Pancreatico-Jejunostomy Fistula After Pancreaticoduodenectomy: Where Do We Stand? Results from an International Survey.

How to reduce grade C postoperative pancreatic fistula (POPF) incidence after pancreaticoduodenectomy (PD) is the pursuit of pancreatic surgeons. This study introduced an innovative pancreaticojejunostomy (PJ) technique with a complete set of perioperative management. All 144 patients in this single-center retrospective cohort study underwent the same PJ technique and perioperative management. The primary endpoint was grade C POPF incidence. The secondary endpoints were grade B POPF rate, drain fluid amylase level, complications, hospital stay duration, and mortality. Risk factors for clinically-relevant POPF (CR-POPF) were assessed by logistic regression analysis. No patient (0.0%) experienced grade C POPF, while 44 (30.6%) developed grade B. No in-hospital death was recorded. Multivariate analysis found relatively high body mass index, laparoscopic surgery, and soft or moderate pancreatic texture independent risk factors for CR-POPF. Our novel PJ anastomosis with modified perioperative management helped avoid grade C POPF. However, grade B POPF incidence was relatively high to some extent because of the enhanced management itself.

Chen’s continuous suture technique for invaginated pancreaticojejunostomy following pancreaticoduodenectomy with no grade B/C POPF and zero motality in 644 patients with soft pancrease and small pancreatic duct

Postoperative pancreatic fistula (POPF) is a major source of morbidity after pancreaticoduodenectomy (PD). The purpose of this retrospective study comparing one-layer pancreaticojejunostomy (PJ) with two-layer PJ after PD was to evaluate whether the one-layer duct-to-mucosa PJ after PD can reduce the incidence of POPF.A total of 194 consecutive patients who underwent PD by one surgeon (Y. Miao) from January 2011 to February 2014 were included in this study. Among those patients, 104 underwent one-layer PJ (one-layer group) and 90 patients underwent two-layer PJ (two-layer group), respectively. Preoperative clinicopathologic features, intraoperative parameters, postoperative morbidity with focus on POPF, were compared between the two groups.The overall incidence of POPF was 19.6% (38/194), and clinically relevant grade B/C POPF rates were 8.6% (16/194) and 3.1% (6/194), respectively. There were no differences in patients' demographics and operation related factors between the two groups. However, the incidence of POPF in the one-layer group was significantly lower than in two-layer group (13.5% [14/104 patients] and 26.7% [24/90 patients] respectively; p=0.021). The median postoperative hospital stay was also significantly lower in the one-layer group compared to the two-layer group (13 days vs. 15 days, p=0.035). One patient in two-layer group died due to postoperative hemorrhage.One-layer duct-to-mucosa pancreaticojejunostomy is a simple and easy technique for pancreaticojejunal anastomosis after PD, and can reduce the POPF rate in comparison to the two-layer technique.

Despite a large number of studies, the ideal technique of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) remains debatable. We compared the two most common techniques of PJ (duct-to-mucosa and dunking) in a randomized trial. This open-label randomized trial was done at a tertiary care center from January 2009 to October 2015. Patients with resectable periampullary tumours with a pancreatic duct diameter ≥2 mm, requiring PD were randomly assigned to one of the two techniques using computer generated random numbers. The primary outcome was postoperative pancreatic fistula (POPF) rate and secondary outcomes were frequency of other postoperative complications. A total of 193 patients were randomized and analyzed (intention-to-treat analysis), 97 in duct-to-mucosa and 96 in dunking group. Both groups were comparable for baseline demographic and clinical profiles. The incidence of POPF in the entire study group was 23.8%. There was no statistically significant difference between the two groups (24.7% vs 22.9%, P = 0.71). Similarly, the incidence of grades B and C (clinically significant) POPF was comparable (16.5% vs 13.5%, P = 0.57). Both groups were comparable with respect to the secondary outcomes. The duct-to-mucosa technique of PJ after PD is not superior to the dunking technique with respect to POPF rate. (CTRI/2010/091/000531).

Objective To explore the effect of modified parachute-like pancreaticojejunostomy on incidence of pancreatic fistula after pancreatoduodenectomy. Methods The clinical data of 123 patients undergoing pancreatoduodenectomy with application of duct-to-mucoca pancreaticojejunostomy were analyzed retrospectively. Interrupted suture technique and modified parachute suture technique were performed in 61 and 62 patients, respectively. Postoperative complications, data during and after pancreatoduodenectomy between two groups were compared. Results There were no significant differences in pancreatic texture, pylorus preservation, pancreatic duct drainage, intraoperative blood loss, and operating time between two groups (P>0.05). No significant differences between two groups were observed on postoperative morbidity of gastrointestinal or intraabdominal hemorrhage, delayed gastric emptying, and intraabdominal abscess (P>0.05). Although there was no significant difference in the incidence of postoperative pancreatic fistula (P>0.05), the grades B/C postoperative pancreatic fistula in modified parachute suture group was significantly less than in interrupted suture group (P<0.05). Conclusions Modified parachute-like pancreaticojejunostomy technique in pancreatoduodenectomy can reduce the incidence of severe postoperative pancreatic fistula. Key words: Pancreaticojejunostomy/MT; Pancreaticoduodenectomy/AE; Pancreatic fistula/ET/PC; Intestinal fistula/ET/PC

