title: The challenge of pancreatic anastomosis.
abstract: OBJECTIVE
  Significant progress in surgical technique and perioperative management has substantially reduced the mortality rate of pancreatic surgery. However, morbidity remains considerably high, even in expert hands and leakage from the pancreatic stump still accounts for the majority of surgical complications after pancreatic head resection. For that reason, management of the pancreatic remnant after partial pancreatoduodenectomy remains a challenge. This review will focus on technique, pitfalls, and complication management of pancreaticoenteric anastomoses.
  
  
  METHODS
  A medline search for surgical guidelines, prospective randomized controlled trials, systematic metaanalysis, and clinical reports was performed with regard to surgical technique and complication management of pancreatic anastomoses.
  
  
  RESULTS
  Pancreaticojejunostomy appears to be most widely performed, but pancreaticogastrostomy is a reasonable alternative. Postoperative treatment with octreotide can be recommended only for patients with soft pancreatic tissue, and neither stents of the pancreatic duct nor drainages have proven to effectively reduce anastomotic complications. Gastroparesis remains the most common complication after pancreatic surgery and should be treated conservatively. However, it may be a symptom of other local complications, such as anastomotic leakage, pancreatic fistula or abscess. All septic complications may finally result in late postoperative hemorrhage, which requires immediate diagnostic workup and therapy. Today, interventional radiology has emerged as a standard tool in the management of local septic complications and bleeding. Therefore, relaparotomy has become less frequent and salvage pancreatectomy is now a rare procedure in case of local complications.
  
  
  CONCLUSIONS
  The surgeon's experience with one or the other technique of pancreatic anastomosis appears to be more important than the technique itself.
authors: Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilian-University of Munich, Munich, Germany. axelkleespies@aol.com
authors: Axel
authors: A
authors: Kleespies
authors: Markus
authors: M
authors: Albertsmeier
authors: Firas
authors: F
authors: Obeidat
authors: Hendrik
authors: H
authors: Seeliger
authors: Karl-Walter
authors: KW
authors: Jauch
authors: Christiane J
authors: CJ
authors: Bruns
mesh_terms: D018784:Abdominal Abscess / Q000175:diagnosis / Q000517:prevention & control / Q000601:surgery; D000465:Algorithms; D000714:Anastomosis, Surgical / Q000379:methods*; D001658:Biliary Fistula / Q000175:diagnosis / Q000517:prevention & control / Q000601:surgery; D004322:Drainage; D005774:Gastrostomy / Q000379:methods; D006801:Humans; D015282:Octreotide / Q000627:therapeutic use; D010185:Pancreatic Fistula / Q000175:diagnosis / Q000517:prevention & control / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000379:methods*; D010193:Pancreaticojejunostomy / Q000379:methods; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control / Q000628:therapy; D019106:Postoperative Hemorrhage / Q000175:diagnosis / Q000517:prevention & control / Q000601:surgery; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation; D015607:Stents; D013529:Surgical Wound Dehiscence / Q000175:diagnosis / Q000517:prevention & control / Q000601:surgery; D013536:Suture Techniques
chemical_list: D015282:Octreotide