Pancreatic Fistula after Pancreatoduodenectomy: Evaluation of Different Surgical Techniques

Postoperative pancreatic fistula (POPF) is one of the most fatal complications of pancreatoduodenectomy. POPF is caused by leakage of pancreatic juice from the pancreatic anastomosis into the abdomen, leading to intra-abdominal complications, such as severe surgical site infections, significant postoperative hemorrhage and multi-organ failure. Many risk factors for POPF have been identified, including patient and surgical technique factors. Our objective was to review the literature on surgical techniques to prevent POPF after pancreatoduodenectomy. Pancreatogastrostomy (PG) has the same incidence of POPF as pancreatojejunostomy (PJ). For PJ anastomosis, the interrupted suture and Blumgart technique also had the same rate of POPF. For soft pancreas it was shown that invagination was better than duct-to-mucosa anastomosis to prevent the POPF. However, a pancreatic duct stent cannot decrease the rate of POPF over the non-stent group. Intraperitoneal drainage cannot prevent POPF, however, it can detect POPF more than the non-drain group. Laparoscopic PD (LPD) and robotic-assisted PD (RAPD) were comparable in rates of POPF with open PD. Overall, no conclusion has been reached regarding the best surgical technique. In any individual case, the surgical technique should be selected based on the surgeon’s experience in reducing the incidence of POPF, and other complications.