External Pancreatic Duct Stent Research Articles

Pancreatic Anastomosis in Robotic-Assisted Pancreaticoduodenectomy: Different Surgical Techniques

Robot-assisted pancreatoduodenectomy (R-PD) may provide challenges but potential benefits for pancreatic-enteric anastomosis fashioning. Despite numerous trials comparing different pancreatic-enteric anastomosis techniques, an ideal method is still missing. This study aims to describe different management strategies and surgical techniques of standardized pancreatic-enteric anastomoses during an R-PD. This study reported the robotic technical steps of the modified end-to-side Blumgart pancreaticojejunostomy, the Cattel-Warren duct-to-mucosa pancreatojejunostomy, with internal or external pancreatic duct stent, and the modified end-to-side, double-layer pancreogastrostomy. A dual-console da Vinci Xi Surgical System® (Intuitive Surgical Xi, Sunnyvale, CA) was used to perform all the R-PD. Different robotic pancreatic-enteric anastomosis techniques can be used during the reconstruction phase, possibly reproducing the open technique. The type of anastomosis and applied mitigation strategies should balance surgical strategy adaptability and operative technique standardization. R-PD should be performed in high-volume centers by surgeons with extensive experience in pancreatic and advanced MI surgery, enabling different but standardized anastomotic techniques based on patients’ risk factors and intraoperative findings. Future studies on robotic pancreatic anastomosis should focus on personalized approaches after adequate risk stratification.

The prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy in patients with FRS\u2009\u2265\u20094: a retrospective cohort study

BackgroundThe prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy remains controversial. This study aimed to evaluate the benefits of external and internal stents using the Fistula Risk Score system with regard to the incidence of clinically relevant postoperative pancreatic fistula.MethodsA total of 382 patients who underwent pancreaticoduodenectomy with duct to mucosa pancreaticojejunostomy were retrospectively enrolled from January 2015 to October 2019. The receiver operating characteristic curve was performed for subgroup analysis of the patients at different levels of risk for pancreatic fistula.ResultsThere were no significant differences in terms of pancreatic fistula or other postoperative complications. According to the receiver operating characteristic curve threshold of 3.5, 172 patients with a Fistula Risk Score ≥ 4 and 210 patients with a Fistula Risk Score < 4 were divided into separate groups. The number of valid cases was insufficient to support the subsequent research in patients with a Fistula Risk Score < 4. In patients with a Fistula Risk Score ≥ 4, the use of an external pancreatic duct stent was significantly more effective than the use of an internal stent, especially with regard to the risk for pancreatic fistula (Grade C) (P = 0.039), at ameliorating the incidence of clinically relevant postoperative pancreatic fistula (P = 0.019). Additionally, the incidence of lymphatic leakage was significantly higher in the external stent group compared with the internal stent group (P = 0.040).ConclusionsCompared with internal stents, the use of an external stent could reduce the incidence of clinically relevant postoperative pancreatic fistula in patients with a Fistula Risk Score ≥ 4. More large-scale prospective clinical trials are warranted to further clarify our results.

Two-in-one method: Novel pancreaticojejunostomy technique for the bifid pancreas.

The bifid pancreas is a rare anatomical variation of the pancreatic duct in which double main pancreatic ducts in the body and tail of the pancreas join at the pancreas head and drain through the major papilla. When pancreaticoduodenectomies are carried out on bifid pancreases, close attention must be paid to the reconstruction because of the possibility that there may be two pancreatic ducts that need to be reconstructed. We present a case of pancreaticoduodenectomy for the bifid pancreas and a novel technique named the ‘two‐in‐one’ method for double pancreatic duct to jejunum anastomosis. Using the two‐in‐one method, we anastomosed one jejunal hole to a double pancreatic duct. Pancreatic texture was normal and postoperative volumes of pancreatic juice from the two external pancreatic duct stents were 250 mL and 100 mL/day, respectively. Postoperative recovery went well although the patient needed a slightly longer hospital stay as a result of surgical site infection. This novel anastomotic technique was as simple to carry out as a normal pancreaticojejunostomy and may be useful for reconstruction of the bifid pancreas.

