External pancreatic stents after pancreaticoduodenectomy reduce pancreatic fistula rates and severity

Abstract

Background: Postoperative pancreatic fistula (PF) is a common complication after pancreaticoduodenectomy (PD). Additional interventions to decrease incidence of PF may add cost and procedural risk to patients with variable Results. The purpose of this study is to evaluate the impact of routine pancreatico-jejunostomy reconstruction over external pancreatic stent on PF rates and severity after PD. Methods: We retrospectively reviewed the medical records of 148 consecutive patients undergoing open pylorus-preserving PD between March 2014 and April 2018. All patients had a temporary trans-anastomotic external pancreatic stent placed. Octreotide was not utilized. Outcomes in 49 patients with PDAC were compared to the remaining group of 99 patients with non-PDAC pathologies. PF risk score was calculated for each patient. Continuous and categorical variables were analyzed by chi square, Fisher's exact tests, Student t-test and Mann-Whitely Rank test. Results: Overall postoperative PF incidence rate was 3.4%. Among patients with PDAC, the average risk score for pancreatic fistula was 2.4 vs 4.4 in the non-PDAC group (p=< 0.001). There were 5 Type B PF in the non-PDAC patients and 0 Type C in the entire patient group as defined by 2017 ISGPS guidelines. No patients in the PDAC group required intervention to address PF where 5 patients required postoperative percutaneous drainage in the non-PDAC cohort. PDAC patients received more crystalloid during PD (4.3 liters vs 3.6 liters; p = 0.01). Significantly more PDAC patients underwent pre-operative chemotherapy (p = 2 major comorbidities, BMI, volume of crystalloid received, peripancreatic inflammation and wound infection could not account for the difference observed in the need for postoperative percutaneous drainage after PF. Conclusion: During PD, reconstruction over an external pancreatic stent led to very low PF incidence with no significant difference observed in severity between patients with PDAC and other high fistula risk pathologies. Routine external pancreatic stent placement after PD, regardless of PF risk, may reduce incidence of PF and need for additional interventions.