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Why is a 0-fistula rate in pancreaticojejunostomy impossible?

Published:January 15, 2021DOI:https://doi.org/10.1016/j.surg.2020.12.002
      In the last 20 years, over 4,000 manuscripts on the subject of the pancreatic anastomosis have been published and listed in PubMed. The Achilles heel of the pancreaticoduodenectomy is the pancreatic anastomosis (although PubMed identifies only 9 manuscripts that mention Achilles heel and the subject of the pancreatic anastomosis). The normal pancreas is an organ that is nearly devoid of connective tissue. Hence, the use of this collagen-poor organ in anastomotic construction has been likened to sewing moonbeams to flatus. Anastomotic leaks are the source of major morbidity and mortality owing to the intraperitoneal release of enterokinase and the activation of pancreatic enzymes with subsequent septic and hemorrhagic complications. The postoperative clinically relevant pancreatic fistula (CR-PF) rate is the standard to measure the success of the pancreatic anastomosis. Fistulas that result in sepsis, percutaneous catheter drainage, reoperation, and death are clinically relevant. The at-risk pancreas is one that is soft, fatty, noncalcific, and nonfibrotic with a small duct.
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