Review
Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy

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Abstract

Background: Leakage at the pancreaticoenteric anastomosis remains a common and serious complication after pancreaticoduodenectomy. Over the past decade, various measures directed towards prevention of pancreatic leakage have been studied. This article reviews the available data on the efficacy of these measures.

Data sources: The Medline database from 1990 to 2000 was searched for studies on the prevention of pancreatic anastomotic leakage, and the bibliographies of the articles were reviewed for additional references.

Results: A meta-analysis of the results of prophylactic octreotide in preventing pancreatic fistula after pancreaticoduodenectomy from data available in three randomized controlled studies yielded an odds ratio of 1.08 (95% confidence interval 0.64 to 1.84). Pending further trials to clarify its role, the routine use of octreotide in pancreaticoduodenectomy cannot be recommended. Retrospective or nonrandomized prospective studies suggested that technical modifications such as duct-to-mucosa anastomosis, pancreaticogastrostomy and external pancreatic duct stenting may reduce the leakage rate, but there is a paucity of randomized trials. A randomized trial comparing pancreaticogastrostomy and pancreaticojejunostomy did not reveal a significant difference in the leakage rate.

Conclusions: Further randomized controlled studies are required to determine the optimum technique of pancreaticoenteric anastomosis after pancreaticoduodenectomy.

Section snippets

Risk factors for pancreatic anastomotic leakage

In order to devise effective measures to prevent pancreatic anastomotic leakage, it is instrumental to identify the associated risk factors. Several factors related to pancreatic anastomotic leakage have been described in the literature. They can be conveniently divided into disease factors (pancreatic texture, pancreatic pathology, pancreatic duct size, pancreatic juice output), procedure-related factors (intraoperative blood loss, operative techniques) and patient factors (age, sex, comorbid

Pharmacological approach to prevent anastomotic leakage

As a high pancreatic juice output in soft pancreas is thought to be an important risk factor for pancreatic anastomotic leakage, it appears rational to postulate that inhibition of exocrine pancreatic secretion in the postoperative period may reduce the anastomotic leakage rate.

This concept was first described by a German group who reported a reduced complication rate after pancreaticoduodenectomy with perioperative infusion of somatostatin [30]. Octreotide, an octapeptide analogue of

Techniques of pancreaticojejunal anastomosis

Various techniques of managing the pancreatic remnant have been studied with the aim of reducing the anastomotic leakage rate. Pancreaticojejunostomy (PJ) is a classical method of reconstruction after pancreaticoduodenectomy. The anastomosis between the pancreatic end and jejunum is performed either as end-to-side, duct-to-mucosa anastomosis, or end-to-end (dunking) or end-to-side invagination anastomosis [43]. In a prospectively randomized study in a canine model, Greene et al [44]

Conclusions

In recent years, pancreaticoduodenectomy has evolved into a safe and effective therapeutic option for malignant and benign diseases of the pancreatic head and periampullary region. Leakage of pancreaticoenteric anastomosis remains a leading cause of morbidity, and at times mortality. Over the past decade, substantial efforts have been invested by pancreatic surgeons to improve the safety of pancreaticoenteric anastomosis using pharmacological or technical approaches. This article provides a

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