External Pancreatic Stents Research Articles

Preoperative risk-stratified analysis: External versus internal pancreatic stents in pancreatoduodenectomy

BackgroundSeveral risk-stratified studies have compared the outcomes of external and internal pancreatic stents in pancreatoduodenectomy (PD), but no resolute standard for a fistula-mitigation strategy exists. The study investigated the efficacy of these stents in a preoperative risk-stratified setting. MethodsData from 285 patients who underwent PD with pancreaticojejunostomy using an external or internal stent from 2015 to 2023 were analyzed. The preoperative pancreatic fistula score (preFRS) was used to classify patients into low-risk (preFRS: 0–5) and high-risk (preFRS: 6–8) groups. ResultsPreFRS accurately predicted the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) as 0% and >40% in patients with preFRS ≤1 and ≥7, respectively. Although no significant difference was observed in postoperative outcomes in low-risk patients, the external stent significantly reduced CR-POPF (21% vs 44%, P = .024) and postpancreatectomy hemorrhage (PPH, 0% vs 19%, P = .02) in high-risk patients, leading to the superiority of the external stent in the entire cohort in terms of CR-POPF (12% vs 24%, P = .033) and PPH (1% vs 11%, P = .013). There were no significant differences in stent-related complications or pancreatic dysfunction. External stent malfunction occurred in 14% and significantly affected CR-POPF development in both low- (20% vs 0%, P < .01) and high-risk groups (60% vs 14%, P = .021). ConclusionThe external pancreatic stent showed a more beneficial effect on CR-POPF and PPH, especially in high-risk patients, without increasing other complications. Risk-stratified strategy and improving stent management might enhance postoperative outcomes.

How i do it: microscope augmented pancreaticojejunostomy.

Post-operative pancreatic fistula (POPF) is perhaps one of most dreaded pancreatoduodenectomy-related complications. Various approaches to mitigate this risk have been explored, with conflicting results and no clear consensus on the comparative superiority of any one technique. We postulate that regardless of technique, the key to reducing POPF is a robust pancreatic anastomosis with careful apposition of tissues, in particular the duct-to-mucosa anastomosis. We describe the fashioning of a pancreatojejunostomy with an external pancreatic stent in the setting of a high-risk anastomosis with help of a 10 × magnification surgical microscope. A technical description with a short, edited video is presented.

Cost Analysis of Externalized Pancreatic Stent Intervention to Mitigate Postoperative Pancreatic Fistula after Pancreatoduodenectomy: Experience of a High-Volume Latin American Center

Introduction: Postoperative pancreatic fistulas (POPF) are a frequent and severe complication of pancreatoduodenectomy. The impact of external pancreatic stent (ES) on the clinical course or cost of POPF is not well understood. We reviewed our experience of pancreatoduodenectomy in a high-volume center in Latin America. Methods: Pancreatoduodenectomies performed between 2006 and 2019 were retrospectively collected regarding demographics, operative variables, and outcomes with a six-month follow-up. POPF were graded according to ISGPS 2016. Standard prices for procedures, length of stay, and imaging only associated with fistulas were considered. Chi-square test and Kruskal-Wallis ANOVA tests were performed to demonstrate differences between ES, internal stents (IS), and no-stent (NS) patient subgroups. Results: A total of 237 pancreatoduodenectomies were performed in the study period. Subgroups were found to be 57.4%, 32.5%, and 10.1% for NS, ES, and IS, respectively. Patients in the ES subgroup had a higher POPF risk score (p < 0.001). Seventy-nine patients developed POPF, of which most were graded B. Although no difference was found in overall POPF incidence, ES was associated with less POPF grade C (p = 0.007). Cost analysis showed patients with an ES had a median cost that was less than other intervention subgroups (p = 0.5). Conclusion: Our results suggest that externalized stents are an inexpensive intervention that might reduce severity and cost associated with POPF, even in patients with higher risk for POPF. Broader cost-assessment calculation should be performed.

Small Bowel Skewer Technique for Pancreatic Stenting in Robotic Whipple

Use of an external pancreatic stent is a proven fistula mitigation strategy for high risk anastomoses during PD. We propose a novel technique for passing and securing an internal - external pancreatic stent from skin via small bowel limb and into pancreas during PJ to facilitate totally robotic reconstruction phase in high fistula risk situations. This will be several slides and a 3 minute video outing the process and technique to be presented in ´Tricks of the Trade´.

