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

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

BACKGROUND

Several 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.

METHODS

Data 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.

RESULTS

PreFRS 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).

CONCLUSION

The 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.

Jejunal Perforation Due to Internal Pancreatic Stents Following Pancreaticoduodenectomy: A Case Series and Technical Modification

Pancreaticoduodenectomy (PD) is a complex surgical procedure performed to treat various conditions, including pancreatic head cancer and ampullary tumors. Postoperative pancreatic fistulas (POPFs) remain one of the most challenging complications of PD, with potentially severe consequences such as abscess formation, bleeding, and even mortality. To mitigate the risk of POPFs, internal pancreatic stents are often employed to promote healing by diverting pancreatic secretions. Although internal stents offer advantages, including the avoidance of external drainage, complications such as stent migration, cholangitis, and liver abscesses have been commonly documented. A jejunal perforation caused by internal pancreatic stents, however, is an extremely rare complication. In this report, we describe three cases of jejunal perforations caused by internal pancreatic stents following PD and present a modified technique to reduce the risk of this complication. Three cases of jejunal perforation following PD were observed. In Case 1, a 69-year-old female developed intra-abdominal abscesses, and computed tomography (CT) revealed a perforation caused by a pancreatic stent, necessitating reoperation. In Case 2, an 83-year-old male exhibited a perforation and hematoma on CT 36 hours after surgery, requiring reoperation. In Case 3, a 66-year-old male presented with an inflammatory response five days post-surgery. CT revealed stent-related perforation, leading to reoperation. All patients fully recovered following surgical intervention. These cases underscore the importance of careful pancreatic stent placement during PD to minimize complications. The likely cause of the jejunal perforations was the perpendicular angle of the stent placement, leading to erosion of the jejunal wall. To address this issue, a modified technique was introduced, involving advancing the stent 5 cm into the jejunal lumen to reduce any direct pressure on the jejunal wall. This adjustment has prevented further cases of perforation, highlighting the critical need for surgical vigilance and technical modifications to enhance patient outcomes following PD.

Endoscopic diagnosis and treatment of recurrent acute pancreatitis after pancreaticojejunostomy: A case report

BACKGROUND

Drainage through pancreatic duct stenting is a crucial step in preventing postoperative pancreatic fistula after pancreaticoduodenectomy. There are virtually no reported cases of recurrent acute pancreatitis following pancreaticoduodenectomy, and there is currently no supporting research on the timing for stent replacement or removal.

CASE SUMMARY

We report a patient in whom a pancreatic duct stent placed during pancreaticoduodenectomy failed to detach as expected, resulting in recurrent episodes of acute pancreatitis. The patient underwent endoscopic retrograde cholangiopancreatography to remove the obstructing pancreatic duct stent, and no abdominal pain or acute pancreatitis episodes were observed during the one-year follow-up.

CONCLUSION

This case highlights the importance of regular follow-up and appropriate management of pancreatic duct stents in patients undergoing pancreaticoduodenectomy. Our findings provide valuable insights for the clinical management of such cases.

Stent A pancreaticojejunostomy after pancreatoduodenectomy: Is it always necessary?

The establishment of a postoperative pancreatic fistula (POPF) is considered the most common and, concomitantly, the most serious complication associated with pancreaticoduodenectomy (PD). The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified. The stenting of the pancreatic duct, with the use of either internal or external stents, has been evaluated in this direction. In theory, it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF. The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF, after PD, by using PubMed and Reference Citation Analysis. In general, previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF; this is at the cost, however, of increased morbidity associated mainly with the stent removal. Certainly, the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract. Bearing in mind the scarcity of high-quality data on the subject, an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.

Application of split pancreatic duct stent in laparoscopic pancreaticoduodenectomy

Laparoscopic pancreaticoduodenectomy (LPD) is a classic surgical method for diseases, such as tumors at the lower end of the common bile duct, pancreatic head, and benign and malignant tumors of the duodenum. Postoperative pancreatic fistula (POPF) is one of the most serious complications of LPD. To reduce the incidence of grade B or C POPF and other complications after LPD, we applied a split pancreatic duct stent combined with the characteristics of internal and external stent drainage. Between September 2020 and September 2022,12 patients underwent placement of the Split pancreatic duct stent during LPD. Data on basic characteristics of patients, surgical related indicators and postoperative POPF incidence were collected and analyzed. The results showed that the average operation time was 294.2 ± 36 minutes, average time for pancreaticojejunostomy was 35.9 ± 4.1 minutes, and average estimated blood loss was 204.2 ± 58.2 mL. Biochemical leakage occurred in 2 patients (16.7%), whereas no grade B or C POPF, 1 case (8.3%) had postoperative bleeding, and no death occurred within 30 days after the operation. Preliminary experience shows that the split pancreatic duct stent can effectively reduce the incidence of complications after LPD, especially grade B or C POPF.

