Strategies for pancreatic anastomosis after pancreaticoduodenectomy: What really matters?

Abstract

Background

The postoperative pancreatic fistula rate remains approximately 10–20% even in institutions treating a high-volume of pancreatic cases. The best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate.

Data sources

Studies were identified by searching PubMed for studies published between January 1934 (when pancreaticogastrostomy was technically feasible) and December 2016. The following search terms were used: “duct-to-mucosa”, “invagination”, “pancreaticojejunostomy”, “pancreaticogastrostomy,” and “pancreaticoduodenectomy”. The search was limited to English publications.

Results

Many technical methods have been developed and optimized to restore pancreaticoenteric continuity, including pancreaticojejunostomy, pancreaticogastrostomy, and stented drainage of the pancreatic duct, among other modifications. Researchers have also attempted to decrease the postoperative pancreatic fistula after pancreaticoduodenectomy by using fibrin glue and somatostatin analogues. However, no significant decrease in postoperative pancreatic fistula has been observed in most of these studies, and only an external pancreatic duct stent has been found to decrease the leakage rate of pancreatic anastomosis after pancreaticojejunostomy.

Conclusion

Pancreatic surgeons should choose a suitable technique according to the characteristics of individual cases.

Introduction

Presently, pancreaticoduodenectomy is regarded as the standard surgical procedure for patients with malignant and premalignant tumors in the pancreatic head and periampullary region. Recently, given the continuous improvements in surgical technique and advancements in perioperative management, the mortality rate associated with pancreaticoduodenectomy has decreased to less than 5% in high-volume centers [1], [2], [3]. However, surgical morbidity after pancreaticoduodenectomy remains high (40–50%) even in large series. In most series, the three leading causes of morbidity after pancreaticoduodenectomy are postoperative pancreatic fistula (POPF), delayed gastric emptying, and wound infection. Among them, POPF is the most frequent major complication of alimentary tract reconstruction after pancreaticoduodenectomy and may lead to other complications, such as intraabdominal abscess, intraabdominal hemorrhage, reoperation, and even death [4], [5]. Pancreatic anastomosis after pancreaticoduodenectomy remains the “Achilles’ heel” of this surgical procedure. Therefore, many diverse strategies have been proposed to diminish POPF rates, including technical modifications. To date, more than 50 types of pancreatic and digestive tract reconstruction techniques have been reported [6]. However, the POPF rate remains approximately 10–20% even in high-volume pancreatic centers [3], [7]. Recently, numerous randomized studies and meta-analyses and systematic reviews have addressed the outcome of different reconstruction strategies. Nevertheless, the best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate. The present review was to investigate the key factors of affecting the outcomes during pancreatic reconstruction and compare the main pancreatic anastomosis technique.