Interventions to reduce post-operative pancreatic fistula after pancreaticoduodenectomy - do we need a change of direction? a systematic review and meta-analysis

Introduction: Various perioperative interventions designed to reduce postoperative pancreatic fistula (POPF) rate after pancreaticoduodenectomy (PD) have been evaluated, but most are unsuccessful. The aim of this study was to provide a contemporary report of the efficacy of different interventions and identify areas for future investigation in this complex field. Method: A systematic review of the literature for RCTs evaluating perioperative interventions to reduce POPF after PD was performed according to the PRISMA guidelines. Meta-anlayses were performed for each intervention. Results: Some 20 interventions (n=6,628 patients, 56 studies) were identified. Four interventions reduced POPF after PD on MA: external pancreatic stent vs. no stent (OR 0.42; 95%CI: 0.25-0.70); p< 0.005); invagination PJ vs. duct to mucosa PJ (OR 0.60; 95%CI: 0.40-0.90; p=0.01); pancreaticogastrostomy (PG) vs. PJ (OR 0.69; 95%CI: 0.49-0.99; p=0.04) and omission of intraabdominal drains in patients with low risk PJ anastomoses (OR 0.52; 95%CI: 0.34-0.81; p< 0.005). Two interventions with data available from only one RCT were shown to reduce POPF: end to side vs. classic pancreaticojejunostomy (PJ) (OR 0.25; 95%CI 0.07-0.96; p=0.041) and closed suction drainage of pancreatic duct (OR 0.44; 95%CI: 0.2-0.99; p=0.045). One intervention, acute normovolaemic haemodilution, increased POPF rate in one RCT (OR 3.29 95%CI:1.11-9.77; p=0.045). Conclusions: Current evidence for perioperative interventions to reduce POPF after PD is heterogenous and frequently from underpowered RCTs. To further clinical knowledge in this complex field future RCTs should be better powered and flexible enough to involve evaluation of the promising novel strategies identified in this review.

Pancreatic fistula prediction scale for laparoscopic pancreatoduodenectomy

Introduction: Despite advancements in surgical technic and improvements in perioperative management, postoperative clinically relevant pancreatic fistula(POPF) remains the most life-threatening complication after laparoscopic pancreatoduodenectomy(LPD). Attempts for reinforcement of high-risk pancreatic anastomoses didn’t show statistically significant decrease in POPF rate. Therefore POPF-prediction become the most promising method for POPF-prevention. Methods: We established post pancreatoduodenectomy fistula risk scale(PP-FRS) derived from a retrospective cohort(n=78). Pancreatic density for the supposed resection line was estimated using preoperative CT(CT-density during delay phase, CT-attenuation coefficient) and intraoperative palpation scoring(0-4, where 4 score corresponds the firmest parenchyma). These risk factors afforded 6-points prediction model, where 5 and 6 points corresponds a high-risk patient. PP-FRS was validated retrospectively (n=31). ROC-AUC and Kendall coefficient were compared with UA-FRS prediction results for the same cohort. Results: CR-POPF occurs in 25% cases(9% - Grade B, 16% - Grade C). ROC-AUC for PP-FRS and UA-FRS was 0.793 and 0.891, respectively. Risk scores strongly correlated with fistula development(p<0.01). Kendall coefficient was 0.429 and 0.498 for PP-FRS and UA-FRS, respectively. Conclusions: A simple 6-points PP-FRS accurately predicts the risk of CR-POPF after LPD. This can be helpful during preoperative counseling, regarding the amount of planned surgical treatment(pancreatic resection or pancreatectomy); intraoperative mitigation strategy(external pancreatic stenting, refusal of somatostatin analogues). While planning a clinical trial PP-FRS can distinguish high-risk patients to form homogeneous comparing groups.