Positive drain fluid culture on postoperative day 1 predicts clinically relevant pancreatic fistula in early drain removal with higher drain fluid amylase after pancreaticoduodenectomy

BACKGROUND

This study aimed to clarify the risk factors of clinically relevant pancreatic fistula after early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Clinical evaluation of early drain removal with a higher drain fluid amylase after pancreaticoduodenectomy has been controversial. The safety and effectiveness have not been sufficiently examined.

METHODS

Between 2015 and 2020, prophylactic surgical drains were prospectively removed on postoperative day 4 regardless of drain fluid amylase level in 364 study-eligible patients who underwent pancreaticoduodenectomy. Patients were classified according to drain fluid amylase on postoperative day 1: 281 patients with drain fluid amylase <4,000 U/L, and 83 patients with drain fluid amylase ≥4,000 U/L.

RESULTS

Clinically relevant pancreatic fistula occurred in 40 of 364 enrolled patients (11.0%). In the entire cohort, male, positive postoperative day 1 drain fluid culture, and postoperative day 1 drain fluid amylase ≥4,000 U/L were independent risk factors for clinically relevant pancreatic fistula after early drain removal. When stratifying by 4,000 U/L of postoperative day 1 drain fluid amylase, the rate of clinically relevant pancreatic fistula in postoperative day 1 drain fluid amylase <4,000 U/L was significantly lower than that in postoperative day 1 drain fluid amylase ≥4,000 U/L (4% vs 35%, P < .001) after early drain removal. Moreover, in postoperative day 1 drain fluid amylase <4,000 U/L, positive postoperative day 1 drain fluid culture did not develop clinically relevant pancreatic fistula after early drain removal. However, in postoperative day 1 drain fluid amylase ≥4,000 U/L, multivariate analysis clarified that positive postoperative day 1 drain fluid culture was the only independent risk factor of clinically relevant pancreatic fistula after early drain removal (odds ratio 26.27, 95% confidence interval 5.59-123.56, P = .001).

CONCLUSION

Positive drain fluid culture on postoperative day 1 might predict clinically relevant pancreatic fistula in early drain removal with a higher drain fluid amylase.

Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy

Purpose

This study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).

Methods

This single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy.

Results

A total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months.

Conclusion

Conversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.

USE of Biodegradable STENTS in Pancreaticoduodenectomy: Initial Experience

Background. Plastic stents have been used to avoid postoperative pancreatic fistula (POPF) following Whipple's Pancreaticoduodenectomy (WPD), but they may cause some stent-related complications. Biodegradable stents have been recently introduced and might be a safe alternative. Here we present our initial experience with their use. Methods. Between March 1, 2020, and September 30, 2020, ten (10) consecutive patients underwent WPD. They all had conventional two-layer pancreaticojejunostomy with the placement of an internal biodegradable stent. They were assessed for technical feasibility, pancreatic leak, and stent-related complications. Results. The use of biodegradable stents was technically feasible in all patients, despite some difficulties in insertion due to stent stiffness and design. After a median follow-up period of 124 days, none of the patients suffered POPF. One patient had a biochemical pancreatic leak with no clinical significance. The median hospital stay was 7 days, and there were no stent-related complications. Conclusion. Biodegradable stents are technically feasible and safe in WPD with good short-term outcomes. They might provide a better alternative to plastic stents and their potential complications. Larger long-term studies are needed to validate efficacy and safety. Few modifications of the stent's design might be needed to facilitate use in open surgery.

