Which Method Should We Select for Pancreatic Anastomosis After Pancreaticoduodenectomy?

Abstract

Background This study was designed to compare surgical, morphological, and functional outcomes of pancreaticoduodenectomy (PD) according to the types of pancreaticoenterostomy performed and to suggest a proper anastomotic method after PD. Methods From January 2001 to December 2006, 147 PDs were performed at Ajou University Medical Center. Surgical, morphological, functional, and nutritional outcomes after PD were retrospectively compared according to the types of management of pancreatic remnant and whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ), including duct-to-mucosa or invagination method, was performed. Results For the reconstruction method, 43 PG (30 ductto-mucosa and 13 invagination) and 100 PJ (33 duct-tomucosa and 67 invagination) were performed. Pancreatic leak rate in PG group (7%) was less than that in PJ group (13%); however, it was not significant (P [ 0.05). On the other hand, there was a significant difference in pancreatic leak between duct-to-mucosa and invagination (3.2 vs. 17.5%, P \ 0.05). Surprisingly, there was no pancreatic leak in PG duct-to-mucosa anastomosis after PD. There were no significant differences in the change of remnant pancreatic duct size, pancreatic thickness, presence of steatorrhea, and new-onset diabetes mellitus (DM) between PG and PJ. In the invagination group, the main pancreatic duct diameter was increased and pancreatic thickness was progressively reduced. Conclusion The duct-to-mucosa method is safer and has a good duct patency and low pancreas atrophy compared with the invagination method. In addition, PG duct-tomucosa is safer than PG invagination, but not in the PJ group. Therefore, we recommend PG duct-to-mucosa for reconstruction after PD because of safety and good duct patency, especially for inexperienced surgeons.

Histomorphological Features of the Pancreatic Remnant as Independent Risk Factors for Postoperative Pancreatic Fistula: A Matched-Pairs Analysis

“…The incidence of clinically significant POPF (12.2%) in our cohort of distal pancreatectomies is consistent with the 12% incidence of grade B/C POPF reported by Nathan et al [2] in a series of 704 distal pancreatectomy cases and by Kleeff et al [23 ]in a series of 302 distal pancreatectomy cases as well as with the 16% POPF rate in 462 distal pancreatectomy cases reported by Ferrone et al [7]. The incidence of clinically significant POPF in our patients with pancreatoduodenectomy is with 2.6% quite low and corresponds well to the results of Büchler et al [29] (2.1%) and Kim et al [30] (3.2%) who used a similar technique of duct-to-mucosa pancreatico-jejunal anastomosis. Our data confirm the observation of Pratt et al [25] that a substantial number of clinically significant POPF present as latent fistulas.…”

Pancreaticojejunostomy versus Pancreaticogastrostomy after Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

“…Overall, 26 articles describing 3,752 patients were identified for the meta-analysis: 22 OCSs (n = 3, 199 patients) [35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56] and 4 RCTs (n = 553 patients) [10,57,58,59]. A total of 1,922 patients underwent PG (RCTs n = 276 patients, OCSs n = 1,646 patients), whilst 1,830 patients underwent PJ (RCTs n = 277 patients, OCSs n = 1,553 patients).…”

Leakage of an Invagination Pancreaticojejunostomy May Have an Influence on Mortality

“…One retrospective, single-institution study revealed a 3.2% rate of POPF in the DmPJ group and a rate of 17.5% in its IPJ group without significant mortality differences. 18 One dual-institution controlled trial, however, found an odds ratio (OR) of 2.4 for POPF incidence between DmPJ and IPJ, again without significant mortality differences. 6 Still, other studies have reported minimal to no difference in risk of fistula formation or mortality.…”