Management of the pancreatic stump after pancreaticoduodenectomy

The aim of the present study was to review the current evidence in the management of the pancreatic stump after pancreaticoduodenectomy (PD). A literature search was conducted using the following key words: PD, Whipple's operation, pancreaticojejunostomy (PJ), pancreaticogastrostomy (PG), dunking, duct to mucosa (DTM) and pancreatic stent. Emphasis was made on randomized, controlled trials and meta-analyses. Simple ligation or occlusion of the pancreatic duct was abandoned due to a high complication rate. Most surgeons fashioned a PJ or PG to restore drainage of pancreatic juice. Dunking and DTM were the two major ways to construct anastomosis. The superiority of the binding technique still needs to be proved. However, Blumgart's modified DTM technique achieved a favourable outcome in some non-randomized trials. Pancreatic fistula was not decreased by internal stent, but an external stent might be helpful. No single type or technique of pancreaticoenteric anastomosis is able to demonstrate significant superiority to others. Similar controversy also occurs in the use of pancreatic stent. For the successful management of the pancreatic stump, no matter which type of anastomosis is employed, a meticulous surgical technique with optimization of blood supply to the anastomosis cannot be overemphasized.