Pancreatic anastomotic leak after the Whipple procedure is reduced using the surgical microscope

Abstract

Pancreatic anastomotic leakage (Leak) is the most common major complication after pancreaticoduodenectomy (PD). In this study we tested the hypothesis that better vision would improve the technical performance of this anastomosis and result in a lower Leak rate. A retrospective review of 266 consecutive patients who underwent PD with pancreaticojejunostomy between 1996 and 2003 was carried out. In the first 196 patients we had used an end-to-side, internally-stented, duct-to-mucosa pancreaticojejunostomy aided by surgical Loupes at 2.5x magnification (Loupes group). In the next 70 patients we substituted the surgical microscope at 12.5x for the surgical Loupes (microscope group). Risk factors associated with Leak were determined for all 266 cases and then the outcomes for each group were compared. Leak was observed in 11.7% of patients (31 of 266). Uni- and multivariate analysis showed 3 independent risk factors for Leak: (1) male gender (odds ratio [OR], 3.10); (2) a pancreatic duct size of less than or equal to 3 mm (OR, 7.75); and (3) not using the microscope (OR, 7.43). The Leak rate in the Loupes group was 15% (29 of 196) and in the microscope group 2.9% (2 of 70, P = .008). The mean hospital length of stay was longer in the Loupes group (11.3 days) as compared to the microscope group (9.0 days, P < .001). In the high-risk subset for Leak with duct size less than or equal to 3 mm (n = 147), the Leak rate was 23% in the Loupes group vs 4.2% in the microscope group (P = .027). The enhanced vision provided by the surgical microscope allowed precise construction of the anastomosis resulting in a significant decrease in Leak, particularly when a patient was at risk for Leak, ie, pancreatic duct less than or equal to 3 mm.