Two-stage pancreatojejunostomy in pancreaticoduodenectomy: a retrospective analysis of short-term results.

BACKGROUND The morbidity associated with pancreatic fistula formation after pancreaticoduodenectomy (PD) still remains high. While theoretically 2-stage pancreatojejunostomy (PJ) is effective for preventing pancreatic juice enzymes from becoming activated by enteric contents, its clinical usefulness remains unknown. The aim of this retrospective study was to evaluate the short-term results of two-stage PJ in PD. PATIENTS AND METHODS In PD cases with a narrow main pancreatic duct and/or soft texture of the pancreas, we performed 2-stage PJ; first an external tube pancreatostomy was performed, in which the tube was not passed through the jejunal loop, followed about 3 months later by second-stage reconstruction for PJ. Between 1998 and 2005, PDs with 1-stage and 2-stage PJ were performed in 53 and 99 patients, respectively, at our institution. Among the latter 99 patients, 13 (13%) also underwent concomitant right or extended right hemi-hepatectomy. In this study, the clinical records of these 152 patients were retrospectively analyzed. RESULTS After PD, a pancreatic fistula occurred in 58% of the patients undergoing 2-stage PJ; however, the fistula healed with conservative therapy in all but 2 patients who required surgical drainage for abdominal abscess. A second-stage pancreato-enteric reconstruction by PJ could be completed about 3 months after the PD in 89 of the 99 (90%) cases. Although the incidence of pancreatic fistula was 16% after the second-stage reconstruction for PJ, completion pancreatectomy was not needed in any of the cases. There were no deaths or other catastrophic events related to the procedure. CONCLUSIONS While it is difficult to completely prevent pancreatic fistula formation after PD, a 2-stage PJ appears to be effective for minimizing pancreatic juice-related adverse events, especially in high-risk patients with a narrow pancreatic duct or undergoing highly invasive surgery, such as hepato-pancreticoduodenectomy.