Pancreatic surgical complications - the case for prophylaxis

Pancreaticoduodenectomy (Whipple's procedure) represents a considerable sur gical challenge. Postoperative complications are common and typically relat ed to leakage of pancreatic exocrine secretions following anastomosis failu re. Pancreatic proteases and lipase leaking from the organ remnant attack t he surrounding tissue, potentially leading to severe inflammation, tissue n ecrosis, and fistula formation. In addition, the soft consistency of the no rmal pancreas can lead to difficulties in manipulating the organ and reduce the integrity of sutures. Pancreatic fistula is the most serious postopera tive complication and especially common following resectional surgery for m alignant disease. Through prophylactic inhibition of digestive secretions, it should be possible to reduce postoperative morbidity after pancreatic su rgery. One such inhibitor is somatostatin-14, an endogenous peptide hormone with pronounced effects on secretion of pancreatic enzymes and hormones, g astrointestinal secretions, and pancreatic blood flow, all of which may dec rease the risk of postoperative complications. A limited number of randomis ed controlled trials have investigated prophylactic administration of somat ostatin-14 and the synthetic somatostatin analogue octreotide in reducing c omplications following pancreatic surgery. While the majority of studies wi th octreotide demonstrated a significant reduction in the overall complicat ion rate, the benefits appeared less marked in relation to events specifica lly related to pancreatic secretion. However, preliminary results from a li mited number of trials with somatostatin-14, administered as a continuous i ntravenous infusion, suggest that prophylactic pharmacotherapy produces a s ignificant decrease in fistula formation and secretion related events after pancreaticoduodenectomy. Due to these promising data, further investigatio n of the role of somatostatin-14 prophylaxis in pancreatic surgery is warra nted in large well controlled trials.