Correlation between Fistula Risk Score with Post Operative Pancreatic Fistula - A Single Centre Indian Study

External pancreatic stents after pancreaticoduodenectomy reduce pancreatic fistula rates and severity

BackgroundPrevious studies reported a higher rate of postoperative pancreatic fistula after minimally invasive distal pancreatectomy compared to open distal pancreatectomy. It is unknown whether the clinical impact of postoperative pancreatic fistula after minimally invasive distal pancreatectomy is comparable with that after open distal pancreatectomy. We aimed to compare not only the incidence of postoperative pancreatic fistula, but more importantly, also its clinical impact. MethodsThis is a post hoc analysis of a multicenter randomized trial investigating a possible beneficial impact of a fibrin patch on the rate of clinically relevant postoperative pancreatic fistula (International Study Group for Pancreatic Surgery grade B/C) after distal pancreatectomy. Primary outcomes of the current analysis are the incidence and clinical impact of postoperative pancreatic fistula after both minimally invasive distal pancreatectomy and open distal pancreatectomy. ResultsFrom October 2010 to August 2017, 252 patients undergoing distal pancreatectomy were randomized, and data of 247 patients were available for analysis: 87 minimally invasive distal pancreatectomy and 160 open distal pancreatectomies. The postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was significantly higher than that after open distal pancreatectomy (28.7% vs 16.9%, P = .029). More patients were discharged with an abdominal surgical drain after minimally invasive distal pancreatectomy compared to open distal pancreatectomy (30/87, 34.5% vs 26/160, 16.5%, P = .001). In patients with postoperative pancreatic fistula, additional percutaneous catheter drainage procedures were performed less often (52% vs 84.6%, P = .012), with fewer drainage procedures (median [range], 2 [1–4] vs 2, [1–7], P = .014) after minimally invasive distal pancreatectomy. ConclusionIn this post hoc analysis, the postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was higher than that after open distal pancreatectomy, whereas the clinical impact was less.

Postoperative pancreatic fistula (POPF) is one of the most fatal complications of pancreatoduodenectomy. POPF is caused by leakage of pancreatic juice from the pancreatic anastomosis into the abdomen, leading to intra-abdominal complications, such as severe surgical site infections, significant postoperative hemorrhage and multi-organ failure. Many risk factors for POPF have been identified, including patient and surgical technique factors. Our objective was to review the literature on surgical techniques to prevent POPF after pancreatoduodenectomy. Pancreatogastrostomy (PG) has the same incidence of POPF as pancreatojejunostomy (PJ). For PJ anastomosis, the interrupted suture and Blumgart technique also had the same rate of POPF. For soft pancreas it was shown that invagination was better than duct-to-mucosa anastomosis to prevent the POPF. However, a pancreatic duct stent cannot decrease the rate of POPF over the non-stent group. Intraperitoneal drainage cannot prevent POPF, however, it can detect POPF more than the non-drain group. Laparoscopic PD (LPD) and robotic-assisted PD (RAPD) were comparable in rates of POPF with open PD. Overall, no conclusion has been reached regarding the best surgical technique. In any individual case, the surgical technique should be selected based on the surgeon’s experience in reducing the incidence of POPF, and other complications.

Postoperative pancreatic fistula (POPF) is the most severe complication after pancreaticoduodenectomy (PD), and this study investigates the effects of single-layer and double-layer pancreaticojejunostomy (PJ) on POPF. Four electronic databases were systematically searched until March 2024: PubMed, Web of Science, Embase, and Cochrane Library. Statistical analysis was performed using Review Manager (RevMan) software. Mean difference (MD) or odds ratios (OR) with 95% confidence intervals (CI) were used to indicate continuous or dichotomous variables, respectively. Ten studies were included, comprising 1811 patients. Compared to the double-layer PJ group, the single-layer PJ group had a similar POPF rate (OR=0.73; P=0.28) and grade C POPF rate (OR=0.55; P=0.12), but a lower grade B POPF rate (OR=0.50; 95% CI: 0.31-0.81; P=0.005). The clinically relevant POPF (CR-POPF) rate was lower in the single-layer PJ group (OR=0.47; 95% CI: 0.31-0.73; P<0.001), especially in the 2017 International Study Group of Pancreatic Surgery (ISGPS) criteria subgroup (OR=0.44; 95% CI: 0.27-0.73; P=0.001), the China subgroup (OR=0.41; 95% CI: 0.26-0.64; P<0.001), and the minimally invasive subgroup (OR=0.40; 95% CI: 0.22-0.74; P=0.003). Compared with double-layer PJ, single-layer PJ after PD might reduce the incidence of CR-POPF.

