Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection

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.

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.

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.

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.