Decreasing the pancreatic leak rate after pancreaticoduodenectomy

An updated systematic review and meta-analysis of the use of octreotide for the prevention of postoperative complications after pancreatic resection

BACKGROUND

The use of octreotide prophylaxis following pancreatic surgery is controversial. We aimed to evaluate the effectiveness of octreotide for the prevention of postoperative complications after pancreatic surgery through this systematic review and meta-analysis.

METHODS

Literature databases (including the MEDLINE, EMBASE, and Cochrane databases) were searched systematically for relevant articles. Only randomized controlled trials (RCTs) were eligible for inclusion in our research. We extracted the basic information regarding the patients, intervention procedures, and all complications after pancreatic surgery and then performed the meta-analysis.

RESULTS

Thirteen RCTs involving 2006 patients were identified. There were no differences between the octreotide group and the placebo group with regard to pancreatic fistulas (PFs) (relative risk [RR] = 0.79, 95% confidence interval [CI] = 0.62-0.99, P = .05), clinically significant PFs (RR = 1.01, 95% CI = 0.68-1.50, P = .95), mortality (RR = 1.21, 95% CI = 0.78-1.88, P = .40), biliary leakage (RR 0.84, 95% CI = 0.39-1.82, P = .66), delayed gastric emptying (RR = 0.83, 95% CI = 0.54-1.27, P = .39), abdominal infection (RR = 1.00, 95% CI = 0.66-1.52, P = 1.00), bleeding (RR = 1.16, 95% CI = 0.78-1.72, P = .46), pulmonary complications (RR = 0.73, 95% CI = 0.45-1.18, P = .20), overall complications (RR = 0.80, 95% CI = 0.64-1.01, P = .06), and reoperation rates (RR = 1.18, 95% CI = 0.77-1.81, P = .45). In the high-risk group, octreotide was no more effective at reducing PF formation than placebo (RR = 0.81, 95% CI = 0.67-1.00, P = .05). In addition, octreotide had no influence on the incidence of PF (RR = 0.38, 95% CI = 0.14-1.05, P = .06) after distal pancreatic resection and local pancreatic resection.

CONCLUSION

The present best evidence suggests that prophylactic use of octreotide has no effect on reducing complications after pancreatic resection.

Anastomotic leaks in gastrointestinal surgery and their prevention

Anastomotic leak in the gastrointestinal tract is one of the most important complications of resection. They are the main cause of reoperation, their occurrence worsens the prognosis of the patient, increasing the proportion of direct mortality, as well as being a significant risk factor for recurrence of cancer. The risk of leaks within the gastrointestinal tract is greatly varied, depending on the location and extent of the resection, but also on patient, disease or a surgical procedure, including surgeon. To determine the potential risk of leakage can be significant for introduction some prophylactic actions. Some of them have the character of general recommendations, as proper nutrition of the patient in the perioperative period, while another part is directly connected to the surgical procedure. The second group includes protective stoma, the use of tissue glues, insertion transrectal drain for rectal anastomosis decompression, the use of stents or the use of collagen matrix coated with fibrinogen and thrombin. Important to reduce the proportion of leaks can be more precise and targeted prophylactic recommendations, based on the individualized determination of risk factors leaks. Further research for this purpose are necessary for this purpose, the big hope can be associated with data obtained through mobile applications.

The view from 10,000 procedures: technical tips and wisdom from master pancreatic surgeons to avoid hemorrhage during pancreaticoduodenectomy

Pancreaticoduodenectomy remains the exclusive technique for surgical resection of cancers located within both the pancreatic head and periampullary region. Amongst peri-procedural complications, hemorrhage is particularly problematic given that allogenic blood transfusions are known to increase the risk of infection, acute lung injury, cancer recurrence and overall 30-day morbidity and mortality rates. Because blood loss can be considered a modifiable factor that reflects surgical technique, rates of perioperative blood loss and transfusion have been advocated as robust quality indicators. We present a correspondence manuscript that outlines peri-procedural concepts detailing a successful pancreaticoduodenectomy with minimal hemorrhage. These tips were collated from master pancreatic surgeons throughout the globe who have performed over 10,000 cumulative pancreaticoduodenectomies. At risk scenarios for hemorrhage include dissections of the superior mesenteric – portal vein, gastroduodenal artery, and retroperitoneal soft tissue margin. General principles in limiting slow continuous hemorrhage that may accumulate into larger total case losses are also discussed. While many of the techniques and tips proposed by master pancreas surgeons are intuitive and straight forward, when taken as a collective they represent a significant contribution to improved outcomes associated with the pancreaticoduodenectomy over the past 100 years.

