Are Internal or External Pancreatic Duct Stents the Preferred Choice for Patients Undergoing Pancreaticoduodenectomy? A Meta-Analysis. Biomed Res Int. 2017;2017:1367238. [PMID: 28466004 PMCID: PMC5390541 DOI: 10.1155/2017/1367238]

Comparison of three reconstruction techniques performed after pancreaticoduodenectomy: Using external, internal, or no stent

BACKGROUND

Postoperative pancreatic fistula (POPF) is the most frequent cause of morbimortality after pancreaticoduodenectomy, but the best technique to use to prevent its development is unclear. The choice of drainage method external duct stent (EDS), internal duct stent (IDS), or non-ductal stent (NDS) is also controversial.

AIM

To compare the three groups (EDS, IDS and NDS), analyzing the patient characteristics, perioperative examinations and survival.

METHODS

Patients who underwent pancreaticoduodenectomy and pancreaticojejunostomy between 2012 and 2020, were divided into the EDS, IDS and NDS groups.

RESULTS

Of the 244 patients included, 129 were in the EDS group, 71 in the IDS group, and 44 in the NDS group. Except for preoperative pancreatitis in the NDS patients, comorbidities were similar among the groups. Patients in the NDS group had a high caliber of the Wirsung duct and frequently presented with a hard pancreas (P < 0.001). A lower rate of grade C POPF was observed in the EDS (1.6%) compared to the NDS (9.1%) and IDS group (14.1%) (P = 0.009). The groups showed similar findings for delayed gastric emptying, postoperative hemorrhage, reoperation, and 5-year survivals. Ninety-day mortality rate was significantly higher in the IDS group (5.6%) compared to the EDS (1.6%) and NDS (4.5%) groups (P = 0.046). Multivariate analysis showed that the use of EDS was a protective factor for grade B/C POPF (P = 0.034), and 90-day mortality (P = 0.018). Additionally, a Wirsung duct diameter < 3 mm was the only risk factor for grade B/C POPF (P = 0.001), and 90-day mortality (P = 0.031).

CONCLUSION

The use of the EDS was a protective factor for grade B/C POPF and 90-day mortality, and the Wirsung duct < 3 mm was a risk factor for grade B/C POPF and 90-day mortality.

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.

Stent placement for the prevention of clinically-relevant postoperative pancreatic fistula following pancreaticojejunostomy: A systematic review and meta-analysis

OBJECTIVES

There remains a lack of consensus regarding the benefits of stent placement following pancreaticojejunostomy in terms of clinically relevant postoperative pancreatic fistulas (CR-POPFs). This study was aimed at analyzing the effects of stent placement, stent technique (internal and external), stent size, and dilation of the main pancreatic duct on CR-POPFs.

METHODS

Our study comprised a systematic review and meta-analysis of randomized controlled trials involving patients undergoing pancreaticojejunostomy. The primary outcome was defined as the incidence of CR-POPFs. Additionally, subgroup analyses were conducted, and pooled analyses were performed to provide comparative references.

RESULTS

Twelve randomized controlled trials, including a total of 1117 patients, were included. Compared with no stent placement, stenting did not exhibit a significant association with reduced CR-POPF incidence (odds ratio [OR] ​= ​0.60, 95% CI: 0.34-1.04, P ​= ​0.07). Subgroup analysis revealed that only external stents, and not internal stents, were significantly associated with a reduced CR-POPF incidence compared with no stent placement (OR ​= ​0.53, 95% CI: 0.28-0.99, P ​= ​0.05 vs. OR ​= ​0.92, 95% CI: 0.28-3.05, P ​= ​0.89). Furthermore, stent placement in patients with a main pancreatic duct diameter of ≤3 ​mm, and not in those with a main pancreatic duct diameter of >3 ​mm, was associated with a significantly reduced CR-POPF incidence compared with no stent placement (OR ​= ​0.24, 95% CI: 0.07-0.78, P ​= ​0.02 vs. OR ​= ​1.58, 95% CI: 0.41-6.06, P ​= ​0.50).

CONCLUSIONS

The findings suggest a potential role for external stent placement in the prevention of CR-POPFs after pancreaticojejunostomy, particularly in patients with undilated pancreatic ducts. The reliability of our findings is constrained by the limited number of studies included.

PROSPERO REGISTRATION NUMBER

CRD42022380103.

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.

