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Technical aspects of pancreatic anastomosis

  • Helwig Wundsam
  • Christiane S. Rösch
  • Ines Fischer
  • Reinhold FüggerEmail author
main topic
  • 4 Downloads

Summary

Background

Despite the significant improvement concerning perioperative mortality, pancreatoduodenectomy is still a challenging procedure. Pancreatic fistula is the most common complication underlying 30-day mortality. More than 61 surgical techniques of pancreatic anastomosis with a vast number of variations have been published. Moreover, various risk factors favoring the development of postoperative pancreatic fistulas have been identified.

Methods

This review article presents an outline of ways to achieve the optimal pancreatic anastomosis, concentrating on technical aspects. The following parameters were assessed in this question: pancreatojejunostomy, pancreaticogastrostomy, stents, tissue patches and sealants, surgical experience, and center-specific technique.

Results

With regard to current literature, there is no scientific evidence of an optimal pancreatic anastomotic technique. A distinct inhomogeneity among the trials concerning definitions, patient selection, anastomotic technique, and patient management is important to mention.

Conclusion

The best strategy for reducing pancreatic fistula rate includes a standardized institutional concept of pancreatic anastomosis, documentation of surgical quality, and continuous enhancement by benchmarking.

Keywords

Pancreatic anastomosis Postoperative pancreatic fistula Fistula risk score Pancreatojejunostomy Pancreatogastrostomy Surgical technique 

