Abstract
Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5–30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy.
Similar content being viewed by others
Data availability
All data referred to this manuscript is available upon request to the authors.
References
Yoshioka R, Yasunaga H, Hasegawa K et al (2014) Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy. Br J Surg 101:523–529
Winter JM, Cameron JL, Campbell KA et al (2006) 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg 10:1199–1210
Hackert T, Werner J, Büchler MW (2011) Postoperative pancreatic fistula. Surgeon 9:211–217
Machado MC, Machado MA (2016) Systematic use of isolated pancreatic anastomosis after pancreatoduodenectomy: five years of experience with zero mortality. Eur J Surg Oncol 42:1584–1590
Peng SY, Wang JW, Lau WY et al (2007) Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg 245:692–698
Kone LB, Maker VK, Banulescu M, Maker AV (2020) A propensity score analysis of over 12,000 pancreaticojejunal anastomoses after pancreaticoduodenectomy: does technique impact the clinically relevant fistula rate? HPB (Oxford) 22:1394–1401
Müller MW, Friess H, Kleeff J et al (2007) Is there still a role for total pancreatectomy? Ann Surg 246:966–974
Del Chiaro M, Rangelova E, Segersvärd R, Arnelo U (2016) Are there still indications for total pancreatectomy? Updates Surg 68:257–263
Andrén-Sandberg Å, Ansorge C, Yadav TD (2016) Are there indications for total pancreatectomy in 2016? Dig Surg 33:329–334
Ratnayake CBB, Wells CI, Kamarajah SK et al (2020) Critical appraisal of the techniques of pancreatic anastomosis following pancreaticoduodenectomy: a network meta-analysis. Int J Surg 73:72–77
Olakowski M, Grudzińska E, Mrowiec S (2020) Pancreaticojejunostomy—a review of modern techniques. Langenbecks Arch Surg 405:13–22
Bolintineanu Ghenciu LA, Bolintineanu SL et al (2023) Clinical consideration of anatomical variations in the common hepatic arteries: an analysis using MDCT angiography. Diagnostics (Basel) 13:1636
Kahraman G, Marur T, Tanyeli E, Yildirim M (2001) Hepatomesenteric trunk. Surg Radiol Anat 23:433–435
Gaujoux S, Sauvanet A, Vullierme MP (2009) Ischemic complications after pancreaticoduodenectomy: incidence, prevention, and management. Ann Surg 249:111–117
Bull DA, Hunter GC, Crabtree TG et al (1993) Hepatic ischemia, caused by celiac axis compression, complicating pancreaticoduodenectomy. Ann Surg 217:244–247
Machado MA, Herman P, Montagnini AL et al (2004) A new test to avoid arterial complications during pancreaticoduodenectomy. Hepatogastroenterology 51:1671–1673
Tang B, Li S, Wang P (2023) Pancreaticoduodenectomy performed for a patient with prepancreatic postduodenal portal vein: a case report and literature review. Front Med (Lausanne) 16(10):1180759
D’Angelica MI, Ellis RJ, Liu JB et al (2023) Piperacillin-tazobactam compared with cefoxitin as antimicrobial prophylaxis for pancreatoduodenectomy: a randomized clinical trial. JAMA 329:1579–1588
Rystedt J, Tingstedt B, Ansorge C et al (2019) Major intraoperative bleeding during pancreatoduodenectomy—preoperative biliary drainage is the only modifiable risk factor. HPB (Oxford) 21:268–274
Cheng TY, Sheth K, White RR et al (2006) Effect of neoadjuvant chemoradiation on operative mortality and morbidity for pancreaticoduodenectomy. Ann Surg Oncol 13:66–74
Laaninen M, Sand J, Nordback I et al (2016) Perioperative hydrocortisone reduces major complications after pancreaticoduodenectomy: a randomized controlled trial. Ann Surg 264:696–702
Antila A, Siiki A, Sand J, Laukkarinen J (2019) Perioperative hydrocortisone treatment reduces postoperative pancreatic fistula rate after open distal pancreatectomy. A randomized placebo-controlled trial. Pancreatology 19:786–792
Yoon SJ, Lee O, Jung JH et al (2022) Prophylactic octreotide for postoperative pancreatic fistula in patients with pancreatoduodenectomy: risk-stratified analysis. Medicine (Baltimore) 101:e29303
Salem MZ, Cunha JE, Coelho AM et al (2003) Effects of octreotide pretreatment in experimental acute pancreatitis. Pancreatology 3:164–168
Droogh DHM, Groen JV, de Boer MGJ et al (2023) Prolonged antibiotic prophylaxis after pancreatoduodenectomy: systematic review and meta-analysis. Br J Surg 110:1458–1466