Pancreaticojejunostomy without pancreatic duct stent after laparoscopic pancreatoduodenectomy: preliminary outcomes from a prospective randomized controlled trial

BACKGROUND

Outcomes of pancreaticojejunostomy without pancreatic duct during open pancreaticoduodenectomy (OPD) are unknown and controversial, and corresponding reports in laparoscopic surgery are lacking.

METHODS

Patients were evaluated at West China Hospital, and standard laparoscopic pancreaticoduodenectomy (LPD) was planned. A prospective randomized trial was conducted, in which the patients were randomly assigned to the no-stent and internal-stent groups in a single-center trial. The primary outcomes were the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) and 90-day mortality. Preliminary results were reported.

RESULTS

From November 2019 to March 2021, we enrolled 90 patients (41 in the no-stent group and 49 in the internal-stent group) in the study. All baseline parameters of both groups, including age, sex ratio, pancreatic duct diameter, and intraoperative blood loss, were comparable between the two groups except for pathological diagnosis and the texture of remnants. Twenty-seven (65.9%) and 19 (38.8%) patients in the no-stent and internal-stent groups, respectively, had soft pancreatic remnants (P = 0.010). The total incidence of CR-POPF was 5.6% and included two patients (4.9%) in the no-stent group and three patients (6.1%) in the internal-stent group (P = 1.000). Only one patient in the internal-stent group died of heart failure within 90 days after the operation. No significant difference in other postoperative complications was observed between the groups except for biochemical fistula [no-stent group vs. internal-stent group = 31.7% vs. 12.2%, (P = 0.024)].

CONCLUSIONS

In a high-volume LPD center, duct-to-mucosa pancreaticojejunostomy without pancreatic duct stent is safe and reliable. In addition, duct-to-mucosa pancreaticojejunostomy without pancreatic duct stent was more challenge. We recommend using the stent during anastomosis and pulling it out after the procedure.

Clinical outcomes and technical description of unstented end to side pancreaticogastrostomy by small posterior gastrotomy

Backgrounds/Aims

Morbidity following Whipple’s surgery largely depends upon the pancreatic stump anastomosis leak. Pancreaticogastrostomy is one of the techniques of pancreatic stump reconstruction and is described variously in the literature. Duct to mucosa pancreaticogastrostomy is described either by a large 3-4 cm posterior gastrotomy or by small gastrotomy of 2-3 mm with the use of internal stents along with. We describe clinical outcomes and technique of 2 layer end to side pancreatico-gastrostomy by a small posterior gastrotomy without the use of internal stents.

Methods

Hospital records of 35 patients where the technique of, small posterior gastrotomy end to side duct to mucosa pancreatico-gastrostomy without internal stents, was used for pancreatic stump reconstruction were studied retrospectively. The data were analyzed for demographic details, stage of the disease, and short term outcomes related to surgical procedure.

Results

The mean duration of surgery was 7.4 hours. Grade A, B, and C POPF were observed in 10 (28.5%), 3 (8.5%), and 1 (2.8%) of patients respectively. The mean time to remove pancreatic drain was 9 days, and the mean time to start oral feeds was 8.9 days. The mean hospital stay was 12.9 days (07-26). Thirty days mortality was 2.8%.

Conclusions

Unstented duct to mucosa end to side pancreatico-gastrostomy technique is comparable with other pancreatico-gastrostomy techniques in outcomes in terms of POPF, morbidity, mortality, and hospital stay. However, to establish the superiority or inferiority of this technique, a larger study is recommended.

Internal stenting across the pancreaticojejunostomy anastomosis and main pancreatic duct after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula is associated with high morbidity and mortality. Studies have reported internal stenting of the pancreaticojejunostomy anastomosis to reduce postoperative pancreatic fistula, but it is still controversial.

MATERIALS AND METHODS

Fifty patients undergoing elective pancreaticoduodenectomy, were included. Patients were divided into 2 groups in randomized fashion; Group A (n-25) without internal stenting across the pancreaticojejunostomy anastomosis and Group B (n-25) with internal stenting of the pancreaticojejunostomy anastomosis. Primary endpoint was the occurrence of postoperative pancreatic fistula.

RESULT

Both the groups were comparable in demographics, co morbidities, pathologies, pancreatic texture and pancreatic duct diameter. Out of 50 patients studied, total 23(46.0%) patients developed postoperative pancreatic fistula. Ten (40%) in group A and 13 (52%) in group B (p 0.156). Sixteen patients (32%) developed Grade A and 7 (14%) patients had Grade B postoperative pancreatic fistula. In group A, 6 patients developed grade A and 4 patients developed grade B postoperative pancreatic fistula. In group B, 10 patients developed grade A and 3 patients developed grade B postoperative pancreatic fistula. There was no Grade C fistula. All patients had satisfactory recovery on conservative management. Eight patients (16%) developed delayed gastric emptying [5 in group A and 3 in group B; p-0.366]. Six patients developed superficial surgical site infection (2 in group A and 4 in group B; p-0.445). The length of hospital stay was comparable in two groups. There was no mortality.