“The whole is greater than the sum of its parts” - a combined strategy to reduce post-operative pancreatic fistula after pancreaticoduodenectomy

Presenter: Maddy Lemke MD, MSc | Western University Background: Post-operative pancreatic fistula (POPF) remains a common complication following pancreaticoduodenectomy (PD), with rates of clinically relevant (CR) POPF of 10-15%. This risk is higher in subgroups of patients, which can be predicted by the fistula risk score. Multiple methods have been employed to reduce risk of POPF following PD, including draining the surgical site, use of medications, and anastomotic techniques. In addition, research in other areas has shown the effect of combining best treatments can together offer greater benefit. This study aims to examine the rates of POPF and peri-operative morbidity for high risk patients undergoing PD where the following strategies have been employed: 1. External pancreatic stent 2. Peri-operative hydrocortisone, with first dose given intra-operatively followed by 100 mg IV q8h for 24h for three days (9 doses) 3. Inner invaginating layer 4. Blumgart outer layer Methods: Patients undergoing PD between January and December 2020 were abstracted from a single institution prospectively collected retrospective database (London Health Sciences Centre, London, Ontario). Information on pre-operative characteristics, peri-operative interventions to reduce POPF, and post-operative outcomes were collected. Patients undergoing all four strategies to reduce POPF outlined above were included in the final study. Patients were selected to undergo such interventions at surgeon discretion when suspected to have an elevated risk of CR-POPF. The following outcomes were reported: CR-POPF, surgical site infection, percutaneous drain insertion, post-operative complication (Clavien-Dindo Grade III or higher) within 30 days, length of stay, re-admission with 30 days and re-operation within 30 days. All outcomes were reported as median with interquartile range (IQR) or frequencies with percentages. Results: A total of 14 patients underwent all four interventions. The median age was 64 (IQR 57-69) and body mass index 30 (IQR 23-32). The medial fistula risk score was 6 (IQR 7-9). Four patients were high risk according to the fistula risk score, six intermediate and four low risk. One patient (7.1%) experienced a CR-POPF; this patient had a high fistula risk score. For comparison, the weighted average of the expected CR-POPF rate is 15.4% and the rate at this institution in July 2020 was 13%. Patient outcomes are described in Table 1. Conclusion: Interventions to decrease the rate of CR-POPF following PD are important but challenging. A combined approach of utilizing and studying multiple effective strategies shows promise in reducing CR-POPF rate for patients with elevated risk of CR-POPF. Further research is required to demonstrate an improved rate of CR-POPF in these patients when compared to similar controls.

Propensity score-matched analysis of internal stent vs external stent for pancreatojejunostomy during pancreaticoduodenectomy: Japanese-Korean cooperative project

BackgroundSeveral studies comparing internal and external stents have been conducted with the aim of reducing pancreatic fistula after PD. There is still no consensus, however, on the appropriate use of pancreatic stents for prevention of pancreatic fistula. This multicenter large cohort study aims to evaluate whether internal or external pancreatic stents are more effective in reduction of clinically relevant pancreatic fistula after pancreaticoduodenectomy (PD). MethodsWe reviewed 3149 patients (internal stent n = 1,311, external stent n = 1838) who underwent PD at 20 institutions in Japan and Korea between 2007 and 2013. Propensity score matched analysis was used to minimize bias from nonrandomized treatment assignment. The primary endpoint was the incidence of clinically relevant pancreatic fistula. This study was registered on the UMIN Clinical Trials Registry (UMIN000032402). ResultsAfter propensity score matched analysis, clinically relevant pancreatic fistula occurred in more patients in the external stents group (280 patients, 28.7%) than in patients in the internal stents group (126 patients, 12.9%) (OR 2.713 [95% CI, 2.139–3.455]; P < 0.001). In subset analysis of a high-risk group with soft pancreas and no dilatation of the pancreatic duct, clinically relevant pancreatic fistula occurred in 90 patients (18.8%) in internal stents group and 183 patients (35.4%) in external stents group. External stents were significantly associated with increased risk for clinically relevant pancreatic fistula (OR 2.366 [95% CI, 1.753–3.209]; P < 0.001). ConclusionPropensity score matched analysis showed that, regarding clinically relevant pancreatic fistula after PD, internal stents are safer than external stents for pancreaticojejunostomy.

External pancreatic stents after pancreaticoduodenectomy reduce pancreatic fistula rates and severity

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.