Novel biodegradable internal stent as a mitigation strategy in high-risk pancreaticojejunostomy: technical notes and preliminary results

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most feared complication after pancreaticoduodenectomy (PD), as it can lead to extremely poor outcomes. We herein report the preliminary results of an anastomotic technique based on the use of a novel internal biodegradable stent (IBS) to mitigate POPF sequelae. Between October 2020 and May 2021, all patients undergoing PD with high-risk pancreatic anastomosis received a pancreato-jejunal (PJ) anastomosis with an Archimedes™ IBS placement. Fifteen patients comprised our study cohort. In 11 cases, a 2-mm Archimedes™ stent was used, and in the remaining four patients, a 2.6-mm stent was used. Overall postoperative complications occurred in eight patients, with four cases being severe. Two patients developed CR-POPF, with one of them dying. In our small preliminary series, PJ anastomosis with an Archimedes™ IBS showed encouraging results in terms of CR-POPF incidence. Further studies are needed to confirm these findings.

Incidence of postoperative pancreatic fistula after using a defined pancreaticojejunostomy technique for laparoscopic pancreaticoduodenectomy: A prospective multicenter study on 1033 patients

OBJECTIVE

This prospective multicenter study aimed to study the incidence of postoperative pancreatice fistula using a defined technique of pancreaticojejunostomy (PJ) in laparoscopic pancreaticoduodenectomy (LPD).

BACKGROUND

PJ is a technically challenging and time-consuming procedure in LPD. Up to now, only a few small sample size studies have been reported on various PJ techniques in LPD, none of which has widely been accepted by surgeons.

METHODS

This prospective study enrolled consecutive patients who underwent LPD using a defined technique of PJ at four institutions in China between January 2017 and December 2020.

RESULTS

Of 1045 patients, after excluding 12 patients (1.2%) due to conversion to open surgery, 1033 patients were analysed. The males comprised of 57.12% (590/1033), and females 42.88% (443/1033), with a mean age of 59.00 years. The mean ± s.d. operation time was (270.2 ± 101.8) min. The median time for PJ was 24min (IQR = 20.0-30.0). The overall incidence of postoperative pancreatic fistula was 12.6%, including 67 patients (6.5%) with Grade A biochemical leak, 50 patients (4.8%) with Grade B, and 13 patients (1.3%) with Grade C pancreatic fistulas. The overall incidence of major complications (Clavien-Dindo score ≥3) was 6.3% and the 30-day mortality was 2.8%.

CONCLUSION

The pancreaticojejunostomy technique for LPD was safe, simple and reproduceable with favorable clinical outcomes. However, further validations using high-quality RCTs are still required to confirm the findings of this study.

Predictors of Postoperative Pancreatic Fistula (POPF) After Pancreaticoduodenectomy: Clinical Significance of the Mean Platelet Volume (MPV)/Platelet Count Ratio as a New Predictor

PURPOSE

In this study, it was aimed to determine the predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) and clinical significance of mean platelet volume (MPV)/total platelet count ratio (MPR) as a new predictor for CR-POPF.

METHODS

A total of 105 patients who underwent PD consecutively due to periampullary located diseases were included in the study. Patients were divided into two groups as CR-POPF and no postoperative pancreatic fistula (No-POPF). Demographic parameters, preoperative serum-based inflammatory indicators, surgical procedures, intraoperative findings, and histopathological parameters were recorded retrospectively from prospectively recorded patient files and compared between the groups.

RESULTS

CR-POPF occurred in 16 (15.2%) patients: 8 (7.6%) were grade B and 8 (7.6%) were grade C according to the ISGPF classification. In univariate analysis, intraoperative blood loss > 580 mL (OR: 5.25, p = 0.001), intraoperative blood transfusion (OR: 5.96, p = 0.002), intraoperative vasoconstrictor medication (OR: 4.17, p = 0.014), benign histopathology (OR: 3.51, p = 0.036), and poor differentiation in malignant tumors (OR: 4.07, p = 0.044) were significantly higher in the CR-POPF group, but not significant in multivariate analysis. Soft pancreatic consistency (OR: 6.08, p = 0.013), pancreatic duct diameter < 2.5 mm (OR: 17.15, p < 0.001), and MPR < 28.9 (OR: 13.91, p < 0.001) were the independent predictors of CR-POPF according to multivariate analysis. Neoadjuvant treatment history and simultaneous vascular resection were less likely to cause CR-POPF development; however, they were insignificant.

