Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection.

BACKGROUND: Leakage of the pancreaticojejunal anastomosis has been a major complication after pancreaticoduodenectomy (Whipple operation), frequently reported in an incidence of 5 percent to 15 percent. The most widely used techniques of anastomosis have been variations of end-to-end pancreaticojejunostomy. Complicating 152 end-to-end anastomoses, done by me (including 98 for carcinoma of the pancreas or ampulla), were 5 pancreatic anastomotic leaks; the fifth patient died of this complication.

STUDY DESIGN: The death resulting from a pancreatic anastomotic fistula led me to change my technique to an end of the pancreas to side of the jejunum, mucosa-to-mucosa, pancreaticojejunostomy (intubated), a modification of the technique described by Cattell and used since 1985 by me in 56 consecutive patients. Patients were monitored for clinical evidence of a pancreatic fistula, including evaluation of amylase content in serum and, in most, in peritoneal drainage. Pancreatography through the exteriorized pancreatic catheter was possible if deemed advisable.

RESULTS: No pancreatic duct was too small or pancreas too soft to permit effective anastomosis. No clinical evidence developed of a pancreatic fistula, "sentinel bleed," or acute pancreatitis, and no patient was recognized to have a high amylase content in the peripancreatic peritoneal drainage. Results of the pancreatogram were negative in three patients with peripancreatic infections and in one with severe cholestasis.

CONCLUSIONS: Although consensus among surgeons does not exist as to technique of pancreatic anastomosis, the end-to-side, mucosa-to-mucosa pancreaticojejunostomy, intubated, has proved safer in my experience than end-to-end pancreaticojejunostomy. The experience has led me to believe that the technique may reduce the incidence of this fistula and contribute to making pancreaticojejunal leakage a preventable complication.