High Risk Pancreatic Anastomosis: Does External Pancreatic Stent Help?

Introduction: The role of external pancreatic stent in pancreatic anastomosis has not been clearly defined In- Hitherto. Method: Patients undergoing high risk pancreatico-jejunostomy after pancreatico-duodenectomy (as defined by small size duct (<3mm) and soft pancreas) were divided into two groups based on the type of trans-anastomotic stent used into External or Internal stent group and the outcomes were evaluated. Result: 99 of the 275 patients had small pancreatic duct. 19 underwent external stenting and 80 had internal stent. Both the groups were comparable in terms of demographic data, presence of jaundice, comorbidity, diabetes mellitus, need for biliary drainage, mean duct diameter, duration of surgery, blood loss. The overall incidence of pancreatic fistula was similar between the two groups (21% vs 20%). The incidence of clinically relevant fistula (grade B & C) was higher in patients with external stent (10.5% vs 5%). Overall Incidence of DGE (42% vs 51%) and post pancreatectomy haemorrhage (0 vs 6.25%) were comparable between the groups. However, patients with external pancreatic stent had a higher incidence of Grade C DGE (10.5% vs 3.75%, p = 0.063). There were three stent related complications, slippage of external stent in one and stent related pancreatitis in two (both with internal stent). The incidence of intra-abdominal collection (31.5% vs 15%, p = 0.09), SSI (47.5% vs 25%) and deep space infections (60% vs 36%, p = 0.08) were higher with external stent. Grade IIIb or more complications were (6.25% vs 3.25%) . Mean in- hospital stay was comparable between the two groups (18.9 vs 14.3 days). There was no difference in mortality (5.2% vs 3.75%). Conclusion: External pancreatic stent neither decreased the incidence nor the severity of pancreatic fistula in patients with high risk anastomosis. instead external stent was associated with a higher incidence of intra-abdominal infective complications.

Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis.

Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis. The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy (PD). We searched PubMed, EMBASE, the Cochrane Library and Web of Science databases until the end of December, 2014. Studies comparing outcomes of external vs. internal stent placement in PD were eligible for inclusion. Included literature was extracted and assessed by two independent reviewers. Seven articles were identified for inclusion: three randomized controlled trials (RCTs) and four observational clinical studies (OCS). The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula (PF) in total [odds ratio (OR) =0.69; 95% confidence interval (CI), 0.48-0.99; P=0.04], PF in soft pancreas (OR =0.30; 95% CI, 0.16-0.56; P=0.0002) and delayed gastric emptying (DGE) (OR =0.58; 95% CI, 0.38-0.89; P=0.01) compared with internal stents. There were no significant differences in other postoperative outcomes between two stenting methods, including postoperative morbidity (OR =0.93; 95% CI, 0.39-2.23; P=0.88), overall mortality (OR =0.70; 95% CI, 0.22-2.25; P=0.55), and intra-abdominal collections (OR =0.67; 95% CI, 0.26-1.71; P=0.40). Based upon this meta-analysis, the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE. Due to the limited number of original studies, more RCTs are needed to further support our result and clarify the issue.

Successful surgical internal drainage of postoperative pancreatic pseudocyst through pancreaticojejunostomy with distal pancreatectomy: a case report.

Pancreatic pseudocyst is usually treated by percutaneous external drainage, endoscopic internal or external drainage, or surgical internal drainage such as cystogastrostomy. Surgical external drainage is an option if these procedures fail. We describe a case of a 70-year-old man with a pancreatic body pseudocyst that developed postoperatively. It was improved by endoscopic external drainage, and the stent was changed to an internal stent. However, surgery was required as the pseudocyst grew again. A direct approach to the pseudocyst was not possible because of severe adhesion. A distal pancreatectomy with pancreaticojejunostomy was performed, and an external pancreatic stent tube was inserted from the cut end into the duodenum to drain the pseudocyst. One month later, the pseudocyst disappeared, and the stent was removed.

Analysis of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy.

