conventional anastomosis technique of two pancreatic ducts to two jejunal holes may be inappropriate.
Suturing the tiny jejunal wall between the two holes may also be difficult. We consider that the two-in-one method may be preferable when the distance between the two ducts is 5 mm or shorter.
When we plan to carry out PD for patients with bifid pancreases, we should consider three types of pancreatic transection and reconstruction based on the location ( In the present case, we cut the pancreas on the level of type 2. We did not ligate one of the double ducts because the patient had a normal pancreatic parenchyma and pancreatic juice flowed from both pancreatic ducts. We considered an additional pancreatic resection for type 3 reconstruction but opted to preserve pan-