Abbreviations

CI

Confidence interval

CR-POPF

Clinically relevant postoperative pancreatic fistula

FRS

Fistula risk score

PG

Pancreatogastrostomy

PJ

Pancreatojejunostomy

POPF

Postoperative pancreatic fistula

RCT

Randomized controlled trail

Notes

Conflict of interest

H. Wundsam, C. S. Rösch, I. Fischer, and R. Függer declare that they have no competing interests.

References

  1. 1.
    Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;  https://doi.org/10.1056/nejmsa012337.CrossRefPubMedGoogle Scholar
  2. 2.
    Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, et al. 1423 Pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10(9):1199–1210; discussion 1210-1.CrossRefGoogle Scholar
  3. 3.
    Gooiker GA, Lemmens VEPP, Besselink MG, Busch OR, Bonsing BA, Molenaar IQ, et al. Impact of centralization of pancreatic cancer surgery on resection rates and survival. Br J Surg. 2014;101(8):1000–5.  https://doi.org/10.1002/bjs.9468 CrossRefPubMedGoogle Scholar
  4. 4.
    Gangl O, Fröschl U, Hofer W, Huber J, Sautner T, Függer R. Unplanned reoperation and reintervention after pancreatic resections: an analysis of risk factors. World J Surg. 2011;35(10):2306–14.  https://doi.org/10.1007/s00268-011-1213-5 CrossRefPubMedGoogle Scholar
  5. 5.
    Fuks D, Piessen G, Huet E, Tavernier M, Zerbib P, Michot F, et al. Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors. Am J Surg. 2009;197(6):702–9.  https://doi.org/10.1016/j.amjsurg.2008.03.004 CrossRefPubMedGoogle Scholar
  6. 6.
    Bassi C, Marchegiani G, Dervenis C, Sarr M, Hilal AM, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161(3):584–591.  https://doi.org/10.1016/j.surg.2016.11.014 CrossRefPubMedGoogle Scholar
  7. 7.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13CrossRefGoogle Scholar
  8. 8.
    Daamen LA, Smits FJ, Besselink MG, Busch OR, Borel Rinkes IH, van Santvoort HC, et al. The pancreatic anastomosis an overview of different anastomosis technique. 2017. http://pancreatic-anastomosis.com/.Google Scholar
  9. 9.
    Daamen LA, Smits FJ, Besselink MG, Busch OR, Borel Rinkes IH, van Santvoort HC, et al. A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy. HPB. 2018;20(9):777–785.  https://doi.org/10.1016/j.hpb.2018.03.003 CrossRefPubMedGoogle Scholar
  10. 10.
    Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, et al. Pancreatic anastomosis after pancreatoduodenectomy: a position statement by the international study group of pancreatic surgery (ISGPS). Surgery. 2017;161(5):1221–34.  https://doi.org/10.1016/j.surg.2016.11.021 CrossRefPubMedGoogle Scholar
  11. 11.
    Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013;216(1):1–14.  https://doi.org/10.1016/j.jamcollsurg.2012.09.002 CrossRefGoogle Scholar
  12. 12.
    Miller BC, Christein JD, Behrman SW, Drebin JA, Pratt WB, Callery MP, et al. A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy. J Gastrointest Surg. 2014;18(1):172–79; discussion 179-80.  https://doi.org/10.1007/s11605-013-2337-8 CrossRefPubMedGoogle Scholar
  13. 13.
    Shubert CR, Wagie AE, Farnell MB, Nagorney DM, Que FG, Lombardo RK, et al. Clinical risk score to predict pancreatic fistula after pancreatoduodenectomy: independent external validation for open and laparoscopic approaches. J Am Coll Surg. 2015;221(3):689–98.  https://doi.org/10.1016/j.jamcollsurg.2015.05.011 CrossRefPubMedGoogle Scholar
  14. 14.
    Kennedy GT, McMillan MT, Sprys MH, Bassi C, Greig PD, Hansen PD, et al. The influence of fellowship training on the practice of pancreatoduodenectomy. HPB. 2016;18(12):965–78.  https://doi.org/10.1016/j.hpb.2016.09.008 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Cattell R. Resection of the pancreas, discussion of special problems. Surg Clin North Am. 1943;23:753–66.Google Scholar
  16. 16.
    Bassi C, Falconi M, Molinari E, Mantovani W, Butturini G, Gumbs AA, et al. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial. Surgery. 2003;134(5):766–71CrossRefGoogle Scholar
  17. 17.
    Langrehr JM, Bahra M, Jacob D, Glanemann M, Neuhaus P. Prospective randomized comparison between a new mattress technique and Cattell (duct-to-mucosa) pancreaticojejunostomy for pancreatic resection. World J Surg. 2005;29(9):1111–9, discussion 1120-1CrossRefGoogle Scholar
  18. 18.
    Kleespies A, Rentsch M, Seeliger H, Albertsmeier M, Jauch KW, Bruns CJ. Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection. Br J Surg. 2009;96(7):741–50.  https://doi.org/10.1002/bjs.6634 CrossRefPubMedGoogle Scholar
  19. 19.
    Berger AC, Howard TJ, Kennedy EP, Sauter PK, Bower-Cherry M, Dutkevitch S, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg. 2009;208(5):738–47; discussion 747-9.  https://doi.org/10.1016/j.jamcollsurg.2008.12.031 CrossRefPubMedGoogle Scholar
  20. 20.
    Grobmyer SR, Kooby D, Blumgart LH, Hochwald SN. Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications. J Am Coll Surg. 2010;210(1):54–9.  https://doi.org/10.1016/j.jamcollsurg.2009.09.020 CrossRefGoogle Scholar
  21. 21.
    Peng SY, Wang JW, Lau WY, Cai XJ, Mou YP, Bin Liu Y, et al. Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg. 2007;245(5):692–8CrossRefGoogle Scholar
  22. 22.
    Hirono S, Kawai M, Okada K‑I, Miyazawa M, Kitahata Y, Hayami S, et al. Modified Blumgart mattress suture versus conventional interrupted suture in pancreaticojejunostomy during pancreaticoduodenectomy. Ann Surg. 2018;269(2):243–51.  https://doi.org/10.1097/SLA.0000000000002802 CrossRefPubMedCentralGoogle Scholar
  23. 23.
