The present study reported 529 consecutive PDs, representing the largest consecutive study of PD without mortality. Although the occurrence of pancreatic fistulas was 38.6%, routine evaluation of amylase level of the drainage fluid and intermittent irrigation through drainage tube might prevent POPF related mortality. Recent advances in surgical techniques and adequate management of postoperative complications have led to improved clinical outcomes of PD, and the mortality following PD has decreased to below 6%[8]. POPF is a main source of major morbidity due to the intraperitoneal release of enterokinase and activation of pancreatic proenzymes resulting in sepsis and haemorrhage. This complication might be inevitable and still causes troublesome short-term outcomes after surgery.
The approach to management PA remains key factor in determining the chance of developing a POPF. Despite multiple randomized studies and meta-analyses, there is no clear evidence or universally accepted guidelines for how to construct the optimal PA after PD[9]. The multiple studies described above have failed to provide definitive, consistent, and convincing level 1 evidence that any one technique of PA is better than the others, either during the traditional open PD or more recently with the laparoscopic PD. Therefore, it should be expected to utilize different forms of PA depending on pancreatic texture and main pancreatic duct in selected situations, which might be a potential solution to evade problem of POPF. PJ is the commonly preferred anastomosis method. Many techniques have been proposed for the reconstruction of pancreatic digestive continuity to prevent complications after PD[10-12]. PG anastomosis has an excellent blood supply, less tension in the anastomosis, and a thick stomach wall, which facilitate the establishment of a sound anastomosis[13]. Furthermore, the acid milieu of the stomach and the absence of enterokinase protect the anastomosis from autodigestion by inactivating the pancreatic proenzymes[14]. Previous studies reported contradictory results regarding the impact of PG versus PJ on the postoperative fistula rate[15-17]. Recently, reconstruction by PG was associated with lower postoperative pancreatic and biliary fistula rates[18]. These principles include good exposure and visualization, the use of a fine, nonstrangulating suture to produce a water-tight patent anastomosis, preservation of the blood supply, tension-free fixation of the gastrointestinal tract to the pancreas, and coverage of the transected pancreas[19]. The present study identified the morbidity of GJ was higher than that of PG significantly for patients with soft pancreas. Generally, it recommended that PG was an optimal approach for these patients.
This study contained 52 patients (9.8%) with clinically relevant PF after PD, which was highly consistent with previous studies. A grade A POPF was not considered clinically important; thus, only grade B/C should account for the incidence of clinically relevant POPF[20]. The prevention of clinically relevant POPF may partially depend on the prompt healing of pancreaticodigestive tract anastomoses, which is attributed to the immediate recovery from a minor pancreatic fistula originating from the pancreatic branch duct or parenchyma at the pancreas surface[5]. Prophylactic drains after pancreatic surgery allow physicians to monitor the occurrence of intra-abdominal bleeding and to detect and drain a pancreatic, biliary, or enteric fistula[21]. Intermittent irrigation aimed to dilute the concentration of intra-abdominal amylase level, which is effective in preventing damage caused by the erosive retention of pancreatic secretions. For symptomatic abdominal collection fluid or abdominal abscess, percutaneous puncture and drainage was the preferred procedure. The reported success rate of the conservative treatment of a POPF is approximately 80%. The relaparotomy should be performed only when patients presented a high output fistula and severe sepsis or haemorrhage and cannot be managed by other means[22].
The results were consistent with the literature that reported a significantly elevated risk of post-PD bleeding in patients with pancreatic fistulas[23, 24]. It was also confirmed that pancreatic leakage and intra-abdominal abscess were correlated to post-PD bleeding[25]. Therefore, any procedure that can prevent pancreatic fistula or intra-abdominal abscess can decrease the post-PD bleeding rate. Prophylactic irrigation around a PJ was reported to possibly decrease the incidence of pancreatic fistulas and infectious complications[26]. It was routinely performed a low-speed intermittent irrigation was added when the drain fluid turned turbid with sediment.
Conclusions
Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and diameter of the main pancreatic duct. The appropriate anastomosis and postoperative management could prevent mortality.