CONCLUSION

Internal stenting of pancreaticojejunostomy anastomosis does not decrease the rate of postoperative pancreatic fistula after pancreaticoduodenectomy.

Novel risk scoring system for prediction of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

The available prediction models for clinically relevant postoperative pancreatic fistula (CR-POPF) do not incorporate both preoperative and intraoperative variables.

AIM

To construct a new risk scoring system for CR-POPF that includes both preoperative and intraoperative factors.

METHODS

This was a retrospective study of patients who underwent pancreaticoduodenectomy (PD) or pylorus-preserving PD (PPPD) between January 2011 and December 2016 at the First Affiliated Hospital of Soochow University. Patients were divided into a study (01/2011 to 12/2014) or validation (01/2015 to 12/2016) group according to the time of admission. POPF severity was classified into three grades: Biochemical leak (grade A) and CR-POPF (grades B and C). Logistic regression was used to create a predictive scoring system.

RESULTS

Preoperative serum albumin ≥ 35 g/L [P = 0.032, odds ratio (OR) = 0.92, 95% confidence interval (CI): 0.85-0.99], hard pancreatic texture (P = 0.004, OR = 0.25, 95%CI: 0.10-0.64), pancreatic duct diameter ≥ 3 mm (P = 0.029, OR = 0.50, 95%CI: 0.27-0.93), and intraoperative blood loss ≥ 500 mL (P = 0.006, OR = 1.002, 95%CI: 1.001-1.003) were independently associated with CR-POPF. We established a 10-point risk scoring system to predict CR-POPF. The area under the curve was 0.821 (95%CI: 0.736-0.905) and the cut-off value was 3.5. Including drain amylase levels improved the predictive power of the model.

CONCLUSION

This study established a 10-point scoring system to predict CR-POPF after PD/PPPD using preoperative and intraoperative parameters. Ultimately, this system could be used to distinguish between high- and low-risk populations in order to facilitate timely interventions after PD.

Internal Versus External Drainage With a Pancreatic Duct Stent For Pancreaticojejunostomy During Pancreaticoduodenectomy for Patients at High Risk for Pancreatic Fistula: A Comparative Study

BACKGROUND

The aim of this study was to determine whether internal or external drainage with a pancreatic duct stent is the optimal pancreaticojejunostomy method to prevent pancreatic fistula (PF) after pancreaticoduodenectomy (PD) for subgroups of patients at high risk for PF.

MATERIALS AND METHODS

A total of 495 patients who underwent PD were reviewed. Univariate and multivariate analyses were used to identify risk factors for PF after PD. We further compared the incidence of PF and outcomes between the internal and external drainage groups for subgroups of patients at high risk for PF.

RESULTS

There was no difference in the incidence of complications according to the Clavien-Dindo classification or the rate of PF after PD in both groups (P = 0.961 and P = 0.505, respectively). The incidence of mortality was 3.8% in the internal drainage group and 3.9% in the external drainage group (P = 0.980). Univariate and multivariate analyses identified male gender (odds ratio [OR] = 2.93; 95% confidence interval [CI], 1.78-4.83; P = 0.000), pancreatic duct diameter (<3 mm) (OR = 2.58; 95% CI, 1.57-4.23; P = 0.000), and soft pancreatic texture (OR = 2.92; 95% CI, 1.71-4.98; P = 0.000) as independent risk factors for PF after PD. No differences in the incidence of PF for the subgroups of patients with one, two, or three risk factors were observed between the internal and external drainage groups (P = 0.334, P = 1.000, and P = 0.936, respectively). No differences in total complications, delayed gastric emptying, postpancreatectomy hemorrhage, biliary fistula, infection complications, reoperation, perioperative mortality, or postoperative hospital stay were noted. In addition, liquid loss and tube-related complications occurred in the external drainage group.

CONCLUSIONS

Internal drainage is the optimal method to prevent PF after PD for subgroups of patients at high risk for PF because the surgical procedure is simple and prevents liquid loss and tube-related complications associated with external drainage. However, no differences in the incidence of PF and other complications after PD were observed between the two approaches.