To explore the morbidity and risk factors of postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy. The data from 196 consecutive patients who underwent pancreaticoduodenectomy, performed by different surgeons, in the General Hospital of the People's Liberation Army between January 1(st), 2013 and December 31(st), 2013 were retrospectively collected for analysis. The diagnoses of POPF and clinically relevant (CR)-POPF following pancreaticoduodenectomy were judged strictly by the International Study Group on Pancreatic Fistula Definition. Univariate analysis was performed to analyze the following factors: patient age, sex, body mass index (BMI), hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pancreatic duct diameter, pylorus preserving pancreaticoduodenectomy, pancreatic drainage and pancreaticojejunostomy. Multivariate logistic regression analysis was used to determine the main independent risk factors for POPF. POPF occurred in 126 (64.3%) of the patients, and the incidence of CR-POPF was 32.7% (64/196). Patient characteristics of age, sex, BMI, hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pylorus preserving pancreaticoduodenectomy and pancreaticojejunostomy showed no statistical difference related to the morbidity of POPF or CR-POPF. Pancreatic duct diameter was found to be significantly correlated with POPF rates by univariate analysis and multivariate regression analysis, with a pancreatic duct diameter ≤ 3 mm being an independent risk factor for POPF (OR = 0.291; P = 0.000) and CR-POPF (OR = 0.399; P = 0.004). The CR-POPF rate was higher in patients without external pancreatic stenting, which was found to be an independent risk factor for CR-POPF (OR = 0.394; P = 0.012). Among the entire patient series, there were three postoperative deaths, giving a total mortality rate of 1.5% (3/196), and the mortality associated with pancreatic fistula was 2.4% (3/126). A pancreatic duct diameter ≤ 3 mm is an independent risk factor for POPF. External stent drainage of pancreatic secretion may reduce CR-POPF mortality and POPF severity.

Clinical value of transanastomotic pancreatic ductal stents placement after pancreaticoduodenectomy: a meta analysis

Objective To systematically review the clinical efficacy of transanastomotic pancreatic ductal stents placement after pancreaticoduodenectomy.Methods According to the Cochrane reviewers handbook (version 5.0 ),literatures were retrived from PubMed,Embase,Cochrane,VIP database,China Biology Medicine disc and CNKI database,and then the quality of the literatures was analyzed.Meta analysis was carried out using the RevMan software ( version 5.0.18 ).A random effects model was adopted,and the results of the meta analysis were presented with odds ratio (OR) and 95％ confidence interval (95％ CI).Results Four randomized controlled trials including 557 patients were retrieved.External stents were used in 160 patients and internal stents in 115 patients.The results of meta analysis showed no significant difference in the rate of fistula,overall postoperative morbidity and mortality between patients who did or did not receive pancreatic stents placement (OR =0.66,0.70,0.63,P ＞ 0.05 ).There were significant differences in the rate of pancreatic fistula and overall postoperative morbidity between patients who received external pancreatic stents placement and those did not receive pancreatic stents placement ( OR =0.48,0.55,P ＜ 0.05 ).There was no significant difference in the mortality rate between patients who received external pancreatic stents placement and those did not receive pancreatic stents placement (OR =0.71,P ＞ 0.05 ).There were no significant difference in the incidence of pancreatic fistula,overall postoperative morbility and mortality between patients who received internal pancreatic stents placement and those did not receive pancreatic stents placement ( x2 =0,0.75,2.11,P ＞ 0.05 ).Conclusions External pancreatic stents placement after pancreaticoduodenectomy can reduce the incidence of postoperative complications.The effects of internal pancreatic stents placement need to be proved by further highquality prospective randomized trials. Key words: Pancreatic neoplasms; Pancreaticoduodenectomy; Pancreatic ductal stents; Meta analysis

Optimizing pancreatectomy outcomes: Follow the evidence

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

Does Prior Adjuvant Chemoradiotherapy Lead to a Safer Pancreatoduodenectomy?

