Skip to main content
SpringerLink
Log in

Pancreatic Anastomoses after Pancreaticoduodenectomy: Do We Need Further Studies?

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Pancreatic anastomotic leak is the single most important factor responsible for the considerable morbidity and mortality associated with pancreaticoduodenectomy. Management of the pancreatic remnant is controversially discussed, reflecting the complexity of anastomosing a pancreas of different textures to the digestive tract. A number of studies evaluating diverse options have often provided conflicting conclusions. This information is confusing particularly to those surgeons outside of large-volume centers with broad experience and to general surgeons who perform pancreatic surgery. A PubMed search with the key words pancreaticoduodenectomy, pancreatic anastomosis, pancreaticojejunostomy, pancreaticogastrostomy, and pancreatic fistula was performed. Major series of pancreatic anastomosis published between 1990 and 2002 were studied from diverse centers worldwide. Their results with regard to pancreatic fistula, morbidity, and mortality were documented. Nine series of pancreaticojejunostomy and seven series of pancreaticogastrostomy were evaluated. Eight comparative studies evaluating the two techniques were also analyzed. A single randomized controlled trial was identified among these comparative studies. Equally good results were observed with the two techniques. Other uncommon methods of management of the pancreatic remnant (duct occlusion and ligation) were also evaluated. Pancreaticojejunostomy followed by pancreaticogastrostomy are the most favored techniques. A duct-to-mucosa anastomosis is preferred over other methods. Fistula rates of less than 5%–10% should be the standard irrespective of the technique used. Unlike in the past, mortality can be reduced even in the event of an anastomotic dehiscence, and this aspect is primarily dependent on a meticulous anastomosis based on sound surgical principles rather than the method per se. Based on the information accumulated, adherence to these specific principles could ensure a safe and reliable pancreatic anastomosis with mimimal morbidity and mortality after pancreaticoduodenectomy, even in the hands of general surgeons operating outside high-volume centers.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Suave L. Des pancreatectomies et specialement de la pancreatectomie cephakique. Rev Chir (Chir) 1908;37:335–385

    Google Scholar 

  2. Crile G Jr. The advantage of bypass operations over radical pancreanticoduodenectomy in the treatment of pancreatic carcinoma. Surg Gynecol Obstet 1970;130:1049–1053

    PubMed  Google Scholar 

  3. Shapiro TM. Adenocarcinoma of the pancreas: a statistical analysis of biliary bypass vs. Whipple resection in good risk patients. Ann Surg 1975;182:715–721

    PubMed  CAS  Google Scholar 

  4. Trede M, Schwall G, Saegar H. Survival after pancreaticoduodenectomy. Ann Surg 1990;211:447–458

    PubMed  CAS  Google Scholar 

  5. Cameron JL, Pitt HA, Yeo CJ, et al. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993;217:430–438

    PubMed  CAS  Google Scholar 

  6. Crist DW, Sitzmann JV, Cameron JL. Improved hospital mortality after the Whipple operation. Ann Surg 1987;206:358–373

    PubMed  CAS  Google Scholar 

  7. Geer RJ, Brennan MF. Prognostic indicators for survival after resection of pancreatic adenocarcinoma. Am J Surg 1993;165:68–73

    PubMed  CAS  Google Scholar 

  8. Barnes SA, Lillemoe KD, Kaufmann HS, et al. Pancreaticoduodenectomy for benign disease. Am J Surg. 1996;171:131–135

    Google Scholar 

  9. Martin RF, Rossi RL, Leslie KA. Long term results of pylorus-preserving pancreaticoduodenectomy for chronic pancreatitis. Arch Surg 1996;131:247–252

    PubMed  CAS  Google Scholar 

  10. Talamini MA, Moesinger RC, Pitt HA, et al. Adenocarcinoma of the ampulla of Vater. A 28 year experience. Ann Surg 1997;225:590–600

    Article  PubMed  CAS  Google Scholar 

  11. Miedema BW, Sarr MG, van Heerdeen JA, et al. Complications following pancreaticoduodenectomy. Current management. Arch Surg 1992;127:945–950

