We read the article by Jester and colleagues in the June 2017
Journal of Gastrointestinal Surgery issue, titled “The impact of
hepaticojejunostomy leaks after pancreatoduodenectomy: A
devastating source of morbidity and mortality” [1].
We were interested in reading the results of their study, which
found that hepaticojejunostomy leaks confer increased morbidity
and mortality, especially when associated with pancreatic fistula,
because we too observed a high mortality rate in these situations in
the 1970s. As surgeons from previous generations may recall, the
mortality after pancreatoduodenectomy was extremely high during
this period of time [2]. We observed that mortality was extremely
high in patients with combined biliary and pancreatic fistulas.
Our hypothesis was that biliary secretion somehow activated the
pancreatic juice, making this usually benign complication extremely
hazardous for the patient. Using this rationale, we devised a modified
technique for reconstruction of the alimentary tract using two
separated jejunal loops for biliary and pancreatic anastomosis. This
resulted in an immediate reduction of mortality and morbidity [3,4].
This technique has become our standard method of reconstruction,
and it was the subject of several comparative studies which
concluded that separation of the biliary and pancreatic conduits
may decrease the severity of pancreatic fistulas, therefore reducing
the morbidity and mortality of pancreatoduodenectomy [5–7]. A
recent prospective randomized study showed that this technique
is not associated with a lower incidence of pancreatic fistula
compared to conventional reconstruction. However, and maybe
much more importantly, the authors do indicate that this technique
may contribute to decreasing fistula severity, the duration of the
hospital stay, and hospital expense [8].
Recently, as we initiated our procedure for laparoscopic
pancreatoduodenectomies, this technique was adapted for the new
era [9], as we not only understood the importance of the isolated
pancreatic anastomosis to decrease the severity of pancreatic
fistulas but also expected difficulties during the long learning
curve of laparoscopic pancreatoduodenectomy. Indeed, we did
not experience any fatality during our first 50 laparoscopic cases,
even in cases with hepaticojejunostomy leaks [10]. The actual
impact of hepaticojejunostomy leaks can only be verified when
a large cohort of patients, such as that of Jester and colleagues
[1], studied, and therefore, we congratulate the authors on this
important study. This is indeed a rare but threatening complication
in which the impact can be minimized if techniques using isolated
pancreatic anastomosis are employed. Pancreatoduodenectomies
are now being performed with minimally invasive techniques
and by low volume centers. The number of procedures is growing