Pancreaticogastrostomy as an Ideal Drainage Procedure After Pancreaticoduodenectomy: Can We Draw a Conclusion?

To the Editor: W ith great interest, we read the article by Menahem and colleagues. The authors conducted an up-to-date metaanalysis of randomized controlled trials comparing pancreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) for prevention of pancreatic fistula after pancreaticoduodenectomy (PD). They concluded that PG was more efficient than PJ in reducing the incidence of postoperative pancreatic fistula. In view of this, should we draw a conclusion and change the current practice? Yet, this is not always the case. Some important remarks regarding the conclusion have to be made. First, as a meta-analysis of trials comparing 2 surgical procedures, the surgical techniques varied among included trials. Conventional PD, pylorus-preserved PD, and PD with extended resection were performed. Either end-to-end PJ or end-to-side PJ was used. The method of PG was also not standardized among included trials. In addition, the type and thickness of suture material and the method of pancreatic anastomosis were diversified on the basis of the surgeon’s discretion. It is reasonable to speculate that the rates of pancreatic fistulas of each arm may be influenced by the most important confounding factor in the surgical trials, the surgical techniques. Second, the incidence of postoperative pancreatic fistula in the PG group pooled in this meta-analysis is still far from satisfactory (11.2%). On the contrary, new surgical techniques of PJ have been continuously developed to win the battle against postoperative pancreatic fistula, with some of them proven to be very effective. For example, the binding PJ was proven to be an effective and safe technique with encouraging results. Also, isolated Roux loop PJ reduced the incidence of pancreatic fistula and improved the safety of PD by separating PJ from the choledochojejunostomy and gastrojejunostomy. In fact, a recent randomized control trial showed comparable incidences of postoperative

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