Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review.

OBJECTIVE To review the current evidence on the efficacy of various interventions directed toward prevention of pancreatic fistula after pancreatoduodenectomy. DATA SOURCES A MEDLINE database search from January 1, 1990, to August 31, 2008, was performed to identify relevant articles using the keywords pancreatoduodenectomy, pancreaticojejunostomy, pancreaticogastrostomy, pancreatic anastomotic leakage, and pancreatic fistula. Additional articles were identified by a manual search of the references from the key articles. STUDY SELECTION Case reports were excluded from this study. DATA EXTRACTION Of the identified studies, only those published in English describing meta-analyses or randomized controlled trials were considered first. In those aspects with limited or no randomized controlled trials, nonrandomized comparative studies and case series were included also. DATA SYNTHESIS The prophylactic use of perioperative somatostatin and its analogues to prevent pancreas-related complications after pancreatic surgery remains controversial and does not result in a reduction of operative mortality. There is no clear evidence for or against a particular type of pancreaticoenteric anastomosis. Pancreaticoenterostomy cannot be replaced by pancreatic ductal obliteration. Pancreaticogastrostomy is equivalent to pancreaticojejunostomy in perioperative morbidity and mortality. CONCLUSION More large-scale comparative studies and randomized controlled trials are required to determine the optimum pharmacologic interventions and technique of pancreaticoenteric anastomosis after pancreatoduodenectomy.