    Senda Y, Shimizu Y, Natsume S, Ito S, Komori K, Abe T, et al. Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy. Br J Surg. 2018;105(1):48–57.  https://doi.org/10.1002/bjs.10727 CrossRefPubMedGoogle Scholar
  24. 24.
    Chen Y, Ke N, Tan C, Zhang H, Wang X, Mai G, et al. Continuous versus interrupted suture techniques of pancreaticojejunostomy after pancreaticoduodenectomy. J Surg Res. 2015;193(2):590–7.  https://doi.org/10.1016/j.jss.2014.07.066 CrossRefPubMedGoogle Scholar
  25. 25.
    El Nakeeb A, Hamdy E, Sultan AM, Salah T, Askr W, Ezzat H, et al. Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study. HPB. 2014;16(8):713–22.  https://doi.org/10.1111/hpb.12210 CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Keck T, Küsters S, Wellner UF, Hopt UT, Karcz KW. Total laparoscopic partial pancreatoduodenectomy and reconstruction via laparoscopic pancreatogastrostomy. Langenbecks Arch Surg. 2012;397(6):1009–12.  https://doi.org/10.1007/s00423-012-0964-2 CrossRefPubMedGoogle Scholar
  27. 27.
    Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak ML, Talamini MA, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg. 1995;222(4):580–8; discussion 588–92.CrossRefGoogle Scholar
  28. 28.
    Tittelbach-Helmrich D, Keck T, Wellner UF. Pancreaticogastrostomy: when and how?. Pankreatogastrostomie wann und wie? 2017.Google Scholar
  29. 29.
    Cheng Y, Briarava M, Lai M, Wang X, Tu B, Cheng N, et al. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev. 2017;9:CD012257.  https://doi.org/10.1002/14651858.CD012257.pub2 CrossRefPubMedGoogle Scholar
  30. 30.
    Wang W, Zhang Z, Gu C, Liu Q, Liang Z, He W, et al. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: a network meta-analysis of randomized control trials. Int J Surg. 2018;57:111–16.  https://doi.org/10.1016/j.ijsu.2018.04.005 CrossRefPubMedGoogle Scholar
  31. 31.
    Keck T, Wellner UF, Bahra M, Klein F, Sick O, Niedergethmann M, et al. Pancreatogastrostomy versus pancreatojejunostomy for reconstruction after PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and long-term results of a multicenter randomized controlled trial. Ann Surg. 2016;263(3):440–9.  https://doi.org/10.1097/SLA.0000000000001240 CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Enkner U, Fröschl U, Gangl O, Függer R. Blood, toil, tears and sweat: Flexibel-endoskopische Interventionen am operierten Pankreas. Eur Surg Aca Chir. 2015;47(2):S302.Google Scholar
  33. 33.
    Poon RTP, Fan ST, Lo CM, Ng KK, Yuen WK, Yeung C, et al. EXternal drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg. 2007;246(3):425–33; discussion 433–5CrossRefGoogle Scholar
  34. 34.
    Winter JM, Cameron JL, Campbell KA, Chang DC, Riall TS, Schulick RD, et al. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg. 2006;10(9):1280–90; discussion 1290CrossRefGoogle Scholar
  35. 35.
    Pessaux P, Sauvanet A, Mariette C, Paye F, Muscari F, Cunha AS, et al. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg. 2011;253(5):879–85.  https://doi.org/10.1097/SLA.0b013e31821219af CrossRefPubMedGoogle Scholar
  36. 36.
    Tani M, Kawai M, Hirono S, Ina S, Miyazawa M, Shimizu A, et al. A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy. Am J Surg. 2010;199(6):759–64.  https://doi.org/10.1016/j.amjsurg.2009.04.017 CrossRefPubMedGoogle Scholar
  37. 37.
    Dong Z, Xu J, Wang Z, Petrov MS. Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev. 2016;5:CD008914.  https://doi.org/10.1002/14651858.CD008914.pub3 CrossRefGoogle Scholar
  38. 38.
    Yap PY, Hwang JS, Bong JJ. A modified technique of pancreaticogastrostomy with short internal stent: a single surgeon’s experience. Asian J Surg. 2018;41(3):250–56.  https://doi.org/10.1016/j.asjsur.2017.01.003 CrossRefPubMedGoogle Scholar
  39. 39.
    Ecker BL, McMillan MT, Asbun HJ, Ball CG, Bassi C, Beane JD, et al. Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg. 2018;267(4):608–16.  https://doi.org/10.1097/SLA.0000000000002327 CrossRefPubMedGoogle Scholar
  40. 40.
    Gong J, He S, Cheng Y, Cheng N, Gong J, Zeng Z. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev. 2018;6:CD009621.  https://doi.org/10.1002/14651858.CD009621.pub3 CrossRefPubMedGoogle Scholar
  41. 41.
    Schindl M, Függer R, Götzinger P, Längle F, Zitt M, Stättner S, et al. Randomized clinical trial of the effect of a fibrin sealant patch on pancreatic fistula formation after pancreatoduodenectomy. Br J Surg. 2018;105(7):811–19.  https://doi.org/10.1002/bjs.10840 CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Kennedy GT, McMillan MT, Maggino L, Sprys MH, Vollmer CM. Surgical experience and the practice of pancreatoduodenectomy. Surgery. 2017;162(4):812–22.  https://doi.org/10.1016/j.surg.2017.06.021 CrossRefPubMedGoogle Scholar
  43. 43.
    Gangl O, Fröschl U, Langer RM, Függer R. Single-layer versus duct-to-mucosa pancreaticojejunostomy in pyloruspreserving pancreatoduodenectomy for ductal adenocarcinoma—an analysis of a single surgeon’s series. Eur Surg. 2016;48(1):34–8.  https://doi.org/10.1007/s10353-015-0373-1.CrossRefGoogle Scholar
  44. 44.
    Dindo D, Demartines N, Clavien P‑A. Classification of surgical complications. Ann Surg. 2004;240(2):205–13CrossRefGoogle Scholar
  45. 45.
    Bai X, Zhang Q, Gao S, Lou J, Li G, Zhang Y, et al. Duct-to-Mucosa vs invagination for pancreaticojejunostomy after pancreaticoduodenectomy: a prospective, randomized controlled trial from a single surgeon. J Am Coll Surg. 2016;222(1):10–8.  https://doi.org/10.1016/j.jamcollsurg.2015.10.003 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgeryOrdensklinikum LinzLinzAustria

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