A 58-year-old presents with obstructive jaundice and a dilated common bile duct. CT shows a low-density mass in the head of the pancreas. During Whipple's procedure (pancreaticoduodenectomy), what is the most critical anastomosis for post-operative morbidity, and what technique reduces the risk of post-operative pancreatic fistula (POPF)?
- A Hepaticojejunostomy; using a Roux-en-Y reconstruction
- B Gastrojejunostomy; using a Billroth II reconstruction
- C Pancreaticojejunostomy or pancreaticogastrostomy; duct-to-mucosa anastomosis with external pancreatic duct stenting ✓
- D Choledochojejunostomy; using T-tube drainage of the common hepatic duct
Explanation
The pancreatic anastomosis (pancreaticojejunostomy or pancreaticogastrostomy) is the most morbidity-associated anastomosis after pancreaticoduodenectomy, with POPF occurring in 10-25% of cases and being the primary driver of post-operative complications and mortality. Risk factors for POPF include a soft pancreatic texture and a small pancreatic duct. Duct-to-mucosa anastomosis with meticulous suture technique, combined with external pancreatic duct stenting that decompresses the anastomosis, is the most evidence-based technique to reduce POPF. Pancreaticogastrostomy may be preferred with a soft gland and non-dilated duct. Perioperative somatostatin analogues provide modest benefit in high-risk patients.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.