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Invited Critique
Stephen W. Behrman, MD
Memphis, Tenn
Arch Surg. 2002;137:1048.
The development of a pancreatic fistula following pancreatoduodenectomy, with its inherent morbidity and mortality, remains important. In reported series, it is most often associated with a soft (normal) pancreas and a nondilated duct of Wirsung. In their article, Suzuki and colleagues raise 2 issues. First, which technique of reestablishing gastrointestinal continuity to the remnant pancreas is superior? Second, they help define just what constitutes a pancreatic fistula.
Published reports have focused on technical nuances and adjunctive agents that may help to diminish pancreaticoenteric disruption. Duct-to-mucosa reconstruction, pancreatic invagination, duct ligation, pancreaticogastrostomy, fibrin glue, duct stenting, octreotide, and combinations thereof have all been supported. Despite varying techniques, most recent series consistently report fistula rates ranging between 5% and 20%. In the accomplished hands of the authors, pancreatic fistula rates with their techniques were equal to, but not better than, others reported in the literature. Should the technique of pancreatic reconstruction vary depending on pancreatic texture? The data presented do not answer that question. Perhaps the lesson for the pancreatic surgeon would be to pick a technique one is most comfortable with that yields consistently good results. With that said, one would be remiss not to critically analyze and perhaps incorporate different and evolving solutions to what is clearly the vulnerable point of reconstruction following pancreatoduodenectomy.
More intriguing was the authors' postoperative assessment of their pancreatic fistulas. Defined in this article and in the recent literature as drainage of 30 to 50 mL of amylase-rich fluid (>3-fold the serum value), the fistula rate was 8%. However, contrast evaluation showed no free extravasation from the pancreatic anastomosis. One wonders whether the "fistulas" reported in this series and others are clinically relevant in the absence of an overt leak. If not, fistula rates reported in this article and other recent reports would approach 0%. One could argue that we should reserve the term pancreatic fistula for what we truly know it is—the drainage of clear watery fluid with amylase values (measured in units per liter) in the tens to hundreds of thousands. With the surgical techniques reported herein and elsewhere, this should indeed be a rare complication following pancreatoduodenectomy. This would lend support to recent reports that routine intraperitoneal drainage following the Whipple operation may not be necessary.
RELATED ARTICLE
Selection of Pancreaticojejunostomy Techniques According to Pancreatic Texture and Duct Size
Yasuyuki Suzuki, Yasuhiro Fujino, Yasuki Tanioka, Kunihiko Hiraoka, Moriatsu Takada, Tetsuo Ajiki, Yoshifumi Takeyama, Yonson Ku, and Yoshikazu Kuroda
Arch Surg. 2002;137(9):1044-1047.
ABSTRACT
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