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World J Gastrointest Oncol. Sep 15, 2014; 6(9): 369-376
Published online Sep 15, 2014. doi: 10.4251/wjgo.v6.i9.369
Reconstruction after pancreatoduodenectomy: Pancreatojejunostomy vs pancreatogastrostomy
Tatiana Gómez, Ana Palomares, Mario Serradilla, Luis Tejedor
Tatiana Gómez, Luis Tejedor, Department of Surgery, Hospital Punta de Europa, 11207 Algeciras (Cádiz), Spain
Ana Palomares, Mario Serradilla, Division of Hepato-Pancreatic-Biliary Surgery, Department of Surgery, Complejo Hospitalario de Jaén, 23007 Jaén, Spain
Author contributions: Gómez T and Palomares A contributed equally to this work, performed the research and wrote the paper; Serradilla M and Tejedor L designed and supervised the research and translated the paper.
Correspondence to: Mario Serradilla, MD, Division of Hepato-Pancreatic-Biliary Surgery, Department of Surgery, Complejo Hospitalario de Jaén, Avda. del Ejército Español 10, 23007 Jaén, Spain. marioserradilla@hotmail.com
Telephone: +34-636-006184 Fax: +34-953-008041
Received: August 29, 2013
Revised: February 25, 2014
Accepted: March 8, 2014
Published online: September 15, 2014
Abstract

Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy (PD) in order to decrease postoperative complications, mainly pancreatic fistulas (PF). In this work, we compare the two most frequent techniques of reconstruction after PD, pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), in order to determine which of the two is better. A systematic review of the literature was performed, including major meta-analysis articles, clinical randomized trials, systematic reviews, and retrospective studies. A total of 64 articles were finally included. PJ and PG are usually responsible for most of the postoperative morbidity, mainly due to the onset of PF, being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia. The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG. PF, delayed gastric emptying and mortality were not different. Although there was heterogeneity between these studies, all were conducted in specialized centers by highly experienced surgeons, and the surgical care was likely to be similar for all the studies. The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa. Exocrine function appears to be worse after PG than after PJ, resulting in severe atrophic changes in the remnant pancreas. Depending on the type of PJ or PG used, the PF rate and other complications can also be different. The best method to deal with the pancreatic stump after PD remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon’s preference and adherence to basic principles such as good exposure and visualization. In conclusion, up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD.

Keywords: Pancreatoduodenectomy, Pancreatojejunostomy, Pancreatogastrostomy, Pancreatic fistula, Pancreatic cancer, Surgical technique

Core tip: Pancreatoduodenectomy is a technique with a high rate of morbidity and mortality. Surgeons try to find the best technique of reconstruction in order to decrease postoperative complications. We compare the two most frequent techniques of reconstruction after pancreatoduodenectomy, namely pancreatojejunostomy and pancreatogastrostomy, to determine which of the two is better. We offer a systematic review of the main papers published with all the pros and cons of each technique. The best method to deal with the pancreatic stump after pancreatoduodenectomy remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon’s preference and adherence to basic principles, such as good exposure and visualization.