progress in surgical technique and perioperative management has significantly reduced the morbidity and mortality rate of pancreatic resection procedures [ 1 , 2 ] .
the majority of postoperative complications after pancreatoduodenectomy ( pd ) arise from pancreatic leakage by the pancreatic stump .
the pancreatic anastomosis is called by some authors the  achilles heel  of pancreatic surgery due to its high rate of complications among all abdominal anastomoses [ 3 , 4 ] . the optimal management of the pancreatic remnant after pd remains a challenge .
more than 80 different methods of pancreaticoenteric reconstruction have been described , indicating the absence of a gold standard technique .
our institution 's eight - year experience using this approach in a nonselected group of patients is presented herein .
the objective of our trial was to compare the two operative approaches for the management of the pancreatic remnant with regard to mean operative time , postoperative complications , oncological parameters , and one - year survival rates .
a retrospective study was performed in a nonselected series of 93 patients treated between september 2002 and december 2009 with suspected pancreatic and periampullary cancers or chronic pancreatitis .
there were 65 men ( 70% ) and 28 women ( 30% ) , and their mean age was 64 years ( range , 4183 years ) .
the first group included 37 patients , in which the pancreatic duct was occluded by stapling and a running 30 polypropylene suture without anastomosis of the pancreatic remnant .
the second group composed of 56  patients , in which a traditional end - to - end or end - to - side invagination pancreaticojejunostomy was performed after pd .
the pancreatic remnant was invaginated into the jejunum by about 2  cm , and two - layer sutures were performed interruptedly . in all cases one drainage tube
was placed posterior to the biliary - jejunal anastomosis , and for the second group the same tube was placed over the pancreatic anastomosis as well .
the drainage was removed on the third postoperative day , unless a pancreatic fistula was confirmed .
the indications for surgery in the first group were pancreatic cancer ( n = 26 , 70.27% ) , carcinoma of the vater 's ampulla ( n = 8 , 21.62% ) , common bile duct carcinoma ( n = 1 , 2.7% ) , and chronic pancreatitis ( n = 2 , 5.40% ) and similarly , in the second group pancreatic cancer ( n = 34 , 60.7% ) , vater 's ampulla carcinoma ( n = 12 , 21.40% ) , common bile duct carcinoma ( n = 6 , 10.7% ) , and chronic pancreatitis ( n = 4 , 7.10% ) ( table 1 ) .  
the decision for occlusion of the pancreatic remnant was directed by two criteria : pancreatic duct preoperative imaging ( either ercp or mrcp depicting an already occluded duct),intraoperative appearance of the duct indicating increased intraductal hydrostatic pressure ( spurt of the pancreatic fluid at the time of opening of the pancreatic duct ) .  
pancreatic duct preoperative imaging ( either ercp or mrcp depicting an already occluded duct ) , intraoperative appearance of the duct indicating increased intraductal hydrostatic pressure ( spurt of the pancreatic fluid at the time of opening of the pancreatic duct ) .
the mean operative time for the occlusion group was 180 minutes ( range 160200 minutes ) versus 220 minutes ( range 190240 minutes ) in the anastomosis group . mean hospitalization time was 6 days ( range 411 days ) for both groups .
the mortality rate was 0% for the first group and 3% ( 1 patient died of myocardial infarction and one of postoperative hemorrhage ) for the anastomotic one .
pancreatic fistula was observed in 13 patients ( 23.2% ) in the anastomotic group and in 2 patients ( 5.4% ) in the occlusion group , and they were all managed conservatively .
pancreatic fistula was defined according to the international study group of pancreatic fistula guidelines , as amylase rich fluid ( with an amylase concentration in the drainage fluid more than 3 times the serum concentration ) .
the fluid was collected by needle aspiration from an intra - abdominal collection or from the intraoperatively placed drain on the third postoperative day .
other complications included 2 wound infections in group one ( 5.4% ) and 3 ( 5.3% ) in group two , 1 bile leak ( 2.7% ) in group one and 2 ( 3.5% ) in group two , 3 cases of delayed gastric emptying ( 8.1% ) in group one and 2 ( 3.6% ) in group two , and 3 urinary tract infections in group one ( 8.1% ) and 4 ( 7.1% ) in group two ( table 2 ) .
