The development of a pancreatic fistula following pancreatoduodenectomy, with its inherent morbidity and mortality, remains important. In reported series, it is most often associated with a soft (normal) pancreas and a nondilated duct of Wirsung. In their article, Suzuki and colleagues raise 2 issues. First, which technique of reestablishing gastrointestinal continuity to the remnant pancreas is superior? Second, they help define just what constitutes a pancreatic fistula.
Published reports have focused on technical nuances and adjunctive agents that may help to diminish pancreaticoenteric disruption. Duct-to-mucosa reconstruction, pancreatic invagination, duct ligation, pancreaticogastrostomy, fibrin glue, duct stenting, octreotide, and combinations thereof have all been supported. Despite varying techniques, most recent series consistently report fistula rates ranging between 5% and 20%. In the accomplished hands of the authors, pancreatic fistula rates with their techniques were equal to, but not better than, others reported in the literature. Should the technique of pancreatic reconstruction vary depending on pancreatic texture? The data presented do not answer that question. Perhaps the lesson for the pancreatic surgeon would be to pick a technique one is most comfortable with that yields consistently good results. With that said, one would be remiss not to critically analyze and perhaps incorporate different and evolving solutions to what is clearly the vulnerable point of reconstruction following pancreatoduodenectomy.