What is the optimal surgical strategy for grade-C pancreatic fistula after pancreaticoduodenectomy? A large retrospective multicenter study

Abstract

Background: The optimal surgical strategy for grade-C POPF is controversial. We aim to identify the optimal surgical strategy for grade-C postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD). Methods: This retrospective study involved nine high-volume Chinese institutions, in which, 5115 patients underwent PD between January 1, 2012 and December 31, 2016. Of them, 53 (1.04%) underwent re-laparotomy for grade-C POPF. We retrospectively reviewed their clinical data. We compared the re-laparotomy techniques used in terms of their outcomes and evaluated risk factors for unfavorable outcomes by using multivariate regression analysis. Results: The following surgical strategies for re-laparotomy were used in this cohort: external wirsungostomy (20 patients, 37.7%), re-pancreaticojejunostomy (15 patients, 28.3%), simple peritoneal drainage (15 patients, 28.3%), completion pancreatectomy (2 patients, 3.77%), and pancreatogastrostomy (1 patient, 1.89%). Postoperative hospital stay in the external wirsungostomy group was significantly shorter than that in the simple peritoneal drainage group (20 days vs. 38 days, P = 0.03), and tended to be lower than that in the re-pancreaticojejunostomy group (20 days vs. 34.5 days, P = 0.068). Mortality and morbidity were comparable among the above three groups. Multivariate regression analysis showed that the presence of biochemical leakage or grade-B POPF prior to the development of grade-C POPF (odds ratio: 0.20, 95% confidence interval: 0.05–0.82) was independently associated with unfavorable outcomes. Conclusion: Pancreas-preserving approaches were preferred for grade-C POPF. External wirsungostomy was associated with shorter postoperative hospital stay. Patients with less severe POPF before progressing to grade-C POPF may have better outcomes after re-laparotomy.