Background:One of the most clinically significant current discussions is the optimal pancreaticojejunostomy (PJ) technique for pancreaticoduodenectomy (PD). We performed a meta-analysis to compare duct-to-mucosa and invagination techniques for pancreatic anastomosis after PD.Methods:A systematic search of PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov up to June 1, 2018 was performed. Randomized controlled trials (RCTs) comparing duct-to-mucosa versus invagination PJ were included. Statistical analysis was performed using RevMan 5.3 software.Results:Eight RCTs involving 1099 patients were included in the meta-analysis. The rate of postoperative pancreatic fistula (POPF) was not significantly different between the duct-to-mucosa PJ (110/547, 20.10%) and invagination PJ (98/552, 17.75%) groups in all 8 studies (risk ratio, 1.13; 95% CI, 0.89–1.44; P = .31). The subgroup analysis using the International Study Group on Pancreatic Fistula criteria showed no significant difference in POPF between duct-to-mucosa PJ (97/372, 26.08%) and invagination PJ (78/377, 20.68%). No significant difference in clinically relevant POPF (CR-POPF) was found between the 2 groups (55/372 vs 40/377, P = .38). Additionally, no significant differences in delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, operation time, or length of stay were found between the 2 groups. The overall morbidity and mortality rates were not significantly different between the 2 groups.Conclusion:The duct-to-mucosa technique seems no better than the invagination technique for pancreatic anastomosis after PD in terms of POPF, CR-POPF, and other main complications. Further studies on this topic are therefore recommended.

Background: Patients at high risk for postoperative pancreatic fistula (POPF) still represent a major concern after pancreaticoduodenectomy (PD). While several meta-analyses of randomized controlled trials (RCTs) have supported pancreaticogastrostomy (PG), other trials have highlighted the superiority of pancreaticojejunostomy (PJ) with externalized transanastomotic stents. This RCT compared PJ to PG, both with externalized transanastomotic stents, specifically in the setting of high POPF risk. Methods: Patients undergoing elective PD were prospectively enrolled. The Fistula Risk Score was intraoperatively calculated to identify patients at high risk for POPF that were subsequently randomized according to a 1:1 allocation. The primary endpoint was POPF. The secondary endpoints were Clavien-Dindo ≥ 3 morbidity, postpancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE) and average complication burden (ACB). Findings: The study lasted from July 2017 to March 2019. A total of 604 patients were screened for eligibility, 82 were at high risk for POPF (FRS 7 - 10), and 72 were randomized to PG (n= 36) or PJ (n= 36). There was no significant difference in the incidence of POPF (50.0 vs. 38.9%, p= 0.477) between PG and PJ, but in the patients who developed a POPF, the ACB was lower for PJ (0.39 vs. 0.25, p= 0.039). Additionally, the rates of PPH (38.9 vs 25.0%, p= 0.312) and DGE (44.4 vs. 50.0%, p= 0.814) were similar, but patients who underwent PG presented a significantly higher incidence of Clavien-Dindo ≥ 3 morbidity (47.2 vs. 22.2%, p= 0.047). Interpretation: In patients at the highest risk for POPF, PG and PJ show similar rates of POPF. However, PG was associated with an increased incidence of Clavien-Dindo ≥ 3 morbidity and with an increased ACB in the patients who developed a POPF. Clinical Trial Registration: NCT03212196 (https://www.clinicaltrial.gov). Funding Statement: This study did not receive any financial support. Declaration of Interests: All other authors declare no competing interests. Ethical Approval Statement: The study protocol was approved by the local ethics committee (Ethics Committee of the provinces of Verona and Rovigo, approval number 1041CESC). The trial was performed in accordance with the good clinical practice guidelines, the principles of the Declaration of Helsinki, and the Consolidated Standards of Reporting Trials (CONSORT) guidelines. All eligible patients provided written informed consent at the time of hospital admission.

Pancreaticojejunostomy With Externalized Stent vs Pancreaticogastrostomy With Externalized Stent for Patients With High-Risk Pancreatic Anastomosis A Single-Center, Phase 3, Randomized Clinical Trial

Prognostic Factors in Neuroendocrine Tumors of the Pancreas: Category: Clinical science - pancreatic cancer.

The diagnostic value of pancreatic amylase analyses from prophylactic abdominal drainage in identifying pancreatic fistula following pancreaticoduodenectomy