Surgery indeed has an important role in long-term outcome in patients with pancreatic head cancer.

We read with interest the article by Petermann et al. [1] in the August 2013 issue of World Journal of Surgery. First of all, we would like to congratulate the authors for their very interesting article. In this retrospective study 101 pancreatic head resections due to pancreatic ductal adenocarcinoma were analyzed. The authors wanted to assess the impact of postoperative complications, stratified by severity, on long-term survival of patients after pancreatic head resection for ductal adenocarcinoma. However, we have several concerns about their conclusions. First, the authors concluded that surgery is not associated with severe postoperative complications. Surgery is the cornestone in the treatment of pancreatic cancer. Pancreaticoduodenectomy (PD) is the standard surgical treatment of pancreas head cancer. Using an optimal pancreatic reconstruction technique is thought to be a major prophylactic measure to minimize the risk of PD-related complications. Also, there are many possibilities of type of reconstruction as well as many possibilities for pancreaticojejunostomies (PJA): (1) layer with or without telescope, (2) layer, end-to-end, end-to-side, ‘‘duct to mucosa,’’ ‘‘Blumgart‘s’’ anastomosis, etc. [2]. Further, we don’t agree with authors’ conclusion that surgery is not associated with severe postoperative complications. They did not mention what kind of reconstructions were performed In accordance with this we could state following facts. Delayed gastric emptying (DGE) occurs dominantly after pylorus-preserving pancreaticoduodenectomy (PPPD) and remains a leading cause of PPPD postoperative complications. Delayed gastric emptying was probably exacerbated by some intra-abdominal complications, such as an anastomotic leak or an abscess. Problems could also be caused by the surgical procedure itself, namely injury to the nerve of Latarjet. In one study the incidence of DGE was significantly reduced in the pyloric ring resection group compared to controls, without an increase in dumping syndrome [3]. Most pancreatic fistulas (PF) can be managed nonoperatively, but a significant number of grade C PF do require reoperative surgical intervention. Risk factors for pancreatic fistula are well recognized and include a soft pancreatic parenchyma, small main pancreatic duct caliber, and a distal pancreatic resection (vs PD) [4]. Type of anastomosis is also very important regarding this problem. For example, there is a statistically significant decrease in fistula rate in the invagination group—PJA with invagination compared to other types of anastomoses [5]. Patients with postoperative hemorrhage often have underlying complications such as pancreatic fistula that require urgent surgical treatment. Pancreatic enzymes in combination with infection can cause erosion of the gastroduodenal artery or splenic artery stump, resulting in significant bleeding requiring immediate treatment. D. Zdravkovic (&) D. Bilanovic T. Randjelovic S. Dikic Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia e-mail: drdarkozdravkovic@gmail.com