Laparoscopic pancreaticojejunostomy with transpancreatic “blumgart” and running “hopkins” sutures and external pancreatic duct stent (PDS)

Background: Laparoscopic pancreaticoduodenectomy (LPD) has been increasingly used in patients at high risk of pancreatic leak due to soft glands and small ducts. Varying open techniques can mitigate the risk of this complication, but translation to laparoscopy can be challenging. We describe a laparoscopic pancreaticojejunostomy with transpancreatic ‘Blumgart’ sutures, anterior and posterior running internal layers and placement of an externalized pancreatic duct stent (PDS) utilizing a Seldinger technique. Methods: A totally LPD was performed with percutaneous introduction of a 8 Fr pediatric feeding tube, via Seldinger technique and standard 11 Fr introducer sheath into the jejunal limb. Sutures were tied together to create double armed sutures (DAS) of adequate length. Two 3-0 Vicryl DAS were used for the transpancreatic stiches, followed by a posterior running 3-0 V-Loc row. The external PDS was placed in the duct and secured with 5-0 Polydioxanone DAS. A second anterior running row was performed and the anastomosis was completed after the final anterior stiches were placed through the intestine and tied down. The PDS exit site was secured similarly to a feeding tube with a 3-0 Vicryl purse string suture and two Witzel stitches. Results: 70 y/o woman with pT2N2 pancreatic acinar cell cancer underwent uncomplicated totally LPD with external stent placement. Patient tolerated the procedure well and was discharged home on POD 5. The externalized PDS was removed at 6 weeks post op. She is now 3 months out from surgery and has not had any complications. She is currently undergoing adjuvant chemotherapy. Conclusion: LPD is an established procedure for the treatment of pancreatic head lesions. Patients at high risk of pancreatic leak - soft glands, small ducts, and/or high BMI - may benefit from adapting open techniques that have been shown to decrease complications such as pancreatic fistulas. This laparoscopic method for placing an external PDS may further mitigate potential complications.

K-RAS Mutant Gene Found in Pancreatic Juice Activated Chromatin From Peri-ampullary Adenocarcinomas.

External pancreatic duct stents inserted after resection of pancreatic head tumors provide unique access to pancreatic juice analysis of genetic and metabolic components that may be associated with peri-ampullary tumor progression. For this pilot study, portal venous blood and pancreatic juice samples were collected from 17 patients who underwent pancreaticoduodenectomy for peri-ampullary tumors. Portal vein circulating tumor cells (CTC) were isolated by high-speed fluorescence-activated cell sorting (FACS) and analyzed by quantitative reverse transcription polymerase chain reaction (RT-PCR) for K-RAS exon 12 mutant gene expression (K-RASmut). DNA, chromatin, and histone acetylated active chromatin were isolated from pancreatic juice samples by chromatin immunoprecipitation (ChIP) and the presence of K-RASmut and other cancer-related gene sequences detected by quantitative polymerase chain reaction (PCR) and ChIP-Seq. Mutated K-RAS gene was detectable in activated chromatin in pancreatic juice secreted after surgical resection of pancreatic, ampullary and bile duct carcinomas and directly correlated with the number of CTC found in the portal venous blood (P = .0453). ChIP and ChIP-Seq detected acetylated chromatin in peri-ampullary cancer patient juice containing candidate chromatin loci, including RET proto-oncogene, not found in similar analysis of pancreatic juice from non-malignant ampullary adenoma. The presence of active tumor cell chromatin in pancreatic juice after surgical removal of the primary tumor suggests that viable cancer cells either remain or re-emerge from the remnant pancreatic duct, providing a potential source for tumor recurrence and cancer relapse. Therefore, epigenetic analysis for active chromatin in pancreatic juice and portal venous blood CTC may be useful for prognostic risk stratification and potential identification of molecular targets in peri-ampullary cancers.

Three hundred and sixty-eight consecutive pancreaticoduodenectomies with zero mortality.