CONCLUSION

Soft pancreatic consistency, pancreatic duct diameter, and preoperative MPR were the independent predictors of CR-POPF following PD. Decreased MPR is a strong predictor for CR-POPF and should be considered when deciding treatment strategies.

Impact of internal and external drainage of the pancreatic duct on pancreatic fistula after pancreaticoduodenectomy: A meta-analysis

BACKGROUND

Based on the domestic and foreign research on the impact of internal and external drainage of the pancreatic duct on pancreatic fistula after pancreaticoduodenectomy (PD), we conducted a meta-analysis to provide doctors with evidence on its applications in clinical work.

AIM

To systematically evaluate the effect of internal and external drainage of the pancreatic duct on pancreatic fistula after PD.

METHODS

PubMed, Embase, Cochrane, CNKI, CBM, Wanfang, and VIP were searched for randomized controlled and retrospective studies on internal and external drainage after PD resection from 2016 to 2021. According to the inclusion and exclusion criteria, the literature was selected, the data were extracted, and the literature quality was evaluated. Rev Man 5.3 software was used for meta-analysis.

RESULTS

A total of four retrospective studies with 1213 patients were included. The results of meta-analysis showed that there was no significant difference in the improvement of clinically relevant pancreatic fistula after PD between internal and external drainage [odds ratio (OR) = 1.42, 95% confidence interval (CI): 0.84-2.40, P = 0.19]. Sensitivity analysis suggested that there was no heterogeneity among the studies (P = 0.33, I² = 8.7%). The difference was statistically significant after pooling the results using the fixed-effects model (OR = 1.83, 95%CI: 1.12-2.99, P = 0.02). External drainage can reduce the incidence of postoperative clinically related pancreatic fistula. Subgroup analysis showed that there was no difference in the improvement of grade B (OR = 0.95, 95%CI: 0.64-1.40, P = 0.78] or grade C pancreatic fistula (OR = 1.58, 95%CI: 0.81- 3.09, P = 0.18).

CONCLUSION

External drainage of the supporting duct can reduce the incidence of clinically relevant pancreatic fistula after surgery, but there is no difference in the improvement of grades B and C pancreatic fistula. Further research is required to verify our findings.

A preserved pancreatic exocrine function after pancreatectomy may be a crucial cause of pancreatic fistula: paradoxical results of the 13C-trioctanoin breath test in the perioperative period

PURPOSE

The aim of this study was to elucidate the association between pancreatic fistula (PF) and the sequential changes in the perioperative exocrine function after pancreatectomy.

METHODS

The subjects were 96 patients who underwent a ¹³C-trioctanoin breath test before and 1 month after pancreatectomy, between 2006 and 2018. We retrospectively compared the pre- and postoperative fat absorption levels between patients with PF (PF group; n = 17) and without PF (non-PF group; n = 79) using the breath test.

RESULTS

The preoperative level of ¹³C-trioctanoin absorption (%dose/h) was comparable between the non-PF and PF groups (36.5 vs. 36.9). In the non-PF group, ¹³C-trioctanoin absorption was significantly decreased after surgery in comparison to the preoperative setting (post-operative 28.5; pre-operative 36.5; p < 0.0001), whereas these values were comparable (post-operative 36.9; pre-operative 34.5; p = 0.129) in the PF group. Moreover, postoperative absorption in the PF group was significantly better than that in the non-PF group (34.5 vs. 28.5%, p = 0.0003). The maximum drain amylase level was significantly higher in patients with a ¹³C-trioctanoin absorption level (%dose/h) of ≥ 30 in comparison to patients with levels of < 30 (2502 vs. 398 U/L, p = 0.001).

CONCLUSION

PF did not exacerbate the pancreatic exocrine function in the early postoperative period, and the acceleration or preservation of the exocrine function after surgery may be an important cause of PF.

Effect of postoperative non-steroidal anti-inflammatory drugs on anastomotic leakage after pancreaticoduodenectomy

Background

Although the association between an increase in anastomotic leakage (AL) and non-steroidal anti-inflammatory drugs (NSAIDs) has been reported in gastrointestinal surgeries, this issue has rarely been addressed for pancreaticoduodenectomy (PD). We aimed to investigate the association between postoperative NSAIDs administration and clinically relevant AL (CR-AL) following PD.