How the radiologist can add value in the evaluation of the pre- and post-surgical pancreas

Disease involving the pancreas can be a significant diagnostic challenge to the interpreting radiologist. Moreover, the majority of disease processes involving the pancreas carry high significant morbidity and mortality either due to their natural process or related to their treatment options. As such, it is critical for radiologists to not only provide accurate information from imaging to guide patient management, but also deliver that information in a clear manner so as to aid the referring physician. This is no better exemplified than in the case of pre-operative staging for pancreatic adenocarcinoma. Furthermore, with the changing healthcare landscape, it is now more important than ever to ensure that the value of radiology service to other providers is high. In this review, we will discuss how the radiologist can add value to the referring physician by employing novel imaging techniques in the pre-operative evaluation as well as how the information can be conveyed in the most meaningful manner through the use of structured reporting. We will also familiarize the radiologist with the imaging appearance of common complications that occur after pancreatic surgery.

A selective approach to the surgical management of periampullary cancer patients and its outcome

BACKGROUND

Pancreaticoduodenectomy is a high risk, complex, technically challenging operation associated with significant perioperative morbidity and mortality. This study on the surgical management of periampullary cancer patients is based on our experience in a period of nearly 13 years.

METHODS

The study was conducted on two groups of patients: group A included 42 patients who were treated between January 2000 and September 2005 and group B included 134 patients who were treated between October 2005 to October 2012. Preoperative, intraoperative and postoperative details of all these patients were collected, tabulated and analyzed to assess the impact of the selective approach introduced in the department with effect from October 2005.

RESULTS

Intraoperative details revealed highly significant differences in the management of the two groups of patients in respect of operative time (250.4 vs 126.6 minutes; P<0.001), operative blood loss (1070.2 vs 414.9 mL; P<0.001) and intraoperative blood transfusion (1.4 vs 0.2 units; P<0.001). Variations between the two groups in the frequency of complications were found to be statistically insignificant. However, the difference between the two groups in the overall morbidity of patients (47.6% vs 26.1%; P=0.009) and the length of their hospital stay (11.8 vs 7.8 days; P<0.001) were significant.

CONCLUSION

A selective approach applied to the surgical management of periampullary cancer patients is a step in the right direction.

Low mortality rate in 97 consecutive pancreaticoduodenectomies: the experience of a group

CONTEXT

Pancreaticoduodenectomy is the procedure of choice for resectable cancer of the periampullary region. These tumors account for 4% of deaths from cancer, being referred to as one of the lowest survival rates at 5 years. Surgery remains a complex procedure with substantial morbidity and mortality. Despite reports of up to 30% mortality rates, in centers of excellence it have been identified as less than 5%. Recent studies show that pancreaticojejunostomy represents the "Achilles' heel" of the procedure.

OBJECTIVE

To evaluate the post-operative 30 days morbidity and mortality rates.

METHODS

Retrospective analysis of 97 consecutive resected patients between July, 2000 and December, 2012. All patients were managed by the same group, and data were obtained from specific database service. The main objective was to evaluate the 30-day mortality rate, but we also studied data of surgical specimen, need for vascular resection and postoperative complications (gastric stasis, pancreatic fistula, pneumonia and reoperation rate).

RESULTS

Thirty-day mortality rate was 2.1% (two patients). Complete resection with no microscopic residual tumor was obtained in 93.8% of patients, and in 67.3% of cases pathology did not detected metastatic nodes. Among postoperative complications were reported 6% of prolonged gastric stasis, 10.3% of pneumonia, 10.3% of pancreatic fistula and 1% of infection in the drain pathway. Two patients underwent reoperation due to bleeding and infected hematoma caused by pancreatic fistula, and another for intestinal obstruction because of adhesions at postoperative day 12.

