Pancreaticoduodenectomy with Pancreaticogastrostomy and an External Pancreatic Stent in Risky Patients: a Propensity Score-matched Analysis

Overview

Journal Langenbecks Arch Surg

Specialty General Surgery

Date 2024 Dec 9

PMID 39652097

Authors

Mohamed Abdelwahab

Ayman El Nakeeb

Ahmed Shehta

Hosam Hamed

Ahmed M Elsabbagh

Mohamed Attia

Reham Abd El-Wahab

Talaat Abd Allah

Mahmoud Abdelwahab Ali

Affiliations

Soon will be listed here.

Abstract

Background: There is an ongoing debate about the most appropriate method for reconstructing the pancreas after a pancreaticoduodenectomy (PD). This study assessed the impact of pancreaticogastrostomy (PG) with an external pancreatic stent on postoperative outcomes following PD in high-risk patients.

Patients And Methods: This study involves a propensity score-matched analysis of high-risk patients who underwent PD with PG reconstruction. The primary outcome measure was the occurrence of Postoperative Pancreatic Fistula (POPF). Secondary outcomes included operative time, intraoperative blood loss, length of hospital stay, re-exploration rate, as well as postoperative morbidity and mortality rates.

Results: The study included 78 patients; 26 patients underwent PD with Pancreatogastrostomy (PG) and an external pancreatic stent, while 52 underwent PG without a pancreatic stent. Blood loss and operative time did not significantly differ between the two groups. The overall postoperative morbidity was higher in the group without a stent than in the stented group (34.6% vs. 15.4%, P = 0.06). No patient in the pancreatic stent group developed a clinically relevant POPF; however, in the non-stented group of PG, 17.3% developed POPF. There were no cases of hospital mortality in the stented group. However, in the non-stented group, two hospital mortality happened (one case was due to the systemic inflammatory response syndrome (SIRS) secondary to POPF grade C, and the other was due to pulmonary embolism.

Conclusion: PG with an external pancreatic stent results in fewer clinically relevant pancreatic fistulas, a decrease in postoperative morbidities, and a non-existent mortality rate in high-risk patients.

References

Are C, Dhir M, Ravipati L . History of pancreaticoduodenectomy: early misconceptions, initial milestones and the pioneers. HPB (Oxford). 2011; 13(6):377-84. PMC: 3103093. DOI: 10.1111/j.1477-2574.2011.00305.x. View

El Nakeeb A, Salah T, Sultan A, El Hemaly M, Askr W, Ezzat H . Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J Surg. 2013; 37(6):1405-18. DOI: 10.1007/s00268-013-1998-5. View

Schuh F, Mihaljevic A, Probst P, Trudeau M, Muller P, Marchegiani G . A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery. Ann Surg. 2021; 277(3):e597-e608. PMC: 9891297. DOI: 10.1097/SLA.0000000000004855. View

Kurumboor P, Palaniswami K, Pramil K, George D, Ponnambathayil S, Varma D . Octreotide Does Not Prevent Pancreatic Fistula Following Pancreatoduodenectomy in Patients with Soft Pancreas and Non-dilated Duct: A Prospective Randomized Controlled Trial. J Gastrointest Surg. 2015; 19(11):2038-44. DOI: 10.1007/s11605-015-2925-x. View

Lei P, Fang J, Huang Y, Zheng Z, Wei B, Wei H . Pancreaticogastrostomy or pancreaticojejunostomy? Methods of digestive continuity reconstruction after pancreaticodudenectomy: a meta-analysis of randomized controlled trials. Int J Surg. 2014; 12(12):1444-9. DOI: 10.1016/j.ijsu.2014.10.024. View

El Nakeeb A, El Hemaly M, Askr W, Ellatif M, Hamed H, Elghawalby A . Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized study. Int J Surg. 2015; 16(Pt A):1-6. DOI: 10.1016/j.ijsu.2015.02.002. View

