Pancreatojejunal leakage after pancreas head resection: Anatomic and surgeon-related factors

Leakage of pancreatojejunostomies after pancreatic resections remains a challenge even at high volume centers. We here utilized a simple pancreas anatomy classification to study the effect of pancreatic anatomy on the development of pancreatic fistula after pancreas resection and pancreatojejunostomies. Also, the effect of surgical experience on the development of pancreatic fistulas was studied. Three hundred ninety-one patients undergoing pancreatic resections and reconstruction with a pancreatojejunostomy were studied. Closed suction drain was placed behind the anastomosis, and drainage fluid was collected postoperatively. A twofold increase over the serum amylase level was considered a fistula and was classified as described by the International Study Group on Pancreatic Fistula Definition. In 67 patients, the structural quality of the pancreatic parenchyma and the diameter of the pancreatic duct were classified as being < 2 mm (2 points), between 2 and 5 mm (1 point), or > 5 mm (0 points). The pancreatic parenchyma was assessed as being soft (2 points), intermediate (1 point), or hard (0 points). Pancreatic leakage as a function of surgeons' experience was also studied. Leakage was found in 25.1%, 8.9% being of type A, 10.2% being of type B, and 5.9% of type C. Pancreatic fistulas were only observed in patients with a score of 2 points or more. Age over 70 years, operations > 6 h, and extended lymphadenectomy or surgeons experience were not associated with a higher leakage rate. In this study, leakage after pancreatojejunostomy was only associated with pancreatic anatomy, classified with a simple score. That score might improve comparability of studies on pancreatic leakage. Furthermore, drainage of pancreatic anastomosis might safely be omitted in patients with a low risk score for leakage.