CONCLUSIONS

The pancreaticoduodenectomy as treatment procedure for periampullary cancers has a low morbidity and mortality rate in services with experience in Hepato-Pancreato-Biliary surgery, remaining as first-line treatment in resectable patients.

Postoperative serum amylase predicts pancreatic fistula formation following pancreaticoduodenectomy

INTRODUCTION

Early identification of patients at risk for developing pancreatic fistula (PF) after pancreaticoduodenectomy (PD) may facilitate prevention or treatment strategies aimed at reducing its associated morbidity.

MATERIALS AND METHODS

A retrospective review of 176 consecutive PD performed between 2006 and 2011 was conducted in order to analyze the association between the serum amylase on postoperative day 1 (POD1) and the development of PF.

RESULTS

Serum amylase was recorded on POD1 in 146 of 176 PD cases (83.0 %). Twenty-seven patients (18.5 %) developed a postoperative PF: 6 type A, 19 type B, and 2 type C. Patients with a PF had a mean serum amylase on POD1 of 659 ± 581 compared to 246 ± 368 in those without a fistula (p < 0.001). On logistic regression, a serum amylase >140 U/L on POD1 was strongly associated with developing a PF (OR, 5.48; 95 % CI, 1.94-15.44). Sensitivity and specificity of a postoperative serum amylase >140 U/L was 81.5 and 55.5 %, respectively. Positive and negative predictive values were 29.3 and 93.0 %, respectively.

CONCLUSION

An elevated serum amylase on POD1 may be used, in addition to other prognostic factors, to help stratify risk for developing PF following PD.

Internal pancreatic duct stent does not decrease pancreatic fistula rate after pancreatic resection: a meta-analysis

BACKGROUND

The use of an internal pancreatic duct stent to improve postoperative outcomes of pancreatic anastomosis remains a matter of debate.

METHODS

A meta-analysis including comparative studies providing data on patients with and without internal stenting during pancreaticojejunostomy anastomosis was performed.

RESULTS

Seven articles including 724 patients were identified for inclusion: 1 randomized controlled trial, 1 quasi-randomized controlled trial, and 5 observational clinical studies. The meta-analysis revealed that there were no significant differences between groups regarding operative outcomes. The use of an internal pancreatic duct stent was not associated with a statistically significant reduction in pancreatic fistula (P = .31), hospital mortality (P = .64), or delayed gastric emptying (P = .17), but it was associated with a higher risk of pancreatic fistulas in soft pancreases (P = .05) and overall morbidity (P = .04).

CONCLUSIONS

The current literature suggests that the use of an internal pancreatic duct stent does not help to reduce the leakage rate of pancreatic anastomosis after pancreatic resection, and it may increase the risk of pancreatic fistulas in soft pancreases.

Whereabouts of an internal short stent placed across the pancreaticojejunostomy following pancreatoduodenectomy

BACKGROUND/PURPOSE

It is generally thought that an internal short stent placed across the pancreaticojejunostomy (PJ) following pancreatoduodenectomy (PD) usually passes spontaneously through the rectum thereafter; however, we experienced some patients who presented with pancreatitis and cholangitis owing to delayed defecation of the stent. The purpose of this study was to clarify when the stent eventually became detached from the PJ and how it passed through the body until it was finally defecated. In addition, we also investigated the factors that may prevent such detachment and defecation.

METHODS

This study retrospectively analyzed 57 patients who had had internal short stents placed across the PJ following PD. Defecation from the body, detachment from the PJ, and distal migration of the stent was confirmed by X-ray or computed tomography (CT) during the postoperative course. The cumulative rates of defecation and detachment of the stents, complications in relation to delayed defecation of the stents, and factors predictive of the delayed defecation, delayed detachment, and distal migration of the stents were analyzed.

