Optimizing pancreatectomy outcomes: Follow the evidence

Abstract

A PubMed search of “pancreatectomy” reveals 10,376 articles, and a fraction of these represent randomized controlled trials (n = 81) [ [1] Available at: http://www.ncbi.nlm.nih.gov/pubmed. Accessed Feb 8, 2012. Google Scholar ]. The number of randomized trials performed to date by surgeons to optimize outcomes in pancreatic resection is remarkable. Some of the recent major trials are shown in Table 1. These trials form the basis for many discussions on teaching rounds and include some of the most debatable topics in surgical Morbidity and Mortality conference, such as the routine use of intraperitoneal drains and when to remove them, preoperative biliary drainage, the use of pancreatic stents, intraoperative fluid restriction, preoperative biliary stent versus no drainage, or how to close the pancreatic stump. Table 1Recent randomized controlled trials in pancreatectomy outcomes. Variable Study, year Randomization Outcome PBD van der Gaag et al., 2010 [8] van der Gaag N.A. Rauws E.A. van Eijck C.H. et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010; 362: 129 Crossref PubMed Scopus (758) Google Scholar PBD versus surgery alone 46% complication rate from PBD procedures performed preoperativelyNo difference in operative complications Anastomotic technique Berger et al., 2009 [9] Berger A.C. Howard T.J. Kennedy E.P. et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg. 2009; 208 (discussion 47): 738 Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar Invagination versus duct to mucosa anastomosis for pancreaticojejunostomy Statistically significant decrease in fistula rate in invagination group Pancreatic stump closure Diener et al., 2011 [10] Diener M.K. Seiler C.M. Rossion I. et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): A randomised, controlled multicentre trial. Lancet. 2011; 377: 1514 Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar Hand sewn versus stapler after distal pancreatectomy No difference in pancreatic fistula or operative mortality Duration of intraperitoneal drainage Bassi et al., 2010 [11] Bassi C. Molinari E. Malleo G. et al. Early versus late drain removal after standard pancreatic resections: Results of a prospective randomized trial. Ann Surg. 2010; 252: 207 Crossref PubMed Scopus (353) Google Scholar Early drain removal (POD 3) versus late drain removal (POD ≥ 5) Significant reduction in pancreatic fistulae, overall complications, and hospital stay and associated costs in early drain removal group Pancreatic stent Pessaux et al., 2011 [12] Pessaux P. Sauvanet A. Mariette C. et al. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: Prospective multicenter randomized trial. Ann Surg. 2011; 253: 879 Crossref PubMed Scopus (194) Google Scholar External pancreatic stent versus no stent Significant decrease in pancreatic fistulae, wound infections, and delayed gastric emptying in stented group Intraoperative fluid management Fischer et al., 2010 [13] Fischer M. Matsuo K. Gonen M. et al. Relationship between intraoperative fluid administration and perioperative outcome after pancreaticoduodenectomy: Results of a prospective randomized trial of acute normovolemic hemodilution compared with standard intraoperative management. Ann Surg. 2010; 252: 952 Crossref PubMed Scopus (87) Google Scholar Acute normovolemic hemodilution versus standard fluid management No difference in transfusions between groupsHemodilution group had a significant increase in pancreatic anastomotic complications likely because of increased fluid administration PBD = Preoperative biliary drainage; POD = Post-operative day. Open table in a new tab PBD = Preoperative biliary drainage; POD = Post-operative day. Perioperative Surgical Care Bundle Reduces Pancreaticoduodenectomy Wound InfectionsJournal of Surgical ResearchVol. 174Issue 2PreviewPancreaticoduodenectomy (PD) is a complex surgical procedure with a historically high morbidity rate. The goal of this study was to determine if the implementation of a 12-measure perioperative surgical care bundle (SCB) was successful in reducing infectious and other complications in patients undergoing PD compared with a routine preoperative preparation group (RPP). Full-Text PDF