The article by Cheng et al. is another attempt to compare the effects of preoperative versus postoperative adjuvant chemoradiotherapy (CRT) for presumably localized pancreatic adenocarcinoma by retrospective analysis of two nonrandomized treatment cohorts. Because the only significant differences in morbidity within the preoperative and postoperative cohorts in this study were in pancreatic leak and intra-abdominal abscess formation (favoring the preoperative CRT cohort), the primary focus of this study was the relative incidence of postoperative pancreatic leaks. The authors aver that preoperative CRT reduces the incidence of both pancreatic leaks and leak-associated morbidity and mortality, and they even go so far as to recommend preoperative CRT in those with ampullary cancer to decrease postoperative leaks. Is this information new, true, or relevant? Ishikawa et al. were the first to examine the question. They described two retrospective nonrandomized cohorts: one treated with preoperative radiotherapy (RT) and the other not. Patients with fistulas were defined as those with amylase levels >2000 U/L in their drains for >1 week. Furthermore, a fistula was defined as major if either bile was seen in the drain fluid or the fistulogram showed entry of dye into the jejunum (all patients had pancreatojejunostomy over external pancreatic stents). Minor fistulas were those without either of these findings but with the defined drain amylase levels. One of 22 patients with preoperative RT developed a major fistula, and 1 of 54 patients without preoperative RT had a major fistula; 3 of 54 had minor fistulas that became major, and 6 had minor fistulas. Because the two immediate major fistulas were attributed to premature withdrawal or occlusion of pancreatic stents, these cases were excluded. The 9 of 53 patients with minor or minor changing to major fistulas without RT were compared with the 0 of 21 patients without fistulas in the post-RT cohort: differences were significant (P = .05). Statistical significance here, however, required that the two major leaks be omitted. Clearly, those receiving preoperative RT seemed to do no worse than those without it. Lowy et al. examined pancreatic leak in patients with and without preoperative CRT in a randomized study of perioperative octreotide. Their definition of fistula was either biochemical (defined as increased drain amylase at postoperative day 3) or clinical (requiring reoperation or drainage). Whereas none of the 46 patients with protocol-based preoperative CRT for pancreatic cancer developed clinical pancreatic fistulas, there were enough with biochemical leaks that no difference was shown between those treated with preoperative CRT and those who had surgery first. Again, preoperative CRT seemed not to be a deterrent to safe recovery from pancreatoduodenectomy, but leaks were no less frequent than in those treated without preoperative therapy. Cheng et al. defined a leak as any drainage fluid at any time after surgery with a value three times that of serum amylase. Multivariate analysis showed that preoperative CRT produced a statistically significant decrease in pancreatic leaks (10.1% vs. 43.3%; P < .001). For those with pancreatic head cancer, 3 (4.8%) of 62 of those with preoperative CRT had a fistula, Received October 19, 2005; accepted October 26, 2005; published online January 1, 2006. Address correspondence and reprint requests to: John Hoffman, MD; E-mail: jp_hoffman@fccc.edu

In situ vs ex situ pancreatic duct stents of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy with billroth I-type reconstruction.

Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, and an external stent of pancreaticojejunostomy has been recommended to prevent pancreatic fistula. Duct-to-mucosa pancreaticojejunostomy should not require placement of an external stent. Nonrandomized control study. University hospital. Seventy-four patients undergoing pancreaticoduodenectomy with duct-to-mucosa pancreaticojejunostomy were allocated to either the ex situ group (external pancreatic stent drainage) or the in situ group (no external drainage). Operative mortality; postoperative complications, particularly pancreatic fistula; and patency of duct-to-mucosa pancreaticojejunostomy. Preoperative factors, indicated disorders, and intraoperative factors were similar for both groups. Mortality rates were 1% (1/74) overall, 3% (1 death) for the in situ group, and 0% for the ex situ group. Morbidity rates were 32% (12/37) for the in situ group and 35% (13/37) for the ex situ group. The incidence of pancreatic fistula was 5.4% and was the same for the in situ and ex situ groups. The incidence of delayed gastric emptying was similar for the in situ (19% [7/37]) and ex situ (14% [5/37]) groups. Ampullary tumors and pancreatic ducts 2 mm or less in diameter had a higher incidence of pancreatic fistula, but the incidence was similar in both treatment groups. Nasogastric tube drainage day, the median hospital stay, and pancreaticojejunostomy patency were similar in both groups. The results were considered to show equivalent outcomes for ex situ and in situ pancreatic stenting of the duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy. The use of transanastomotic stents has to be selective according to the individual characteristics of each patient. We recommend their use with ampullary tumors or small ducts (< or =2 mm).