RESULTS

Defecation of the stent was confirmed in 35 patients. The median time to defecation after PD and the cumulative defecation rate at 1 year were 454 days and 41 %, respectively. Acute pancreatitis occurred in 2 patients with the stent remaining in the pancreatic duct. One patient experienced acute cholangitis owing to migration of the stent to the bile duct. Multivariate analysis showed that ≥5 stitches in the duct-to-mucosa anastomosis, stent size of ≥5 Fr, and pancreatic fistula classified as either Grade B or C were independent predictive factors for delayed defecation of the stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed detachment of the stent. A stent size of ≥5 Fr was a risk factor for distal migration of the stent.

CONCLUSION

In more than half of the study patients, internal short stents were not defecated within 1 year. Retrieval of the stent should be considered following the migration of an internal short stent. A stent size of ≥5 Fr was an independent predictive factor for delayed defecation and distal migration of a stent. Five or more stitches in the duct-to-mucosa anastomosis was an independent predictive factor for delayed defecation and detachment of a stent.

The impact of internal or external transanastomotic pancreatic duct stents following pancreaticojejunostomy. Which one is better? A meta-analysis

BACKGROUND

The use of pancreatic duct stent to improve postoperative outcomes of pancreatic anastomosis remains a matter of debate, and the value of stenting when performing anastomosis for normal pancreas (soft and duct less than 3 mm) needs further study. The aim of the present meta-analysis was to evaluate the perioperative outcomes of patients with stenting during pancreatic anastomosis and compare the effect of external stent with that of internal stent indirectly.

METHODS

A systematic literature search (EMBASE, MEDLINE, PubMed, The Cochrane Library, and Web of Science) was performed to identify studies evaluating external stent or internal stent. Included literature was assessed and extracted by two independent reviewers. A meta-analysis including comparative studies providing data on patients with and without external stenting or internal stenting during pancreaticojejunostomy anastomosis was performed.

RESULTS

Thirteen articles including 1,867 patients were identified for inclusion: five randomized controlled trials study and eight observational clinical studies. Meta-analyses revealed that use of external stent was associated with a significantly decreased risk for pancreatic fistula in total (odds ratio (OR) 0.47; 95 % confidence interval (CI) 0.31-0.71; P = 0.0004; I (2) = 3 %), pancreatic fistula in normal pancreas(OR 0.5; 95 % CI 0.30-0.82; P = 0.007; I (2) = 5 %), and overall morbidity(OR 0.64; 95 % CI 0.45-0.90; P = 0.01; I (2) = 0 %); however, the meta-analysis showed that there were no significant differences between internal stenting and non-stenting groups as regards perioperative outcomes and that in fact it may increase pancreatic fistula rate in normal pancreas(OR 1.97; 95 % CI 1.05-3.69; P = 0.03; I (2) = 0 %).

CONCLUSIONS

The results of this analysis demonstrate a trend toward reduced pancreatic fistula with the use of external pancreatic stents in pancreaticojejunostomy. An internal stent does not impact development of fistula and that in fact it was not useful in a soft pancreas. Our conclusion may be limited to stenting during the duct-to-mucosa pancreaticojejunostomy anastomosis, and the value of stenting during invagination anastomosis needs further study.

How fibrosis influences imaging and surgical decisions in pancreatic cancer

Our understanding of pancreatic ductal adenocarcinoma (PDAC) is shifting away from a disease of malignant ductal cells-only, toward a complex system where tumor evolution is a result of interaction of cancer cells with their microenvironment. This change has led to intensification of research focusing on the fibrotic stroma of PDAC. Pancreatic stellate cells (PSCs) are the main fibroblastic cells of the pancreas which are responsible for producing the desmoplasia in chronic pancreatitis (CP) and PDAC. Clinically, the effect of desmoplasia is two-sided; on the negative side it is a hurdle in the diagnosis of PDAC because the fibrosis in cancer resembles that of CP. It is also believed that PSCs and pancreatic fibrosis are partially responsible for the therapy resistance in pancreatic cancer. On the positive side, a fibrotic pancreas is safer to operate on compared to a fatty and soft pancreas which is prone for postoperative pancreatic fistula. In this review the impact of pancreatic fibrosis on diagnosis of pancreatic cancer and surgical decisions are discussed from a clinical point of view.