Only a limited number of reports have documented zero mortality in consecutive pancreaticoduodenectomy series. The aim of this study is to review and verify our management aiming to eliminate mortality after pancreaticoduodenectomy. Three hundred and sixty-eight consecutive patients undergoing pancreaticoduodenectomy between 2002 and 2015 were retrospectively reviewed. During this period, in order to enhance the safety of pancreaticoduodenectomy, we have used a consistent strategy consisting of early ligation of the inferior pancreatoduodenal artery, mucosal sutureless pancreaticojejunostomy combined with external pancreatic duct stenting, conditional two-stage pancreaticojejunostomy, jejunal decompression using tube jejunostomy, application of an omental flap to cover the stump of the gastroduodenal artery, and careful postoperative drain management. Major postoperative complications (Clavien-Dindo grade ≥ IIIa) occurred in 20 patients (5%). Grade A/B/C pancreatic fistula was observed in 49/29/4 patients (13%/8%/1%), respectively. Reoperation and readmission was necessary in five and four patients (1% and 1%), respectively. There was no in-hospital or 90-day mortality. To achieve zero mortality in pancreaticoduodenectomy, it is crucial to incorporate various strategies to minimize the degree of surgical invasiveness and the damage caused by pancreatic fistula with a meticulous approach to perioperative management.

Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis.

Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis. The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy (PD). We searched PubMed, EMBASE, the Cochrane Library and Web of Science databases until the end of December, 2014. Studies comparing outcomes of external vs. internal stent placement in PD were eligible for inclusion. Included literature was extracted and assessed by two independent reviewers. Seven articles were identified for inclusion: three randomized controlled trials (RCTs) and four observational clinical studies (OCS). The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula (PF) in total [odds ratio (OR) =0.69; 95% confidence interval (CI), 0.48-0.99; P=0.04], PF in soft pancreas (OR =0.30; 95% CI, 0.16-0.56; P=0.0002) and delayed gastric emptying (DGE) (OR =0.58; 95% CI, 0.38-0.89; P=0.01) compared with internal stents. There were no significant differences in other postoperative outcomes between two stenting methods, including postoperative morbidity (OR =0.93; 95% CI, 0.39-2.23; P=0.88), overall mortality (OR =0.70; 95% CI, 0.22-2.25; P=0.55), and intra-abdominal collections (OR =0.67; 95% CI, 0.26-1.71; P=0.40). Based upon this meta-analysis, the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE. Due to the limited number of original studies, more RCTs are needed to further support our result and clarify the issue.

External pancreatic duct stent reduces pancreatic fistula: A meta-analysis and systematic review

BackgroundPostoperative pancreatic fistula formation (POPF) remains one of the most common and detrimental complications following pancreaticojejunostomy (PJ). The aim of this meta-analysis is to analyze the efficacy of external pancreatic duct stent placement in preventing POPF formation following PJ. MethodsThe primary end-point was the incidence of POPF formation following pancreaticoduodenectomy (PD) in the presence and absence of external stent placement. Secondary outcomes examined were the incidence of perioperative mortality, delayed gastric emptying, postoperative wound infection, operative time, blood loss, and length of hospital stay. ResultsFour trials were included comprising 416 patients. External pancreatic duct stenting was found to reduce the incidence of both any grade POPF formation (OR 0.37, 95% CI = 0.23 to 0.58, p = 0.0001) and clinically significant (grade B or C) POPF formation (OR 0.50, 95% CI = 0.30 to 0.84, p = 0.0009) following PD. The use of an external stent was also found to significantly lessen length of hospital stay (SMD −0.39, 95% CI = −0.63 to −0.15, p = 0.001). ConclusionsThis analysis has shown that external pancreatic duct stenting is indeed efficacious in the incidence of both any grade as well as clinically significant POPF formation following PD. Length of hospital stay was also found to be significantly less by external duct stenting.

