Journal of Gastrointestinal Surgery

, Volume 23, Issue 11, pp 2211–2215 | Cite as

The Effect of Pancreaticojejunostomy Technique on Fistula Formation Following Pancreaticoduodenectomy in the Soft Pancreas

  • Lisbi RivasEmail author
  • Sara L. Zettervall
  • Tammy Ju
  • Samantha Olafson
  • Jeremy Holzmacher
  • Paul P. Lin
  • Khashayar Vaziri
Original Article



A soft pancreas has been associated with an increased risk of post-operative pancreatic fistula formation. Few studies have evaluated the effect of anastomotic technique (duct to mucosa vs invagination) on fistula formation. This study aims to compare the effect of anastomotic technique on fistula formation among patients with a soft pancreas in a large multiinstitutional database.


The targeted pancreas module of the American College of Surgeons–National Surgical Quality Improvement Program (NSQIP) Database was used. All patients with a soft pancreas who underwent pancreaticoduodenectomy from 2014 to 2015 were identified. Demographic data, comorbid conditions, operative variables, and 30-day outcomes were compared using univariate and multivariable analyses.


A total of 975 patients met inclusion criteria. Eight-hundred fifty four (88%) underwent a duct to mucosa pancreaticojejunostomy technique and 121 (12%) underwent invagination. Patients who underwent invagination had higher 30-day mortality (5.8% vs 1.4%, p < 0.01), higher fistula formation (38% vs 25%, p < 0.01), and more often had percutaneous drain placement post-operatively (27% vs 14%, p < 0.01). Following multivariable analysis, invagination remained associated with pancreatic fistula formation (OR 2.5, CI 1.4–4.3) and post-operative percutaneous drain placement (OR 1.8, CI 1.1–2.9).


Invagination technique for pancreaticojejunostomy in patients with a soft pancreas is associated with increased rates of pancreatic fistula. Surgeons should consider utilizing a duct to mucosa technique when feasible to decrease morbidity following pancreaticoduodenectomy in this patient population.


Post-operative pancreatic fistula Pancreaticojejunostomy NSQIP 



  1. 1.
    Fu S-J, Shen S-L, Li S-Q, et al. Risk factors and outcomes of postoperative pancreatic fistula after pancreatico-duodenectomy: an audit of 532 consecutive cases. BMC Surg. 2015;15(1):34. Scholar
  2. 2.
    Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery. 2005;138(1):8–13. Scholar
  3. 3.
    Gouma DJ, van Geenen RC, van Gulik TM, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg. 2000;232(6):786–795. Scholar
  4. 4.
    Greenblatt DY, Kelly KJ, Rajamanickam V, et al. Preoperative Factors Predict Perioperative Morbidity and Mortality After Pancreaticoduodenectomy. Ann Surg Oncol. 2011;18(8):2126–2135. Scholar
  5. 5.
    Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg. 2004;8(8):951–959. Scholar
  6. 6.
    Mathur A, Pitt HA, Marine M, et al. Fatty pancreas: a factor in postoperative pancreatic fistula. Ann Surg. 2007;246(6):1058–1064. Scholar
  7. 7.
    Berger AC, Howard TJ, Kennedy EP, 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):738–747. Scholar
  8. 8.
    Hua J, He Z, Qian D, Meng H, Zhou B, Song Z. Duct-to-Mucosa Versus Invagination Pancreaticojejunostomy Following Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis. J Gastrointest Surg. 2015;19(10):1900–1909. Scholar
  9. 9.
    Sun X, Zhang Q, Zhang JY, et al. Meta-analysis of invagination and duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: An update. Int J Surg. 2016;36(2016):240–247. Scholar
  10. 10.
    Bai X, Zhang Q, Gao S, 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):10–18. Scholar
  11. 11.
    KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Accessed 1 Sep 2018
  12. 12.
    Fragulidis GP, Arkadopoulos N, Vassiliou I, et al. Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump. Pancreas. 2009;38(7):e177–82. Scholar
  13. 13.
    Wellner UF, Kayser G, Lapshyn H, et al. A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively. HPB (Oxford). 2010;12(10):696–702. Scholar
  14. 14.
    Manabu K, Satoshi K, Hiroki Y, Keita W, Keiji S, Fuyuhiko M. Predictive risk factors for clinically relevant pancreatic fistula analyzed...: EBSCOhost. J Hepatobiliary Pancreat Sci. 2011;18:601–608. Scholar
  15. 15.
    Pratt WB, Callery MP, Vollmer CMJ. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg. 2008;32(3):419–428. Scholar
  16. 16.
    Hu BY, Wan T, Zhang WZ, Dong JH. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol. 2016;22(34):7797–7805. Scholar
  17. 17.
    Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg. 1995;221(6):635–638. Scholar
  18. 18.
    Suzuki Y, Fujino Y, Tanioka Y, et al. Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size. Arch Surg. 2002;137(9):1044–7; discussion 1048. Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.Department of SurgeryGeorge Washington University Medical CenterWashingtonUSA

Personalised recommendations