Negrini D, Ihsan M, Freitas K et al (2022) The clinical impact of the perioperative epidural anesthesia on surgical outcomes after pancreaticoduodenectomy: a retrospective cohort study. Surg Open Sci 10:91–96
Doussot A, Decrock M, Calame P et al (2021) Fluorescence-based pancreas stump perfusion is associated with postoperative acute pancreatitis after pancreatoduodenectomy a prospective cohort study. Pancreatology. https://doi.org/10.1016/j.pan.2021.05.009
Levi Sandri GB, Abu Hilal M, Dokmak S, Edwin B, Hackert T, Keck T, Khatkov I, Besselink MG, Boggi U, E-AHPBA Innovation & Development Committee (2023) Figures do matter: a literature review of 4587 robotic pancreatic resections and their implications on training. J Hepatobiliary Pancreat Sci 30:21–35
Xu J, Ji SR, Zhang B et al (2018) Strategies for pancreatic anastomosis after pancreaticoduodenectomy: what really matters? Hepatobiliary Pancreat Dis Int 17:22–26
Guo C, Xie B, Guo D (2022) Does pancreatic duct stent placement lead to decreased postoperative pancreatic fistula rates after pancreaticoduodenectomy? A meta-analysis. Int J Surg 103:106707
PARANOIA Study Group, Halle-Smith JM, Pande R, Hall L et al (2022) Perioperative interventions to reduce pancreatic fistula following pancreatoduodenectomy: meta-analysis. Br J Surg 109:812–821
Gurram RP, Harilal SL, Gnanasekaran S et al (2023) External pancreatic ductal stenting in minimally invasive pancreatoduodenectomy: how to do it? Ann Hepatobiliary Pancreat Surg 27:211–216
Ozdemir E, Gokler C, Gunes O et al (2022) Isolated Roux loop versus conventional pancreaticojejunostomy following pancreaticoduodenectomy. Ann Ital Chir 93:248–253
Clemente G, De Rose AM, Panettieri E et al (2022) Pancreatico-jejunostomy on isolated loop after pancreatico-duodenectomy: is it worthwhile? J Gastrointest Surg 26:1205–1212
Ke S, Ding XM, Gao J et al (2013) A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy. Surgery 153:743–752
Komi N, Tamura T, Tsuge S et al (1986) Relation of patient age to premalignant alterations in choledochal cyst epithelium: histochemical and immunohistochemical studies. J Pediatr Surg 21:430–433
Kim Y, Hyun J, Lee J et al (2014) Anomalous union of the pancreaticobiliary duct without choledochal cyst: is cholecystectomy alone sufficient? Langenbecks Arch Surg 399:1071–1076
Deng S, Luo J, Ouyang Y et al (2022) Application analysis of omental flap isolation and modified pancreaticojejunostomy in pancreaticoduodenectomy (175 cases). BMC Surg 22:127
Nour HM, Peristeri DV, Ahsan A et al (2022) Regional vessels wrapping following pancreaticoduodenectomy reduces the risk of postoperative extra-luminal bleeding. A systematic review. Ann Med Surg (Lond) 82:104618
Van Buren II G, Bloomston M, Hughes SJ et al (2014) A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg 259:605–612
Cheng Y, Xia J, Lai M et al (2016) Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev 10:CD010583
Machado MC, Machado MA (2019) Drainage after distal pancreatectomy: still an unsolved problem. Surg Oncol 30:76–80
Cameron JL, He J (2015) Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg 220:530–536
Finks JF, Osborne NH, Birkmeyer JD (2011) Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 364:2128–2137
Carroll JE, Smith JK, Simons JP et al (2010) Redefining mortality after pancreatic cancer resection. J Gastrointest Surg 14:1701–1708
Nimptsch U, Krautz C, Weber GF et al (2016) Nationwide In-hospital mortality following pancreatic surgery in Germany is higher than anticipated. Ann Surg 264:1082–1090
Farges O, Bendersky N, Truant S et al (2017) The theory and practice of pancreatic surgery in France. Ann Surg 266:797–804
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethical Standards, conflicts of interest, Research involving human participants and/or animals, and Informed consent
Authors have no conflict of interest or disclosures.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Machado, M.C., Machado, M.A. How I do it. Pancreatojejunostomy: surgical tips to mitigate the severity of postoperative pancreatic fistulas after open or minimally invasive pancreatoduodenectomy. Updates Surg (2024). https://doi.org/10.1007/s13304-024-01867-7
Received:
Accepted:
Published:
DOI: https://doi.org/10.1007/s13304-024-01867-7