A Meta-Analysis and Systematic Review of Pancreatic Duct Stent

Abstract Background: Two methods of pancreatic duct decompression following pancreaticoduodenectomy (PD) are currently employed, the internal and external pancreatic duct stent. Previous analysis of the efficacy of ductal decompression following PD has been confounded by either including both the internal and external stent method or by small sample size. The aim of this meta-analysis was to analyze the efficacy of the external pancreatic duct stent method alone in preventing Post-Operative Pancreatic Fistula (POPF) formation and other complications in patients undergoing PD. Methods: A systematic literature search was conducted using the Medline, Cochrane Library, SCI, and EMBASE databases on all studies published from January 1970 to March 2012 reporting the peri-operative outcomes following PD. The primary end-point was the incidence of POPF formation in the presence of external pancreatic duct stent placement. Secondary outcomes considered included the incidence of post-operative mortality, Delayed Gastric Emptying (DGE), postoperative wound infection, operative time and blood loss, and length of hospital stay. Results: Four trials were included comprising 416 patients. There was a statistically significant decrease in the incidence of both any grade POPF formation (OR 0.37, 95% CI=0.23 to 0.58, P=0.0001) and clinically significant (grade B or C) POPF formation (OR 0.50, 95% CI=0.30 to 0.84, P=0.0009) in patients receiving an external pancreatic duct stent versus no stent following PD. Total length of hospital stay was also found to be shortened with the use of an external stent (SMD -0.39, 95% CI=-0.63 to -0.15, P=0.001). Conclusions: There is a decreased incidence of POPF formation following PD in patients receiving an external pancreatic duct stent versus patients receiving no stent. Total length of hospital stay was also found to be favorably affected by placement of an external pancreatic duct stent.

OC-108 Effect of internal and external pancreatic duct stents on outcome after pancreaticoduodenectomy: meta-analysis of randomised and observational studies

IntroductionPancreatic fistula (PF) remains a significant cause of morbidity and mortality after pancreaticoduodenectomy. The relative merits of external (ES) and internal (IS) pancreatic stents on postoperative outcome have not been...

Optimizing pancreatectomy outcomes: Follow the evidence

A PubMed search of “pancreatectomy” reveals 10,376 articles, and a fraction of these represent randomized controlled trials (n = 81) [ [1] Available at: http://www.ncbi.nlm.nih.gov/pubmed. Accessed Feb 8, 2012. Google Scholar ]. The number of randomized trials performed to date by surgeons to optimize outcomes in pancreatic resection is remarkable. Some of the recent major trials are shown in Table 1. These trials form the basis for many discussions on teaching rounds and include some of the most debatable topics in surgical Morbidity and Mortality conference, such as the routine use of intraperitoneal drains and when to remove them, preoperative biliary drainage, the use of pancreatic stents, intraoperative fluid restriction, preoperative biliary stent versus no drainage, or how to close the pancreatic stump. Table 1Recent randomized controlled trials in pancreatectomy outcomes. Variable Study, year Randomization Outcome PBD van der Gaag et al., 2010 [8] van der Gaag N.A. Rauws E.A. van Eijck C.H. et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010; 362: 129 Crossref PubMed Scopus (758) Google Scholar PBD versus surgery alone 46% complication rate from PBD procedures performed preoperativelyNo difference in operative complications Anastomotic technique Berger et al., 2009 [9] Berger A.C. Howard T.J. Kennedy E.P. et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg. 2009; 208 (discussion 47): 738 Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar Invagination versus duct to mucosa anastomosis for pancreaticojejunostomy Statistically significant decrease in fistula rate in invagination group Pancreatic stump closure Diener et al., 2011 [10] Diener M.K. Seiler C.M. Rossion I. et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): A randomised, controlled multicentre trial. Lancet. 2011; 377: 1514 Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar Hand sewn versus stapler after distal pancreatectomy No difference in pancreatic fistula or operative mortality Duration of intraperitoneal drainage Bassi et al., 2010 [11] Bassi C. Molinari E. Malleo G. et al. Early versus late drain removal after standard pancreatic resections: Results of a prospective randomized trial. Ann Surg. 2010; 252: 207 Crossref PubMed Scopus (353) Google Scholar Early drain removal (POD 3) versus late drain removal (POD ≥ 5) Significant reduction in pancreatic fistulae, overall complications, and hospital stay and associated costs in early drain removal group Pancreatic stent Pessaux et al., 2011 [12] Pessaux P. Sauvanet A. Mariette C. et al. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: Prospective multicenter randomized trial. Ann Surg. 2011; 253: 879 Crossref PubMed Scopus (194) Google Scholar External pancreatic stent versus no stent Significant decrease in pancreatic fistulae, wound infections, and delayed gastric emptying in stented group Intraoperative fluid management Fischer et al., 2010 [13] Fischer M. Matsuo K. Gonen M. et al. Relationship between intraoperative fluid administration and perioperative outcome after pancreaticoduodenectomy: Results of a prospective randomized trial of acute normovolemic hemodilution compared with standard intraoperative management. Ann Surg. 2010; 252: 952 Crossref PubMed Scopus (87) Google Scholar Acute normovolemic hemodilution versus standard fluid management No difference in transfusions between groupsHemodilution group had a significant increase in pancreatic anastomotic complications likely because of increased fluid administration PBD = Preoperative biliary drainage; POD = Post-operative day. Open table in a new tab PBD = Preoperative biliary drainage; POD = Post-operative day. Perioperative Surgical Care Bundle Reduces Pancreaticoduodenectomy Wound InfectionsJournal of Surgical ResearchVol. 174Issue 2PreviewPancreaticoduodenectomy (PD) is a complex surgical procedure with a historically high morbidity rate. The goal of this study was to determine if the implementation of a 12-measure perioperative surgical care bundle (SCB) was successful in reducing infectious and other complications in patients undergoing PD compared with a routine preoperative preparation group (RPP). Full-Text PDF