finally , no difference regarding one year survival rates was recorded . according to the literature
, the function of the langerhans ' islets is not affected by pancreatic duct occlusion . in our series
, there was no difference between the two groups regarding patient 's needs for pancreatic enzymes replacement or the development of postoperative diabetes .
in general no chronic abdominal pain and chronic pancreatitis differences were detected between the two groups ( table 3 ) .
during the last two decades pd is used with increasing frequency for the management of malignant , and also for benign periampullary lesions .
postoperative mortality rate has decreased significantly in comparison to the previous years and is reported below 5% in high volume centers , but morbidity is still considered high .
anastomotic leakage at the pancreaticojejunostomy is one of the most severe complications of pd with 525% rate among series according to different definitions [ 7 , 8 ] , leading to prolonged hospital stay , interventional radiology procedures , relaparotomy , and high mortality rates .
many anastomotic techniques have been described in order to prevent leakage from the pancreatic anastomosis , but unfortunately with no uniform results .  
an interesting approach to this problem is the occlusion of the pancreatic remnant after pd .
the absence of the pancreaticojejunal anastomosis could prevent a large portion of the postoperative complications of pancreatic surgery .
occlusion can be performed either by suturing the pancreatic duct with nonabsorbable suture material or by using synthetic materials , like fibrin glue solution , tissucol , and neoprene .
moreover , it has been reported that a pancreatic fistula resulting from an oversewn pancreatic remnant is less dangerous than one from a pancreaticojejunal anastomosis because there is no defect of the small bowel , which could lead to activation of leaking pancreatic enzymes .   in our series ,
pancreatic fistula rate was significantly lower in the pancreatic occlusion group , and the ones which occurred were managed with prolonged pancreatic drainage , indicating a low grade fistula .
the most significant anatomic features influencing the development of this complication are the consistency of the pancreatic parenchyma and the size of the pancreatic duct .
furthermore , if both of the preoperative imaging studies ( ercp and mrcp ) and the intraoperative findings indicate a dilated duct , then the pancreatic remnant occlusion technique seems to be a rather interesting alternative option . despite the classic knowledge that dilated ducts indicate easier and more durable duct - to - mucosa pancreaticojejunal anastomosis , in our series dilated ducts in fibrotic pancreas with spurt of the pancreatic fluid at the time of opening of the pancreatic duct mean an already occluded duct , which we occlude once again after pancreatectomy by stapling and oversewing .  
pancreatic remnant occlusion is a safe , less complicated alternative management of the pancreatic stump during whipple 's procedure .
additionally , it neither affects the oncologic principles of the surgical procedure nor the long - term survival of patients treated for cancer of the head of the pancreas .
pancreatic remnant occlusion is a safe , time consuming , and less complicated alternative management of the pancreatic stump during whipple 's procedure .
additionally , it does not affect the oncologic principles and long - term survival of patients treated for cancer of the head of the pancreas .
 
 introduction . to present our experience regarding the use of pancreatic stump occlusion technique as an alternative management of the pancreatic remnant after pancreatoduodenectomy ( pd ) 
 . methods . between 2002 and 2009 , 
 hospital records of 93 patients who had undergone a whipple 's procedure for either pancreatic - periampullary cancer or chronic pancreatitis were retrospectively studied . in 37 patients 
 the pancreatic duct was occluded by stapling and running suture without anastomosis of the pancreatic remnant , whereas in 56 patients a pancreaticojejunostomy was performed . 
 operative data , postoperative complications , oncological parameters , and survival rates were recorded . results . 
 2/37 patients of the occlusion group and 9/56 patients of the anastomosis group were treated for chronic pancreatitis , whereas 35/37 and 47/56 patients for periampullary malignancies . 
 the duration of surgery for the anastomosis group was significantly longer ( mean time 220 versus 180 minutes ) . 
 mean hospitalization time was 6 days for both groups . 
 the occlusion group had a lower morbidity rate ( 24% versus 32% ) . 
 with regard to postoperative complications , a slightly higher incidence of pancreatic fistulas was observed in the anastomosis group . 
 conclusions . 
 pancreatic remnant occlusion is a safe , technically feasible , and reducing postoperative complications alternative approach of the pancreatic stump during whipple 's procedure . 
1. Introduction 
2. Materials and Methods
3. Results
4. Discussion
5. Conclusions