Pancreatic fistula following pancreatoduodenectomy. Evaluation of different surgical approaches in the management of pancreatic stump. Literature review

Abstract

Pancreatoduodenectomy is the gold standard operation for malignant and benign diseases of the pancreas and periampullary region. Even if improvements in intensive care management and surgical technique have dramatically reduced postoperative mortality after pancreatic surgery, morbidity remains high (30-50%), also in specialized pancreatic units. In order to reduce postoperative complications, particularly pancreatic fistula, different surgical techniques and their modifications have been proposed. In order to determine the better management of the pancreatic stump after pancreatoduodenectomy, the Authors analysed and compared derivative - pancreaticojejunal, pancreaticogastrostomy - vs no-derivative technique - pancreatic stump closure (duct ligation or mechanical suture, duct occlusion by fibrin glue or cyanoacrylate). A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, analysing the risk factors and the incidence of short-medium term postoperative complications. Up to now, even if derivative procedures are preferred as gold standard the best method to deal a pancreatic stump is still controversial and remains matter of research. Pancreatic surgeons must have more than one technique for managing the pancreatic remnant.

Comparison of Different Techniques of Pancreatic Stump Management in Robot-Assisted Pancreaticoduodenectomy

“…Using TPG reconstruction as a reference, there were significant differences with CG occlusion of the pancreatic duct, showing a higher incidence of POPF in the CG group (p < 0.01). This is consistent with the date in the existing literature [50][51][52]. Hence, we examined TPG versus PJ reconstruction, known as the gold standard technique [41].…”

Pancreatic stump closure after pancreatoduodenectomy in elderly patients: a retrospective clinical study

“…The high incidence and potential severity of PF in PD have led some authors to re-propose the avoidance of any pancreatic anastomosis by closing/occluding the main duct, because a fistula from the over-sewn pancreatic remnant (without enzymatic activation) is less dangerous than one related to anastomotic procedures [8, 10, 11, 36–39]. Nevertheless, this technique was rarely used because of the risk of postoperative pancreatitis, permanent exocrine and endocrine insufficiency, the fear of severe hemorrhagic complications.…”

Risk factors and prevention of postoperative pancreatitis after pancreatectomy

“…Осложнения после резекционных операций на ПЖ существенно ухудшают ближайшие результаты лечения [8]. При отсутствии ПП послеоперацион-ный период протекает более благоприятно.…”

“…Возник-новение острого панкреатита в ответ на операцион-ную травму паренхимы органа приводит к гастро-стазу, несостоятельности швов панкреатодигестив-ного анастомоза, образованию панкреатического свища и аррозионному кровотечению. Частота воз-никновения панкреатического свища составляет от 5 до 40%, при этом почти половина летальных ис-ходов обусловлена сепсисом и аррозионным крово-течением [1,2,8].…”

“…Летальность после этих операций в специализи-рованных клиниках составляет 5%, а количество ос-ложнений в послеоперационном периоде может до-стигать 50% [8]. Первопричиной значительной части осложнений является послеоперационный панкреа-тит (ПП) как ответная реакция на операционную травму ПЖ [4].…”