title: Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS).
abstract: Clinically relevant postoperative pancreatic fistula (grades B and C of the ISGPS definition) remains the most troublesome complication after pancreatoduodenectomy. The approach to management of the pancreatic remnant via some form of pancreatico-enteric anastomosis determines the incidence and severity of clinically relevant postoperative pancreatic fistula. Despite numerous trials comparing diverse pancreatico-enteric anastomosis techniques and other adjunctive strategies (pancreatic duct stenting, somatostatin analogues, etc), currently, there is no clear consensus regarding the ideal method of pancreatico-enteric anastomosis.
  
  
  
  An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the best contemporary literature concerning pancreatico-enteric anastomosis and worked to develop a position statement on pancreatic anastomosis after pancreatoduodenectomy.
  
  
  
  There is inherent risk assumed by creating a pancreatico-enteric anastomosis based on factors related to the gland (eg, parenchymal texture, disease pathology). None of the technical variations of pancreaticojejunal or pancreaticogastric anastomosis, such as duct-mucosa, invagination method, and binding technique, have been found to be consistently superior to another. Randomized trials and meta-analyses comparing pancreaticogastrostomy versus pancreaticojejunostomy yield conflicting results and are inherently prone to bias due to marked heterogeneity in the studies. The benefit of stenting the pancreatico-enteric anastomosis to decrease clinically relevant postoperative pancreatic fistula is not supported by high-level evidence. While controversial, somatostatin analogues appear to decrease perioperative complications but not mortality, although consistent data across the more than 20 studies addressing this topic are lacking. The Fistula Risk Score is useful for predicting postoperative pancreatic fistula as well as for comparing outcomes of pancreatico-enteric anastomosis across studies.
  
  
  
  Currently, no specific technique can eliminate development of clinically relevant postoperative pancreatic fistula. While consistent practice of any standardized technique may decrease the rate of clinically relevant postoperative pancreatic fistula, experienced surgeons can have lower postoperative pancreatic fistula rates performing a variety of techniques depending on the clinical situation. There is no clear evidence on the benefit of internal or external stenting after pancreatico-enteric anastomosis. The use of somatostatin analogues may be important in decreasing morbidity after pancreatoduodenectomy, but it remains controversial. Future studies should focus on novel approaches to decrease the rate of clinically relevant postoperative pancreatic fistula with appropriate risk adjustment.
authors.affiliation: Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India. Electronic address: shailushrikhande@hotmail.com.
authors.forename: Shailesh V
authors.initials: SV
authors.lastname: Shrikhande
authors.affiliation: Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
authors.forename: Masillamany
authors.initials: M
authors.lastname: Sivasanker
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, PA.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Vollmer
authors.affiliation: Department of Surgery, Klinikum Rechts der Isar, Technische Universitat Munchen, Munich, Germany.
authors.forename: Helmut
authors.initials: H
authors.lastname: Friess
authors.affiliation: Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Marc G
authors.initials: MG
authors.lastname: Besselink
authors.affiliation: Department of Digestive Surgery, University Hospital of Graz, Austria.
authors.forename: Abe
authors.initials: A
authors.lastname: Fingerhut
authors.affiliation: Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Yeo
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Carlos
authors.initials: C
authors.lastname: Fernandez-delCastillo
authors.affiliation: Department of First Surgery, Agia Olga Hospital, Athens, Greece.
authors.forename: Christos
authors.initials: C
authors.lastname: Dervenis
authors.affiliation: Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Christoper
authors.initials: C
authors.lastname: Halloran
authors.affiliation: Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Gouma
authors.affiliation: First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia.
authors.forename: Dejan
authors.initials: D
authors.lastname: Radenkovic
authors.affiliation: Department of General Surgery, Mayo Clinic, Jacksonville, FL.
authors.forename: Horacio J
authors.initials: HJ
authors.lastname: Asbun
authors.affiliation: Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom.
authors.forename: John P
authors.initials: JP
authors.lastname: Neoptolemos
authors.affiliation: Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Jakob R
authors.initials: JR
authors.lastname: Izbicki
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
authors.affiliation: Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland.
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Conlon
authors.affiliation: Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain.
authors.forename: Laureano
authors.initials: L
authors.lastname: Fernandez-Cruz
authors.affiliation: Department of Surgery, Humanitas University, Milan, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Montorsi
authors.affiliation: Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Max
authors.initials: M
authors.lastname: Bockhorn
authors.affiliation: Department of Digestive & HPB Surgery, Hopital Edouard Herriot, HCL, UCBL1, Lyon, France.
authors.forename: Mustapha
authors.initials: M
authors.lastname: Adham
authors.affiliation: Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom.
authors.forename: Richard
authors.initials: R
authors.lastname: Charnley
authors.affiliation: Glasgow Royal Infirmary, Glasgow, United Kingdom.
authors.forename: Ross
authors.initials: R
authors.lastname: Carter
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Thilo
authors.initials: T
authors.lastname: Hackert
authors.affiliation: Department of Surgery, Klinikum Großhadern, University of Munich, Munich, Germany.
authors.forename: Werner
authors.initials: W
authors.lastname: Hartwig
authors.affiliation: Pancreas Center, Nanjing Medical University, Nanjing, P.R. China.
authors.forename: Yi
authors.initials: Y
authors.lastname: Miao
authors.affiliation: Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Michael
authors.initials: M
authors.lastname: Sarr
authors.affiliation: Department of Surgery and Oncology, Pancreas Institute, University Hospital Trust of Verona, Verona, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Bassi
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Markus W
authors.initials: MW
authors.lastname: Büchler
mesh_terms: D000714:Anastomosis, Surgical; D006801:Humans; D016577:Pancreaticoduodenectomy; D018579:Patient Selection; D017410:Practice Guidelines as Topic