Reply to Letter to the Editor

Dear Editor:

Firstly, we appreciate the interest expressed by Díaz-Vallejo et al.¹ in our study² which aimed to show the results obtained with external drainage of the duct of Wirsung after performing a cephalic duodenopancreatectomy (CDP) in patients with pancreatic or periampullary tumours, above all assessing postoperative complications and mortality. In the introduction to our paper, we commented on the results obtained in three important comparative series between pancreaticojejunostomy and pancreaticogastrostomy, the aim was to analyse the incidence of pancreatic fistulas (PF) or overall morbidity, and we reached the conclusion that no significant differences were found between the two procedures in the three studies.^3–5 We provide the authors of this letter with details about the significance and number of patients in these series: 151 in the series of Bassi et al.³, 445 patients from randomised controlled studies out of a total of 2150 in the series of Wente et al.⁴, and 5316 in the series of Ecker et al.⁵. The authors of this letter refer us to a study by Ibrahim et al.⁶, which is a low quality study, very summarised and without any specified statistical analysis, which reviews six comparative, randomised controlled series, and the authors of the review conclude that pancreaticojejunostomy has a higher PF rate than pancreaticogastrostomy. However, Cheng et al.⁷ (Cochrane Library) conducted a review study, with exhaustive statistical analysis, in which 1629 patients undergoing CDP from 10 randomised controlled series were analysed, and concluded that neither of the two pancreatic duct bypasses mentioned is superior to the other in terms of morbidity and mortality, and that international studies with a larger number of patients are needed to demonstrate the superiority of one of the two procedures over the other. Interestingly, five of the six series reviewed by Ibrahim et al.⁶ are included in this study, and therefore we disagree with the conclusions of this summary study, with fewer cases and no statistical analysis.

We believe that in addition to the technique of pancreatic duct diversion, CDP outcomes are related to multiple variables (surgeon experience, number of cases performed, use of tutors, patient age and comorbidity, degree of tumour invasion, consistency of the pancreas, calibre of the duct of Wirsung, blood transfusion, postoperative care, etc.). It is therefore difficult to attribute the incidence of fistulae to any one variable alone, including the type of post-CDP pancreatic diversion. Currently, mortality associated with CDP is below 5% in hospitals with experience in pancreatic surgery; however, morbidity (PF, infection, haemorrhage, delayed gastric emptying, etc.) remains between 31%–53%.²

To be more precise and in line with your last comment, there are eponyms in the medical literature which can be used because they are widespread. Thus, the main pancreatic duct, also called duct of Wirsung, has been well known since its discovery in the 17th century by J. Georg Wirsung. Duct of Wirsung is one of the commonest eponyms in the world of medicine, known to all surgeons and widely used in the surgical literature, which is what our paper is about. Respecting your opinion, we believe that pancreatic duct or duct of Wirsung can be used interchangeably in publications, as many surgeons are accustomed to doing.

Authors’ contributions

Carlos Jiménez-Romero: design of the study; drafting of the article; critical revision and approval of final revision.

Alberto Marcacuzco Quinto: design of the study and data acquisition and collection.

Oscar Caso Maestro: data acquisition and collection; analysis and interpretation of the results.

Iago Justo Alonso: critical revision and approval of the final revision: design of the study.

Funding

No funding was received for this work.

Conflict of interests

The authors have no conflict of interests to declare.