    PubMed  CAS  Google Scholar 

  12. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997;226:248–260

    Article  PubMed  CAS  Google Scholar 

  13. Bassi C, Butturini G, Molinari E, et al. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg 2004;21:54–59

    Article  PubMed  Google Scholar 

  14. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13

    Article  PubMed  Google Scholar 

  15. Goldsmith HS, Ghosh BC, Huvos AG. Ligation versus implantation of the pancreatic duct after pancreaticoduodenectomy. Surg Gynecol Obstet 1971;132:87–92

    PubMed  CAS  Google Scholar 

  16. Papachristou DN, Fortner JG. Pancreatic fistula complicating pancreatectomy for malignant disease. Br J Surg 1981;68:238–240

    PubMed  CAS  Google Scholar 

  17. Friess H, Boehnert M, Shrikhande S, et al. 2002. Surgery for pancreatic cancer and the management of its complications. In Jagannath P, Hepato-Pancreato-Biliary Surgery: Current Concepts, Delhi, India, B. I. Churchill Livingstone, pp 209–222

  18. Tran K, Van Eijck C, Di Carlo V, et al. Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial. Ann Surg 2002;236:422–428

    Article  PubMed  Google Scholar 

  19. Dicarlo V, Chiesa R, Pontiroli AE, et al. Pancreaticoduodenectomy with occlusion of the residual stump with neoprene injection. World J Surg 1989;13:105–111

    CAS  Google Scholar 

  20. Sarr MG, Behrns KE, van Heerdeen JA. Total pancreatectomy. An objective analysis of its use in pancreatic cancer. Hepatogastroenterology 1993;40:418–421

    PubMed  CAS  Google Scholar 

  21. Aston SJ, Longmire WP Jr. Management of the pancreas after pancreaticoduodenectomy. Ann Surg 1974;179:322–327

    PubMed  CAS  Google Scholar 

  22. Marcus SG, Cohen H, Ranson JHC. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221:635–648

    PubMed  CAS  Google Scholar 

  23. Roder JD, Stein HJ, Bottcher KA, et al. Stented versus nonstented pancreaticojejunostomy after pancreaticoduodenectomy. A prospective study. Ann Surg 1999;1:41–48

    Google Scholar 

  24. Papadimitriou JD, Fotopoulus AC, Smyrniotis B, et al. Subtotal pancreaticoduodenectomy. Use of a defunctionalized loop for pancreatic stump drainage. Arch Surg 1999;134:135–139

    PubMed  CAS  Google Scholar 

  25. Greene BS, Loubeau JM, Peoples JB, et al. Are pancreaticoenteric anastomoses improved by duct-to-mucosa sutures? Am J Surg 1991;161:45–50

    Article  PubMed  CAS  Google Scholar 

  26. Miyagawa S, Makuuchi M, Lygidakis NJ, et al. A retrospective comparative study of reconstructive methods following pancreaticoduodenectomy—pancreaticojejunostomy vs. pancreaticogastrostomy. Hepatogastroenterology 1992;39:381–384

    PubMed  CAS  Google Scholar 

  27. Kim SW, Youk EG, Park YH. Comparison of pancreatogastrostomy and pancreatojejunostomy after pancreatoduodenectomy performed by one surgeon. World J Surg 1997;21:640–643

    Article  PubMed  CAS  Google Scholar 

  28. Lin PW, Lee JC, Lee PC, et al. A simple, secure and universal pancreaticojejunostomy following pancreaticoduodenectomy. HPB Surg 1997;10:305–310

    PubMed  CAS  Google Scholar 

  29. Arnaud JP, Tuech JJ, Cervi C, et al. Pancreaticogastrostomy compared with pancreaticojejunostomy after pancreaticoduodenectomy. Eur J Surg 1999;165:357–362

    PubMed  CAS  Google Scholar 

  30. Ohwada S, Ogawa T, Kawate S, Tanahashi Y, Iwazaki S, Tomizawa N, Yamada T, Ohya T, Morishita Y. Results of duct-to-mucosa pancreaticojejunostomy for pancreaticoduodenectomy Billroth I type reconstruction in 100 consecutive patients. J Am Coll Surg 2001;193:29–35

    Article  PubMed  CAS  Google Scholar 

  31. Z’graggen K, Uhl W, Friess H, et al. How to do a safe pancreatic anastomosis. J. Hepatobiliary Pancreat Surg 2002;9:733–737

