OPTIMAL MANAGEMENT OF THE PANCREATIC REMNANT AFTER PANCREATICODUODENECTOMY

Objective The authors evaluated methods of operative management of the pancreatic remnant after pancreaticoduodenectomy. Summary Background Data Despite reductions in mortality after pancreaticoduodenectomy, le akage from the pancreatic remnant still may cause significant morbidit y. Patients with small, unobstructed pancreatic ducts or soft, friable pancreata are at particularly high risk. Although numerous surgical t echniques have been described to avoid such complications, no single m ethod is suitable for all patients. Methods The authors retrospectivel y reviewed the medical records of 114 consecutive patients who underwe nt pancreaticoduodenectomy. Sixty-nine patients were men (6.1 %) and 4 5 were women (39%), with median age 66 years. Underlying disease was m alignant in 87 (76%) and benign in 27 (24%). Patients were divided int o groups based on risk for postoperative pancreatic fistula and on the operative management of the pancreatic remnant. Sixty-eight patients underwent end-to-side pancreaticojejunostomy, 13 of whom were high ris k (group 1A) and 55 of whom were low risk (group 1B). Thirty-seven pat ients, all high risk, had either pancreatic duct closure by oversewing (N = 19, group 2) or end-to-end pancreaticojejunal invagination (N = 18, group 3). Nine patients underwent total pancreatectomy (group 4). Morbidity related to prolonged pancreatic drainage (PPD) of greater th an 20 days was determined. Results Overall incidence of PPD was 17% an d caused the only death. Patients considered high risk for postoperati ve pancreatic fistula had a 36% incidence of PPD compared with 2% in p atients considered low risk (p < 0.0001). Prolonged pancreatic drainag e frequency related to the method of pancreatic remnant management was as follows: group 1A, 15%, group 1B, 2%; group 2, 79%; and group 3, 6 % (p < 0.001 for group 2 vs. other groups). No serious sequelae follow ed PPD in 15 patients (79%); however, 4 patients required reoperation for pseudocyst or abscess drainage; one in group 1A (who died) and thr ee in group 2. Multivariate analysis revealed that operative technique (oversewing of the pancreatic duct) and male sex were significant fac tors predisposing a patient to the development of PPD. Conclusions Aft er pancreaticoduodenectomy, pancreatic remnant management by end-to-si de pancreaticojejunostomy appeared safe in low-risk patients. In high- risk patients, end-to-end pancreaticojejunal invagination was the safe st option. Morbidity was greatest after pancreatic duct closure withou t anastomosis.