[Use of fibrin based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract: preliminary results of the multicentre, prospective, randomised, controlled, and simple blind phase IV clinical trial: Protissucol001]

INTRODUCTION

A multicentre, prospective, randomised, controlled, and simple blind clinical trial was started in January 2007, with the aim of demonstrating the efficacy of fibrin-based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract.

MATERIAL AND METHODS

A study on the prevention of anastomotic healing defects by applying biological adhesives along the suture line began in January 2007, and included the hospitals, Gregorio Marañón, Universitario de San Carlos, and Hospital del Sureste, in Madrid. The enrolled patients were randomised to one of 2 groups: the study group in which the adhesive was applied to the suture line, and a control group in which it was not applied. The primary outcome of the study was the presence or absence of leaks. The trial was approved by the corresponding Clinical Research Ethics Committees and the Spanish Medicines Agency (AEMPS) and registered www.clinicaltrials.gov (NCT01306851). The authors declared not to have any conflict of interests with the company, Baxter, which markets the product in Spain.

RESULTS

A total of 104 patients were recruited between January 2007 and November 2010, of whom 52 were randomised to the study group, and 52 to the control group. A total of 22 anastomotic leaks were recorded, of which 7 (13.4%) were in the study group, and 15 (28.8%) in the control group (P=.046). The leak risk index was 0.384, which means that there was a 61% reduction in leaks in the patients who had the fibrin-based biological adhesive applied. There were 3 (5.7%) further surgeries in the study group, compared to 12 (23%) in the control group (P=.12). On analysing the mortality, it was observed that 3 patients in the study group and 4 patients in the control group died (5.7% vs. 7.7%, P=.5). No other significant differences were found as regards the type of suture, surgical time, or pre-surgical history, except that the use of drainages appeared to be a protective factor of anastomotic leak (P=.041), although the use or not of a drainage was not a controlled factor, but at the discretion of each surgeon.

CONCLUSIONS

Our study demonstrates, significantly, that in the 104 patients in the study that fibrin based biological adhesives are capable of preventing anastomotic leaks in the high risk digestive tract, reducing the risk of leaks by 61% and a further surgeries. This is the first clinical trial that shows these significant results. If our results are maintained at the end of the study, it will show that anastomotic leaks can be prevented with the application of these adhesives, thus their application may be recommended in all the anastomosis of the high risk digestive tract.

Reconstruction by Pancreaticogastrostomy versus Pancreaticojejunostomy following Pancreaticoduodenectomy: A Meta-Analysis of Randomized Controlled Trials

Objectives. The aim of our study was to evaluate and compare the results of pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). Methods. Published data of randomized clinical trials (RCTs) comparing the clinically relevant outcomes of PG versus PJ after PD were analyzed. Two reviewers assessed the quality of each trial and collected data independently. The Cochrane Collaboration's RevMan 5.0 software was used for statistical analysis. Proportions were combined, and the odds ratio (OR) with its 95% CI was used as the effect size estimate. Results. Four RCTs published in 1995 or later were included in this meta-analysis, in which 276 patients underwent PG and 277 patients underwent PJ followed PD. In the combined results of PG versus PJ, a significant difference in the morbidity of intra-abdominal complications (OR, 0.34; 95% CI, 0.23–0.49; P < 0.00001) was found, but no significant difference could be found for pancreatic fistula (OR, 0.69; 95% CI, 0.42–1.12 , P = 0.13) mortality (OR, 1.09; 95% CI, 0.42–2.83; P = 0.87), recovery with no complications (OR, 1.26; 95% CI, 0.90–1.78; P = 0.18), biliary fistula (OR, 0.55; 95% CI, 0.22–1.35; P = 0.19), or in delayed gastric emptying (OR, 0.55; 95% CI, 0.33–1.01; P = 0.06). Conclusions. Current RCTs suggest that PG is better than PJ for pancreatic reconstruction after PD.