    PubMed  Google Scholar 

  32. Strasberg SM, Drebin JA, Mokadam NA, et al. Prospective trial of a blood supply-based technique of pancreaticojejunostomy: effect on anastomotic failure in the Whipple procedure. J Am Coll Surg 2002;194:746–758 discussion 759–760

    PubMed  Google Scholar 

  33. Peng S, Liu Y, Mou Y, et al. Binding pancreaticojejunostomy: clinical report of 150 cases. Zhonghua Yi Xue Za Zhi 2002;82:368–370

    PubMed  Google Scholar 

  34. van Berge Henegouwen MI, De Wit LT, Van Gulik TM, et al. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg 1997;185:18–24

    PubMed  Google Scholar 

  35. O’Neil S, Pickleman J, Aranha GV. Pancreaticogastrostomy following pancreaticoduodenectomy: review of 102 consecutive cases. World J Surg 2001;25:567–571

    PubMed  CAS  Google Scholar 

  36. Tripodi AM, Sherwin CF. Experimental transplantation of the pancreas into the stomach. Arch Surg 1934;28:345–356

    Google Scholar 

  37. Person EC Jr, Glenn F. Pancreaticogastrostomy, experimental transplantation of the pancreas into the stomach. Arch Surg 1939;39:530–550

    CAS  Google Scholar 

  38. Waugh JM, Clagett OT. Resection of the duodenum and head of pancreas for carcinoma. An analysis of thirty cases. Surgery 1946;20:224–232

    Google Scholar 

  39. Delcore R, Thomas JH, Pierce GE, et al. Pancreatogastrostomy: a safe drainage procedure after pancreatoduodenectomy. Surgery 1990;108:641–645 discussion 645–647

    PubMed  CAS  Google Scholar 

  40. Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995;222:580–588 discussion 588–592

    Article  PubMed  CAS  Google Scholar 

  41. Kapur BM, Misra MC, Seenu V, et al. Pancreaticogastrostomy for reconstruction of pancreatic stump after pancreaticoduodenectomy for ampullary carcinoma. Am J Surg 1998;176:274–278

    Article  PubMed  CAS  Google Scholar 

  42. Takano S, Ito Y, Oishi H, et al. A retrospective analysis of 88 patients with pancreaticogastrostomy after pancreaticoduodenectomy. Hepatogastroenterology 2000;47:1454–1457

    PubMed  CAS  Google Scholar 

  43. Schlitt HJ, Schmidt U, Simunec D, et al. Morbidity and mortality associated with pancreatogastrostomy and pancreatojejunostomy following partial pancreatoduodenectomy. Br J Surg 2002;89:1245–1251

    Article  PubMed  CAS  Google Scholar 

  44. Mason GR. Pancreatogastrostomy as reconstruction for pancreatoduodenectomy: review. World J Surg 1999;23:221–226

    PubMed  CAS  Google Scholar 

  45. Takano S, Ito Y, Watanabe Y, et al. Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy. Br J Surg 2000;87:423–427

    PubMed  CAS  Google Scholar 

  46. Aranha GV, Hodul P, Golts E, et al. A comparison of pancreaticogastrostomy and pancreaticojejunostomy following pancreaticoduodenectomy. J Gastrointest Surg 2003;7:672–682

    Article  PubMed  Google Scholar 

  47. Oussoultzoglou E, Bachellier P, Bigourdan JM, et al. Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy. Arch Surg 2004;139:327–335

    PubMed  Google Scholar 

  48. Mason GR, Freeark RJ. Current experience with pancreatogastrostomy. Am J Surg 1995;169:217–219

    Article  PubMed  CAS  Google Scholar 

  49. Matsusue S, Takeda H, Nakamura Y, et al. A prospective analysis of the factors influencing pancreaticojejunostomy performed using single method, in 100 consecutive pancreaticoduodenectomies. Surg Today 1998;28:719–726

    Article  PubMed  CAS  Google Scholar 

  50. Bartoli FG, Arnone GB, Ravera G, et al. Pancreatic fistula and relative mortality in malignant disease after pancreaticoduodenectomy. Reviews and statistical meta-analysis regarding 15 years of literature. Anticancer Res 1991;11:1831–1848

    PubMed  CAS  Google Scholar 

  51. Al-Sharaf C, Ishe I, Dawiskiba S, et al. Characteristics of the gland remnant predict complications after subtotal pancreaticoduodenectomy. Dig Surg 1997;14:101–106

