Dunking pancreaticojejunostomy versus duct-to-mucosa anastomosis.

Following the resectional aspect of pancreaticoduodenectomy, three anastomoses are used to reestablish gastrointestinal continuity. The pancreatic-enteric anastomosis is by far the most problematic, and has been considered by many the Achilles heel of the pancreaticoduodenal resection. Multiple clinical trials have been published focusing on improving outcomes of the pancreatic-enteric anastomosis, including elements such as the use of prophylactic octreotide, the use of sealants, stenting of the pancreatic duct, and surgical technique. There are two widely used methods to accomplish an end-to-side pancreaticojejunostomy (PJ) after pancreaticoduodenectomy: either invagination PJ or duct-to-mucosa PJ. Two prospective randomized trials have evaluated these techniques, the first a trial by Bassi and co-authors, and the second a trial by Berger et al. In this article we will focus on our current technique for both invagination pancreaticojejunostomy and duct-to-mucosa pancreaticojejunostomy, recognizing that careful surgical technique, surgeon experience, and surgical volume are factors that are important in yielding the best outcomes.