Patel K, Teta A, Sukharamwala P, Thoens J, Szuchmacher M, DeVito P . External pancreatic duct stent reduces pancreatic fistula: a meta-analysis and systematic review. Int J Surg. 2014; 12(8):827-32. DOI: 10.1016/j.ijsu.2014.06.008. View

Cai H, Lu F, Zhang M, Cai Y, Wang X, Li Y . Pancreaticojejunostomy without pancreatic duct stent after laparoscopic pancreatoduodenectomy: preliminary outcomes from a prospective randomized controlled trial. Surg Endosc. 2022; 36(5):3629-3636. DOI: 10.1007/s00464-021-08909-w. View

Wente M, Veit J, Bassi C, Dervenis C, Fingerhut A, Gouma D . Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007; 142(1):20-5. DOI: 10.1016/j.surg.2007.02.001. View

10.

Dindo D, Demartines N, Clavien P . Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240(2):205-13. PMC: 1360123. DOI: 10.1097/01.sla.0000133083.54934.ae. View

11.

Parray A, Chaudhari V, Shrikhande S, Bhandare M . "Mitigation strategies for post-operative pancreatic fistula after pancreaticoduodenectomy in high-risk pancreas: an evidence-based algorithmic approach"-a narrative review. Chin Clin Oncol. 2022; 11(1):6. DOI: 10.21037/cco-22-6. View

12.

Gupta A, Nandi S, Tiwari S, Choraria A, Chaudhary V . 32 Consecutive Cases of Whipple's Operation with Single-Layer End to Side Dunking Pancreatojejunostomy Without Any Pancreatic Fistula: Our Institutional Experience. Indian J Surg Oncol. 2018; 9(2):162-165. PMC: 5984845. DOI: 10.1007/s13193-017-0707-5. View

13.

Qin H, Luo L, Zhu Z, Huang J . Pancreaticogastrostomy has advantages over pancreaticojejunostomy on pancreatic fistula after pancreaticoduodenectomy. A meta-analysis of randomized controlled trials. Int J Surg. 2016; 36(Pt A):18-24. DOI: 10.1016/j.ijsu.2016.10.020. View

14.

Xiong J, Altaf K, Mukherjee R, Huang W, Hu W, Li A . Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy. Br J Surg. 2012; 99(8):1050-61. DOI: 10.1002/bjs.8788. View

15.

Zhou Y, Zhou Q, Li Z, Lin Q, Gong Y, Chen R . The impact of internal or external transanastomotic pancreatic duct stents following pancreaticojejunostomy. Which one is better? A meta-analysis. J Gastrointest Surg. 2012; 16(12):2322-35. DOI: 10.1007/s11605-012-1987-2. View

16.

Markar S, Vyas S, Karthikesalingam A, Imber C, Malago M . The impact of pancreatic duct drainage following pancreaticojejunostomy on clinical outcome. J Gastrointest Surg. 2012; 16(8):1610-7. DOI: 10.1007/s11605-012-1852-3. View

17.

Zhou Y, Yang C, Wang S, Chen J, Li B . Does external pancreatic duct stent decrease pancreatic fistula rate after pancreatic resection?: a meta-analysis. Pancreatology. 2011; 11(3):362-70. DOI: 10.1159/000330222. View

18.

Pessaux P, Sauvanet A, Mariette C, Paye F, Muscari F, Sa Cunha A . External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg. 2011; 253(5):879-85. DOI: 10.1097/SLA.0b013e31821219af. View

19.

Poon R, Fan S, Lo C, Ng K, Yuen W, Yeung C . External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg. 2007; 246(3):425-33. PMC: 1959348. DOI: 10.1097/SLA.0b013e3181492c28. View

20.

Tani M, Kawai M, Hirono S, Ina S, Miyazawa M, Shimizu A . A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy. Am J Surg. 2010; 199(6):759-64. DOI: 10.1016/j.amjsurg.2009.04.017. View