Strategies for pancreatic anastomosis after pancreaticoduodenectomy:What really matters?

Background: The postoperative pancreatic fistula rate remains approximately 10–20% even in institutions treating a high-volume of pancreatic cases. The best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate.Data sources: Studies were identified by searching Pub Med for studies published between January 1934 (when pancreaticogastrostomy was technically feasible) and December 2016. The following search terms were used: "duct-to-mucosa", "invagination", "pancreaticojejunostomy", "pancreaticogastrostomy," and"pancreaticoduodenectomy". The search was limited to English publications.Results: Many technical methods have been developed and optimized to restore pancreaticoenteric continuity, including pancreaticojejunostomy, pancreaticogastrostomy, and stented drainage of the pancreatic duct, among other modifications. Researchers have also attempted to decrease the postoperative pancreatic fistula after pancreaticoduodenectomy by using fibrin glue and somatostatin analogues. However, no significant decrease in postoperative pancreatic fistula has been observed in most of these studies, and only an external pancreatic duct stent has been found to decrease the leakage rate of pancreatic anastomosis after pancreaticojejunostomy.Conclusion: Pancreatic surgeons should choose a suitable technique according to the characteristics of individual cases.

Decision-making in high-risk leakage duodenopancreatectomy:pancreatic anastomosis or total pancreatectomy?

The Italian team from Verona,questions the place of total pancreatectomy(TP)as an alternative to pancreaticoduodenectomy(PD)in patients at high risk of pancreatic fistula in a monocentric retrospective study running from July 2017 to December 2019(1).A total of 702 patients were included,566 PD of which 101 were at high risk of pancreatic fistula(HR-PD),136 TP of which 86 were PD converted to TP(C-TP)for positive margin of pancreatic section for malignancy(49%),extensive vascular resection(14%)or technical reasons(27%)such as residual non-reconstructible pancreas/friable pancreas/microscopic Wirsung’s duct,10% for other reasons(bleeding......)Patients in the HR-PD group received externalized stent of the Wirsung duct.

Novel invagination procedure for pancreaticojejunostomy using double purse string sutures:A technical note

BACKGROUND Postoperative pancreatic fistula(POPF)is one of the most serious complications after pancreaticoduodenectomy(PD),and the choice of pancreaticojejunostomy(PJ)is considered a key factor affecting the occurrence of POPF.Numerous anastomotic methods and their modifications have been proposed,and there is no method that can completely avoid the occurrence of POPF.Based on our team’s experience in pancreatic surgery and a review of relevant literature,we describe a novel invagination procedure for PJ using double purse string sutures,which has resulted in favourable outcomes.AIM To describe the precise procedural steps,technical details and clinical efficacy of the novel invagination procedure for PJ.METHODS This study adopted a single-arm retrospective cohort study methodology,involving a total of 65 consecutive patients who underwent PD with the novel invagination procedure for PJ,including the placement of a pancreatic stent,closure of the residual pancreatic end,and two layers of purse-string suturing.Baseline data included age,sex,body mass index(BMI),pancreatic texture,pancreatic duct diameter,operation time,and blood loss.Clinical outcomes included the operation time,blood loss,and incidence of POPF,postoperative haemorrhage,delayed gastric emptying,postoperative pulmonary infection,postoperative abdominal infection,and postoperative pulmonary infection.RESULTS The mean age of the patients was 59.12(±8.08)years.Forty males and 25 females were included,and the mean BMI was 21.61 kg/m^(2)(±2.74).A total of 41.53% of patients had a pancreatic duct diameter of 3 mm or less.The mean operation time was 263.83 min(±59.46),and the mean blood loss volume was 318.4 mL(±163.50).Following the surgical intervention,only three patients showed grade B POPF(4.62%),while no patients showed grade C POPF.Five patients(5/65,7.69%)were diagnosed with postoperative haemorrhage.Six patients(6/65,9.23%)experienced delayed gastric emptying.Four patients(4/65,6.15%)developed postoperative pulmonary infection,while an equivalent number(4/65,6.15%)exhibited postoperative abdominal infection.Additionally,two patients(2/65,3.08%)experienced postoperative pulmonary infection.CONCLUSION The novel invagination technique for PJ is straightforward,yields significant outcomes,and has proven to be safe and feasible for clinical application.

Modified Blumgart anastomosis without pancreatic duct-to-jejunum mucosa anastomosis for pancreatoduodenectomy：a feasible and safe novel technique

Objective：This study proposed a modified Blumgart anastomosis（m-BA）that uses a firm ligation of the main pancreatic duct with a supporting tube to replace the pancreatic duct-to-jejunum mucosa anastomosis,with the aim of simplifying the complicated steps of the conventional BA（c-BA）.Thus,we observe if a difference in the risk of postoperative pancreatic fistula（POPF）exists between the two methods.Methods：The m-BA anastomosis method has been used since 2010.From October 2011 to October 2015,147 patients who underwent pancreatoduodenectomy（PD）using BA in Tianjin Medical University Cancer Institute and Hospital were enrolled in this study.According to the type of pancreatojejunostomy（PJ）,50 patients underwent m-BA and 97 received c-BA.The two patient cohorts were compared prospectively to some extent but not randomized,and the evaluated variables were operation time,the incidence rate of POPF,and other perioperative complications.Results：The operation time showed no significant difference（P〉0.05）between the two groups,but the time of duct-to-mucosa anastomosis in the m-BA group was much shorter than that in the c-BA group（P〈0.001）.The incidence rate of clinically relevant POPF was 12.0%（6/50）in the modified group and 10.3%（10/97）in the conventional group（P〉0.05）,which means that the modified anastomosis method did not cause additional pancreatic leakage.The mean length of postoperative hospital stay of the m-BA group was 23 days,and that of the c-BA group was 22 days（P〉0.05）.Conclusions：Compared with the conventional BA,we suggest that the modified BA is a feasible,safe,and effective operation method for P J of PD with no sacrifice of surgical quality.In the multivariate analysis,we also found that body mass index（≥25

Pancreatic fistula after pancreatectomy:Evolving definitions,preventive strategies and modern management

Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a demanding procedure and whereas mortality after a pancreaticoduodenectomy is currently < 3%-5% in experienced high-volume centers, post-operative morbidity is considerable, about 30%-50%. At present, the single most significant cause of morbidity and mortality after pancreatectomy is the development of pancreatic leakage and fistula (PF). The occurrence of a PF increases the length of hospital stay and the cost of treatment, requires additional investigations and procedures, and can result in life-threatening complications. There is no universally accepted definition of PF that would allow standardized reporting and proper comparison of outcomes between different centers. However, early recognition of a PF and prompt institution of appropriate treatment is critical to the prevention of potentially devastating consequences. The present article, reviews the evolution of post resection pancreatic fistula as a concept, and discusses evolving definitions, the current preventive strategies and the management of this problem.