    Article  Google Scholar 

  52. Sato N, Yamaguchi K, Chijiiwa K, et al. Risk analysis of pancreatic fistula after pancreatic head resection. Arch Surg 1998;133:1094–1098

    PubMed  CAS  Google Scholar 

  53. Hamanaka Y, Nishihara K, Hamasaki T, et al. Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency duct size, and leakage. Surgery 1996;19:281–287

    Google Scholar 

  54. Ishikawa O, Ohigashi H, Imaoka S, et al. Concomitant benefit of preoperative irradiation in preventing pancreas fistula formation after pancreaticoduodenectomy. Arch Surg 1991;126:885–889

    PubMed  CAS  Google Scholar 

  55. Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg 2000;232:419–429

    PubMed  CAS  Google Scholar 

  56. Buchler M, Friess H, Klempa I, et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg 1992;163:125–131

    PubMed  CAS  Google Scholar 

  57. Pederzoli P, Bassi C, Falconi M, et al. Efficacy of octreotide in the prevention of complications of elective pancreatic surgery. Br J Surg 1994;81:265–26

    PubMed  CAS  Google Scholar 

  58. Montorsi M, Zago M, Mosca F, et al. Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery 1995:117:26–31

    PubMed  CAS  Google Scholar 

  59. Friess H, Beger Hg, Sulkowski U, et al. Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis. Br J Surg 1995;82:1270–1273

    PubMed  CAS  Google Scholar 

  60. Lowy AM, Lee JE, Piaters Pw, et al. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for maliganant disease. Ann Surg 1997;226:632–641

    Article  PubMed  CAS  Google Scholar 

  61. Sikora SS, Posner MC. Management of the pancreatic stump following pancreaticoduodenectomy. Br J Surg 1995;82:1590–1597

    PubMed  CAS  Google Scholar 

  62. Matsumoto Y, Fujii H, Miura K, et al. Successful pancreatojejunal anastomosis for pancreatodenectomy. Surg Gynecol Obstet 1992;175:555–562

    PubMed  CAS  Google Scholar 

  63. Tsuji M, Kimura H, Konishi K, et al. Management of continuous anastomosis of pancreatic duct and jejunal mucosa after pancreaticoduodenectomy: historical study of 300 patients. Surgery 1998;123:617–621

    PubMed  CAS  Google Scholar 

  64. Hwang TL, Jan YY, chen MF. Secural pancreaticojejunal anastomosis for the pancreaticoduodenectomy. Hepatogastroenterology 1996;43:275–277

    PubMed  CAS  Google Scholar 

  65. Biehl T, Traverso LW. Is stenting necessary for a successful pancreatic anastomosis? Am J Surg 1992;163:530–532

    Article  PubMed  CAS  Google Scholar 

  66. Yoshimi F, Ono H, Asato Y, et al. Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy in patients undergoing pancreatoduodenectomy to promote earlier discharge from hospital. Surg Today 1996;26:665–667

    Article  PubMed  CAS  Google Scholar 

  67. Shibuya T, Uchiyama K, Imai S, et al. Improvement of pancreaticojejunostomy in pancreatoduodenectomy. Int Surg 1995;80:57–60

    PubMed  CAS  Google Scholar 

  68. Roder JD, Stein HJ, Bottcher KA, et al. Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy. A prospective study. Ann Surg 1999;229:41–48

    Article  PubMed  CAS  Google Scholar 

  69. Shrikhande S, Jagannath P. Current options in diagnosis and management of ampullary carcinoma. Indian J Surg 2003;65:347–353

    Google Scholar 

  70. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002;346:1128–1137

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Dr. Ernest Borges Marg, Parel, Mumbai, 400 012, India

    Shailesh V. Shrikhande MS, Sajid S. Qureshi MS, Nanda Rajneesh MS & Parul J. Shukla MS

Authors
  1. Shailesh V. Shrikhande MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sajid S. Qureshi MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nanda Rajneesh MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Parul J. Shukla MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Shailesh V. Shrikhande MS.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Shrikhande, S.V., Qureshi, S.S., Rajneesh, N. et al. Pancreatic Anastomoses after Pancreaticoduodenectomy: Do We Need Further Studies?. World J. Surg. 29, 1642–1649 (2005). https://doi.org/10.1007/s00268-005-0137-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-005-0137-3

Keywords

Search

Navigation