Use of pancreatic duct stents after pancreaticoduodenectomy

After pancreaticoduodenectomy, the pancreatic anastomosis carries the highest risk of leak and cause of morbidity and mortality. In this review article, three randomized controlled clinical trials and a fourth prospective trial focused on pancreaticoduodenectomy that contribute to level-one evidence are examined. The Johns Hopkins group demonstrated that internal pancreatic duct stenting did not decrease the frequency or severity of postoperative pancreatic fistulas. The Queen Mary Hospital group demonstrated that external drainage of the pancreatic duct with a stent reduced the leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy. The University of Athens group demonstrated that internal stenting of the pancreaticojejunostomy anastomosis did not reduce the incidence of pancreatic fistula and related complications. Finally, the French Surgery Research Group demonstrated that the use of an external stent through the pancreatic anastomosis reduced the pancreatic fistula rate. In summary, two studies do not demonstrate an advantage to the use of internal pancreatic duct stents and two studies demonstrate a possible advantage to the use of external pancreatic duct stents, especially in highest risk patients with soft glands and small pancreatic ducts.

Does External Pancreatic Duct Stent Decrease Pancreatic Fistula Rate after Pancreatic Resection? A Meta-Analysis

Objectives: The use of an external pancreatic duct stent to prevent fistula formation of pancreatic anastomosis remains a matter of debate. This study is a meta-analysis of the available evidence. Methods: Articles published until the end of March 2011 comparing external stenting and non-stenting in pancreatic anastomosis were included. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model. Results: Six articles were identified for inclusion: 3 randomized controlled trials and 3 observational clinical studies. The meta-analysis revealed that the use of an external pancreatic duct stent was associated with a statistically significant reduction in overall postoperative morbidity (OR 0.56; 95% CI 0.39–0.81; p = 0.002), pancreatic fistula (OR 0.34; 95% CI 0.23-0.15; p<0.001), severity of pancreaticfistula (OR 0.70; 95% CI 0.32–1.57; p = 0.04), delayed gastric emptying (OR 0.44; 95% CI 0.25–0.80; p = 0.007), and length of hospital stay (WMD -3.95; 95% CI -6.38 to -1.52; p = 0.001). Conclusions:The current literature suggests that the use of an external pancreatic duct stent reduced the leakage rate of pancreatic anastomosis after pancreatic resection.