Does external pancreatic duct stent decrease pancreatic fistula rate after pancreatic resection?: a meta-analysis

OBJECTIVES

The use of an external pancreatic duct stent to prevent fistula formation of pancreatic anastomosis remains a matter of debate. This study is a meta-analysis of the available evidence.

METHODS

Articles published until the end of March 2011 comparing external stenting and non-stenting in pancreatic anastomosis were included. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model.

RESULTS

Six articles were identified for inclusion: 3 randomized controlled trials and 3 observational clinical studies. The meta-analysis revealed that the use of an external pancreatic duct stent was associated with a statistically significant reduction in overall postoperative morbidity (OR 0.56; 95% CI 0.39-0.81; p = 0.002), pancreatic fistula (OR 0.34; 95% CI 0.23-0.15; p < 0.001), severity of pancreatic fistula (OR 0.70; 95% CI 0.32-1.57; p = 0.04), delayed gastric emptying (OR 0.44; 95% CI 0.25-0.80; p = 0.007), and length of hospital stay (WMD -3.95; 95% CI -6.38 to -1.52; p = 0.001).

CONCLUSIONS

The current literature suggests that the use of an external pancreatic duct stent reduced the leakage rate of pancreatic anastomosis after pancreatic resection. and IAP.

Does the type of pancreaticojejunostomy after Whipple alter the leak rate?

Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.

Peri-operative blood transfusion and operative time are quality indicators for pancreatoduodenectomy

BACKGROUND

Minimization of blood loss during pancreatoduodenectomy requires careful surgical technique and specific preventative measures. Therefore, red blood cell (RBC) transfusions and operative time are potential surgical quality indicators. The aim of the present study was to compare peri-operative RBC transfusion and operative time with 30-day morbidity/mortality after pancreatoduodenectomy.

METHODS

All pancreatoduodenectomies (2005 to 2008) were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). RBC transfusions and operative time were correlated with 30-day morbidity/mortality.

RESULTS

Pancreatoduodenectomy was completed in 4817 patients. RBC transfusions were given to 1559 (32%) patients (1-35 units). Overall morbidity and mortality rates were 37% and 3.0%, respectively. Overall 30-day morbidity increased in a stepwise manner with the number of RBC transfusions (R = 0.69, P < 0.01). Although RBC transfusions and operative times were not statistically linked (P = 0.87), longer operative times were linearly associated with increased 30-day morbidity (R = 0.79, P < 0.001) and mortality (R = 0.65, P < 0.01). Patients who were not transfused also displayed less morbidity (33%) and mortality (1.9%) (P < 0.05).

DISCUSSION

Peri-operative RBC transfusion after pancreatoduodenectomy is linearly associated with 30-day morbidity. Longer operative time also correlates with increased morbidity and mortality. Therefore, blood transfusions and prolonged operative time should be considered quality indicators for pancreatoduodenectomy.

Comparison of the efficacy of different methods of pancreaticojejunostomy

AIM: To compare the efficacy of end-to-end invaginated pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy and binding pancreaticojejunostomy.

METHODS: The clinical data of 157 patient who underwent pancreaticoduodenectomy at our hospital from February 1999 to May 2009 were collected. Of all patients, 61 underwent end-to-end invaginated pancreaticojejunostomy, 66 underwent duct-to-mucosa pancreaticojejunostomy and 30 underwent binding pancreaticojejunostomy. The anastomotic time, postoperative complications, death rate and length of stay were compared.

RESULTS: The mean time to complete end-to-end invaginated pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy and binding pancreaticojejunostomy was 35.85 ± 4.73, 37.18 ± 6.12 and 20.75 ± 4.05 min, respectively. The mean time to complete binding pancreaticojejunostomy was significantly shorter than that to complete end-to-end invaginated pancreaticojejunostomy and duct-to-mucosa pancreaticojejunostomy (both P < 0.05). No significant differences were noted in complication rate, mortality rate and length of stay among the three groups. No pancreatic leakage was observed after binding pancreaticojejunostomy.

CONCLUSION: Satisfactory efficacy and low complication rate can be achieved using any of the three methods of pancreaticojejunostomy. Binding pancreaticojejunostomy has more convenient procedure, shorter operative time and less complications than the other two methods.