Different types of pancreatico-enteric anastomosis

Abstract

The pancreatico-enteric anastomosis has widely been regarded as the 'Achilles heel' of the modern day, single-stage, pancreatoduodenectomy (PD). A review of the literature was carried out to address the evolution of the pancreatico-enteric anastomosis following PD, the spectrum of anastomoses performed around the world, and finally present the current evidence in support of each anastomosis. Pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are the most common forms of pancreatico-enteric reconstruction following PD. There is no difference in postoperative pancreatic fistula (POPF) rates between PG and PJ, as well as individual variations, except in a high-risk anastomosis where performance of a PJ may be preferred. The routine use of glue, trans-anastomotic stents or omental wrapping is of no proven benefit. Externalised trans-anastomotic stents may have a role in mitigating the risk of a clinically relevant POPF in high-risk anastomoses. Pancreatico-enteric anastomosis is an important component of reconstruction following PD even though it is fraught with the risk of development of a POPF. Adherence to the tenets of anastomotic reconstruction and performance of a safe and reproducible anastomosis with a low clinically-relevant POPF rate remain the mainstay of achieving the best outcomes. Appropriate selection and opportune use of fistula mitigation strategies may help provide optimal outcomes when faced with the need to perform a high-risk pancreatico-enteric anastomosis.

Intraoperative Pancreatic Assessment in Pancreaticoduodenectomy The Correlation with Pancreatic Fistula Formation

“…Type B and C fistula had more severe consequences than the other type. 16 Pancreatic fistula in this study is quite high due to no amylase examination from the drain in a few patients. Subjects with no clinical sign and pancreatic fluid in drain considered as pancreatic fistula after pancreaticoduodenectomy.…”

“…Anastomosis leaks after Pancreaticojejunostomy are the most critical factor in morbidity and mortality. 16 However, no study focused on the pancreas' factor that may influence the incidence of pancreatic fistula at dr. Cipto Mangunkusumo General Hospital (CMGH), Jakarta. Thus, we run a study that aims to identify pancreas' factor on pancreaticojejunal anastomosis.…”

Implementation of Robotic Assistance in Pancreatic Surgery: Experiences from the First 101 Consecutive Cases

“…Despite all technical improvements during the last decades, the pancreatico-enteric anastomosis can still be referred to as the Achilles’ heel of current PD [ 23 ]. The superiority of neither reconstruction via pancreaticojejunostomy (PJ) nor PG in terms of complication rates and especially POPF incidence and severity for RPD is certain as, just like in open surgery, some studies advocate PG [ 24 ], while others prefer a PJ.…”

Predicting post‐operative pancreatic fistulae using preoperative pancreatic imaging: a systematic review

“…POPF remains the ‘Achilles heel’ of the modern day PD . Currently, the ‘gold standard’ for assessment of pancreatic texture is surgeon's subjective evaluation through manual palpation .…”