Potential risk factors for nonalcoholic steatohepatitis related to pancreatic secretions following pancreaticoduodenectomy

To identify risk factors for nonalcoholic steatohepatitis following pancreaticoduodenectomy, with a focus on factors related to pancreatic secretions. The medical records of 228 patients who had a pancreaticoduodenectomy over a 16-mo period were reviewed retrospectively. The 193 patients who did not have fatty liver disease preoperatively were included in the final analysis. Hepatic steatosis was diagnosed using the differences between splenic and hepatic attenuation and liver-to-spleen attenuation as measured by non-enhanced computed tomography. Fifteen patients (7.8%) who showed postoperative hepatic fatty changes were assigned to Group A, and the remaining patients were assigned to Group B. Patient demographics, preoperative laboratory findings (including levels of C-peptide, glucagon, insulin and glucose tolerance test results), operation types, and final pathological findings did not differ significantly between the two groups; however, the frequency of pancreatic fistula (P = 0.020) and the method of pancreatic duct stenting (P = 0.005) showed significant differences between the groups. A multivariate analysis identified pancreatic fistula (HR = 3.332, P = 0.037) and external pancreatic duct stenting (HR = 4.530, P = 0.017) as independent risk factors for the development of postoperative steatohepatitis. Pancreatic fistula and external pancreatic duct stenting were identified as independent risk factors for the development of steatohepatitis following pancreaticoduodenectomy.

Stenting Versus Non-Stenting in Pancreaticojejunostomy

We prospectively investigated the efficacy of an external pancreatic duct stent to prevent pancreatic fistula in the nonfibrotic pancreas after pancreaticojejunostomy, in which the degree of pancreatic fibrosis was assessed objectively by using dynamic magnetic resonance imaging (MRI). Among the 67 consecutive patients who underwent pancreatic head resection, 45 patients were judged to have a normal pancreas without fibrosis based on the preoperative assessment of pancreatic fibrosis based on MRI. The patients were randomly allocated to 1 of 2 groups with (n=23) or without (n=22) use of an external pancreatic duct stent in performing a pancreaticojejunostomy. Pancreatic fistula developed in 8 (34.5%) patients in the stented group: 3 grade A and 5 grade B; whereas in the nonstented group, 9 (40.9%) patients developed pancreatic fistula: 3 grade A and 6 grade B. There were no significant differences in the incidence or severity of pancreatic fistula between the 2 groups. The utility of the external pancreatic duct stent after pancreaticojejunostomy was not found in the nonfibrotic pancreases, which were sorted according to the degree of pancreatic fibrosis using the pancreatic time-signal intensity curve analysis from MRI.

Complications after pancreaticoduodenectomy: intraabdominal abscess

The development of intraabdominal abscess (IAA) following pancreaticoduodenectomy (PD) is an important problem. It is a common cause of readmission to the hospital following discharge. Rates of IAA do not appear to depend on whether the pancreas is anastomosed to the stomach or jejunum, nor whether a duct-to-mucosa or invagination technique is used. Most surgeons favor the use of closed-suction drains after PD. The use of fibrin glue sealant does not appear to reduce the rate of IAA. The use of preoperative biliary stenting increases wound infection rates, but not IAA rates. The use of internal and external pancreatic duct stents with PD to prevent IAA have yielded mixed results.

Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy

Background: Leakage at the pancreaticoenteric anastomosis remains a common and serious complication after pancreaticoduodenectomy. Over the past decade, various measures directed towards prevention of pancreatic leakage have been studied. This article reviews the available data on the efficacy of these measures. Data sources: The Medline database from 1990 to 2000 was searched for studies on the prevention of pancreatic anastomotic leakage, and the bibliographies of the articles were reviewed for additional references. Results: A meta-analysis of the results of prophylactic octreotide in preventing pancreatic fistula after pancreaticoduodenectomy from data available in three randomized controlled studies yielded an odds ratio of 1.08 (95% confidence interval 0.64 to 1.84). Pending further trials to clarify its role, the routine use of octreotide in pancreaticoduodenectomy cannot be recommended. Retrospective or nonrandomized prospective studies suggested that technical modifications such as duct-to-mucosa anastomosis, pancreaticogastrostomy and external pancreatic duct stenting may reduce the leakage rate, but there is a paucity of randomized trials. A randomized trial comparing pancreaticogastrostomy and pancreaticojejunostomy did not reveal a significant difference in the leakage rate. Conclusions: Further randomized controlled studies are required to determine the optimum technique of pancreaticoenteric anastomosis after pancreaticoduodenectomy.