Open Total Pancreatectomy With Modified Cattell-Imanaga Reconstruction: How Do We Do It?

: The Cattell-Imanaga reconstruction (CIR) is considered a more physiologic reconstruction after pancreaticoduodenectomy, as it promotes a more physiological mixing of alimentary and biliopancreatic secretions and facilitates endoscopic access to the anastomoses compared with traditional techniques. However, its application after total pancreatectomy (TP) has not previously been reported. This study describes the surgical technique and institutional experience with CIR, named modified CIR (mCIR), in patients undergoing open TP at a high-volume pancreatic surgery center. The mCIR positions the gastro-/duodeno-jejunostomy (G/DJ) proximally and the hepatico-jejunostomy (HJ) distally on a single transmesocolic limb. 89 patients underwent open TP with mCIR. Both en bloc and stepwise TP were performed; stepwise was mainly used for positive frozen margins (51.7%), high POPF risk (34.8%), or need for vascular resection to reduce POPF-related vascular complications (12.4%). Grade B-C biliary fistula occurred in 6.7% of patients, cholangitis secondary to hepatico-jejunostomy (HJ) stricture in 2.2%, delayed gastric emptying (DGE) in 11%, and duodeno-jejunostomy (DJ) leakage in 1.1%. An endoscopic interventional approach was generally preferred for the management of HJ complications. Major morbidity and 90-day mortality were 23.6% and 3.4%, respectively. The readmission rate was 9.7%, mainly due to infected or symptomatic collections. This is the first study to describe mCIR following TP and to report postoperative outcomes in line with previously reported results for traditional reconstruction techniques.