Method

We retrospectively evaluated 2,163 consecutive patients who underwent PD between 2007 and 2019. The patients were divided into two groups: patients who received and did not receive NSAIDs by postoperative day (POD) 5. We conducted a propensity score analysis using inverse probability of treatment weighting (IPTW) to adjust the baseline differences between both groups. We compared the occurrence of CR-AL and other postoperative outcomes before and after IPTW. Further, we used the multivariable binary logistic regression method for a sensitivity analysis for CR-AL.

Results

A total of 2,136 patients were included in the analysis. Of these, 222 (10.4%) received NSAIDs by POD 5. The overall occurrence rate of CR-AL was 14.9%. After IPTW, postoperative NSAIDs were significantly associated with CR-AL (odds ratio [OR] 1.24, 95% confidence interval [CI], 1.05-1.47; P=0.012), prolonged postoperative hospitalization (OR 1.31, 95% CI 1.14-1.50, P<0.001), and unplanned readmission within 30 days postoperatively (OR 1.48, 95% CI 1.15-1.91, P=0.002). However, this association was not consistent in the sensitivity analysis.

Conclusion

Postoperative NSAIDs use was significantly associated with an increase in CR-AL incidence following PD. However, sensitivity analysis failed to show its association, which precludes a firm conclusion of its detrimental effect.

Superior perianastomotic fluid collection in the early postoperative period affects pseudoaneurysm occurrence after pancreaticoduodenectomy

PURPOSE

Pseudoaneurysm (PA) after pancreaticoduodenectomy (PD) is a harmful complication due to postoperative pancreatic fistula. However, the preventive method for PA is unclear. This study aimed to assess the risk factors for PA after PD and to evaluate the clinical features of patients with PA.

METHODS

Medical records of 54 patients who underwent PD and developed clinically relevant postoperative pancreatic fistula (POPF) were retrospectively reviewed. We evaluated postoperative computed tomography (CT) findings, including the perianastomotic fluid collection (PFC) location on postoperative day 4. Perioperative findings and postoperative CT findings were compared between patients with and without PA after PD.

RESULTS

The PA group included nine patients (17%). The median postoperative day of diagnosis of PA was 17 (range, 7-33). The PA locations were the gastroduodenal artery stump (n = 3), dorsal pancreatic artery (DPA) stump from the common hepatic artery (n = 4), DPA stump from the replaced right hepatic artery (n = 1), and inferior pancreaticoduodenal artery stump (n = 1). The prevalence of falciform ligament wrap to the hepatic artery was lower (33% vs. 78%, p = 0.014) and superior PFC prevalence was higher (100% vs. 58%, p = 0.019) in the PA group than in the non-PA group. Superior PFC reached the dorsal part of the caudate lobe of the liver in all patients with PA. Furthermore, all PAs occurred at the arteries that could not be wrapped by the falciform ligament.

CONCLUSION

Prevention of superior PFC and falciform ligament wrapping may reduce PA occurrence after PD with clinically relevant POPF.

Short internal pancreatic stent reduces pancreatic fistula in pancreatoduodenectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major complication of pancreatoduodenectomy (PD). A pancreatic stent is usually used for drainage of the pancreatic duct, but the best type of the stent remains unclear. The aim of this study was to investigate perioperative factors and their influence on the risk of CR-POPF following PD.

METHODS

From 2006 to 2019, the records of 246 patients who underwent PD were retrospectively reviewed, and the relationship between perioperative factors including type of pancreatic stent and CR-POPF was investigated. External or internal pancreatic stents were used for drainage of the pancreatic duct, and the internal stent was inserted 1 cm into the jejunum to decrease stent obstruction.

RESULTS

External and internal pancreatic stents were used in 137 and 109 patients, respectively. Multivariate analysis revealed that the diameter of the main pancreatic duct (odds ratio = 0.292, 95% confidence interval = 0.140-0.605, P = 0.001), diagnosis (odds ratio = 3.359, 95% confidence interval = 1.498-7.693, P = 0.003), and type of pancreatic stent (odds ratio = 0.435, 95% confidence interval = 0.203-0.934, P = 0.033) were independent factors related to CR-POPF after PD. Internal stent was associated with a low rate of CR-POPF (P < 0.001) and short postoperative hospital stay (P < 0.001) compared to external stent.

CONCLUSION

A short pancreatic internal stent could decrease the incidence of CR-POPF.