Pancreaticojejunostomy Anastomosis Techniques After Pancreaticoduodenectomy: A Critical Review

Abstract

Despite advanced new anastomosis techniques and auxiliary anastomosis materials, unfortunately, the rate of pancreaticojejunostomy (PJ) anastomotic fistula developing after pancreatoduodenectomy (PD) has not fallen to the anticipated level. The aim of this review was to evaluate different PJ techniques in the context of the current literature. The method used for PJ anastomosis is one of the most critical risk factors. Also, the rate of pancreatic fistula after the operation (PFAO) is exceptionally high in patients with a soft pancreas, narrow pancreatic duct diameter, or a posteriorly located pancreatic duct. Meta-analyses comparing duct-mucosa-PJ (dm-PJ) and invagination-PJ (i-PJ) have demonstrated similar rates of PFAO, morbidity, and mortality. Although a lower rate of PFAO was originally reported when using the binding-PJ approach, recent studies have contradicted this, showing similar rates of PFAO, morbidity, and mortality. A recent meta-analysis comparing Blumgart anastomosis (BA) and conventional pancreaticojejunostomy (c-PJ) reported that BA was significantly associated with a lower grade B/C PFAO ratio. However, in a subgroup analysis, there was no significant impact on grade B/C PFAO in patients with soft pancreatic stumps. The literature also includes reports of internal or external stents and prophylactic octreotide being used to reduce the rate of PFAO. In conclusion, pancreatic fistula development after PD is multifactorial. The surgeon can reduce bleeding and avoid sepsis with meticulous dissection and taking extra care throughout the entire operation. Based on the results of meta-analyses, standard dm-PJ anastomosis and BA techniques performed carefully can be recommended as a standard, leading to a more controlled PFAO rate.