Does Pancreatic Ductal Anatomy Play a Role in Determining Outcomes of Pancreatic Anastomoses?

Pancreatoduodenectomy (PD) is the surgical procedure performed for cancers of the head of the pancreas. Despite a substantial reduction in mortality rates following PD, morbidity remains high secondary to major post-operative complications. Post-operative pancreatic fistula (POPF), the commonest major complication following PD, results from the failure of the pancreato-enteric anastomosis. There appears to be a correlation between intrinsic pancreatic features like the texture of the gland and duct size and the outcome of the pancreatic anastomosis. Based on current clinical research data, we propose a new hypothesis called the pancreatic ductal anatomy concept. We hypothesize that morphological variations, anomalies or aberrations of the main pancreatic duct play a role in the outcome of the pancreatic anastomosis, irrespective of its type. The consequence of aberrant ductal anatomy is that certain areas of the remnant pancreas remain either undrained or partially drained, or have blocked ductules/ducts. This results in localized obstructive pancreatitis causing an inflammatory reaction which jeopardizes the anastomosis. We also propose two maneuvers which could possibly play a role in predicting potential problems and also planning the surgical resection and reconstruction in order to reduce the incidence of POPF. The first modality is the use of pre-operative magnetic resonance imaging (MRI) of the pancreatic duct, and the second maneuver is the gentle cannulation test of the pancreatic duct with a soft, narrow tube following transection of the pancreatic neck. These factors would alert the surgeon about potential ductal variations and could facilitate the surgical approach