Pancreaticogastrostomy for High‐risk Gland After Pancreaticoduodenectomy: An Eligible Choice? Letter to the Editor

Abstract

We read with interest the paper published by Dr. Niedergethmann and colleagues [1]. In this study, through ‘‘riskadapted pancreatic anastomosis,’’ the rate of pancreatic fistula (PF) after pancreaticoduodenectomy (PD) has been reduced. We give the authors particular credit for controlling the many variables involved in the performance of a pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) and congratulate the authors on their work. In this study, PG revealed a PF rate of 7% and PJ accounted for 19% of PF. Patients with high-risk glands received perioperative octreotide until postoperative day 5 and a high dose of pantoprazole. Patients with standard anastomosis received neither octreotide nor high-dose pantoprazole. A meta-analysis of seven identified randomized controlled trials reporting comparisons between the octreotide group and without octreotide group, perioperative octreotide is associated with a significant reduction in the incidence of PF after elective pancreatic surgery [2]. My first question is whether a lower rate of PF after patients receiving PG was conducted by octreotide and pantoprazole. During January 2004 to December 2006, the rate of PF after patients receiving duct-to-mucosa PJ was 22%, but patients receiving duct-to-mucosa PJ showed a lower rate of PF (13%) during January 2007 to December 2008. I find this hard to explain only by RAP. My second question is whether it might be influenced by a learning curve of PG in your institution. A randomized, controlled trial by Bassi et al. reported a total of 151 patients with soft remnant who were randomized to receive PG or duct-to-mucosa PJ. Compared with duct-to-mucosa PJ, PG did not show any significant differences in the PF (13 vs. 16%) [3]. Another randomized, controlled trial by Bassi et al. reported 144 patients with soft residual tissue who were assigned randomly to receive a duct-to-mucosa PJ or a PJ; however, the two methods revealed no significant difference in regards to the PF (13 vs. 16%) [4]. Recently, a number of techniques of managing the soft pancreatic remnant have been studied in relation to the PF. Peng et al. have described a new technique of binding PJ after PD in their randomized, controlled trial. They reported a 0% incidence of PF, which is the lowest ever published in the literature [5]. Subsequently, in a series report, 45 consecutive patients with soft pancreas and nondilated main pancreatic duct underwent a binding PJ, and only four patients (8.9%) developed a PF [6]. An easier method reported by Hakamada et al. for performing a PJ for the soft pancreas using a fast-absorbable suture, PF was noted in 3% of the patients in the duct-to-mucosa contact method group [7]. The surgeon is an important factor for the prevention of PF. The reconstruction of pancreatic digestive continuity after PD performed with fine sutures, minimal handling, and a good blood supply is likely to yield a favorable result. Therefore, we suggested that a meticulous level of surgical skill and perioperative octreotide may be associated with a significant reduction in the incidence of PF. Y. S. Hu D. K. Feng (&) Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, 17 Changle Western Road, Xi’an 710032, Shanxi Province, China e-mail: doukefeng2010@126.com