Reconstruction after pancreatoduodenectomy: Pancreatojejunostomyvspancreatogastrostomy

Abstract

Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy (PD) in order to decrease postoperative complications, mainly pancreatic fistulas (PF). In this work, we compare the two most frequent techniques of reconstruction after PD, pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), in order to determine which of the two is better. A systematic review of the literature was performed, including major meta-analysis articles, clinical randomized trials, systematic reviews, and retrospective studies. A total of 64 articles were finally included. PJ and PG are usually responsible for most of the postoperative morbidity, mainly due to the onset of PF, being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia. The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG. PF, delayed gastric emptying and mortality were not different. Although there was heterogeneity between these studies, all were conducted in specialized centers by highly experienced surgeons, and the surgical care was likely to be similar for all the studies. The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa. Exocrine function appears to be worse after PG than after PJ, resulting in severe atrophic changes in the remnant pancreas. Depending on the type of PJ or PG used, the PF rate and other complications can also be different. The best method to deal with the pancreatic stump after PD remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles such as good exposure and visualization. In conclusion, up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD. Core tip: Pancreatoduodenectomy is a technique with a high rate of morbidity and mortality. Surgeons try to find the best technique of reconstruction in order to decrease postoperative complications. We compare the two most frequent techniques of reconstruction after pancreatoduodenectomy, namely pancreatojejunostomy and pancreatogastrostomy, to determine which of the two is better. We offer a systematic review of the main papers published with all the pros and cons of each technique. The best method to deal with the pancreatic stump after pancreatoduodenectomy remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles, such as good exposure and visualization. TOPIC HIGHLIGHTSeptember 15, 2014|Volume 6|Issue 9|

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“…Furthermore, a meta-analysis of 11 studies including 909 patients who underwent PG and 856 patients who underwent PJ published in 2019 by Jin Y et al [4] revealed that POPF incidence was substantially lower in the PG group than that in the PJ group, whereas the incidence of grade B and C fistula was not statistically different between the two groups. Other studies, however, have found no significant differences in the incidence of POPF, total morbidity, and death between the PG and PJ groups [17,18,19]. End-to-side duct-to-mucosa anastomosis or end-to-side invagination methods are used for PG anastomosis.…”

A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy

“…32 Most of the formerly published meta-analyses on pancreaticogastrostomy versus pancreaticojejunostomy conclude, however, that pancreaticogastrostomy is associated with a lower rate of POPF. [33][34][35][36][37][38][39][40][41][42][43][44][45][46] The rich blood supply, anatomical apposition, wider lumen and thicker wall of the stomach compared to the jejunum are arguments mentioned in favor of pancreaticogastrostomy. [47][48][49] This is partially in line with the results, although the current meta-analysis is updated with the latest RCT on this subject, which proves otherwise.…”

What is the pancreatic duct size limit for a safe duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy? A retrospective study

“…In some cases, pancreaticogastrostomy (PG) is performed, in which instead of joining to jejunum, the pancreatic stump is invaginated to the stomach lumen [ 12 ]. Although both PG and DPJ are preferred over DTM anastomosis when the pancreatic duct is very small, studies have shown that there is no significant difference in the rate of POPF between different anastomotic techniques [ 13 - 15 ] and none of the technical variations of PJ or PG anastomosis has been found to be consistently superior to another [ 16 ]. Currently, DTMPJ remains the anastomosis of choice after PD in many centers worldwide.…”