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Petrova E, Mazzella E, Wellner U, Keck T, Bausch D, Bechstein W, Schnitzbauer A. Monopolar electrocautery versus scalpel for pancreatic neck transection during open pancreatoduodenectomy: A retrospective, registry-based study. Surgery 2024:S0039-6060(24)00188-0. [PMID: 38789356 DOI: 10.1016/j.surg.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/27/2024] [Accepted: 03/17/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND The method of transecting the pancreatic parenchyma during pancreatic resection may influence the rate of complications, including pancreatic fistula and bleeding. The objective of this study is to compare the transection of the pancreatic parenchyma during pancreatoduodenectomy with monopolar electrocautery versus scalpel in terms of postoperative complications. METHODS A retrospective analysis of patients with open pancreatoduodenectomy from the German DGAV StuDoQ|Pancreas registry (January 2013 to December 2021) was performed. Transection of the pancreatic parenchyma with a scalpel versus monopolar electrocautery was compared regarding postoperative pancreatic fistula B/C, post-pancreatectomy hemorrhage B/C, and major complications (Clavien-Dindo classification ≥3) rates. Multivariable analysis with adjustment for potential confounders and surgical center cluster effect was performed. RESULTS Overall, 6,752 patients were included in the study. In 4,072 (60.3%), transection was performed with a scalpel and, in 2,680 (39.7%), with electrocautery. Transection with electrocautery was associated with higher postoperative pancreatic fistula B/C (15.4% vs 12.8%; P = .003), post-pancreatectomy hemorrhage B/C (11% vs 7.4%; P < .001), and major complications (33.4% vs 29.6%; P = .001) rates. In the multivariable analysis, after adjustment for potential confounders and surgical center, the association of the transection method with postoperative pancreatic fistula B/C (odds ratio = 1.01; 95% CI, 0.79-1.2; P = .962), post-pancreatectomy hemorrhage B/C (odds ratio = 1.23; 95% CI, 0.94-1.6; P = .127), and major complications (odds ratio = 1.09; 95% CI, 0.93-1.27; P = .297) was not significant. CONCLUSION The study found no significant association between transection of the pancreatic parenchyma during open pancreatoduodenectomy with a scalpel compared with monopolar electrocautery regarding pancreatic fistula, postoperative bleeding, or overall major complication rates.
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Affiliation(s)
- Ekaterina Petrova
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt, Germany.
| | - Elena Mazzella
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt, Germany
| | - Ulrich Wellner
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Dirk Bausch
- Department of Surgery, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Herne, Germany
| | - Wolf Bechstein
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt, Germany
| | - Andreas Schnitzbauer
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt, Germany
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Mastalier B, Cauni V, Tihon C, Septimiu Petrutescu M, Ghita B, Popescu V, Andras D, Radu IM, Vlasceanu VG, Floroiu MF, Draghici C, Botezatu C, Cretoiu D, Varlas VN, Lazar AM. Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score. J Clin Med 2023; 12:6193. [PMID: 37834836 PMCID: PMC10573877 DOI: 10.3390/jcm12196193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/07/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.
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Affiliation(s)
- Bogdan Mastalier
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Victor Cauni
- Urology Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania;
| | - Constantin Tihon
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Marius Septimiu Petrutescu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Bogdan Ghita
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Valentin Popescu
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Dan Andras
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Ion Mircea Radu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Vasile Gabriel Vlasceanu
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Marius Florian Floroiu
- Anaesthesia Intensive Care Unit, Colentina Clinical Hospital, 020125 Bucharest, Romania; (M.F.F.); (C.D.)
| | - Cristian Draghici
- Anaesthesia Intensive Care Unit, Colentina Clinical Hospital, 020125 Bucharest, Romania; (M.F.F.); (C.D.)
| | - Cristian Botezatu
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
| | - Dragos Cretoiu
- Fetal Medicine Excellence Research Center, Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
- Department of Genetics, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania
| | - Valentin Nicolae Varlas
- Department of Obstetrics and Gynaecology, Filantropia Clinical Hospital, 011171 Bucharest, Romania
- Department of Obstetrics and Gynaecology, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu St., 020021 Bucharest, Romania
| | - Angela Madalina Lazar
- Department of Surgery, Department of Functional Sciences, Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd., 050474 Bucharest, Romania; (B.M.); (V.P.); (D.A.); (C.B.); (A.M.L.)
- General Surgery Clinic, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.T.); (M.S.P.); (B.G.); (I.M.R.); (V.G.V.)
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Dumitrascu T, Popescu I. Outcomes of Duct-to-Mucosa vs. Invagination Pancreatojejunostomy: Toward a Personalized Approach for Distal Pancreatic Stump Anastomosis in Central Pancreatectomy? J Pers Med 2023; 13:jpm13050858. [PMID: 37241028 DOI: 10.3390/jpm13050858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ) and distal pancreatic invagination into jejunum anastomoses (PJ) after CP. (2) Methods: All patients with CP and jejunal anastomoses (between 1 January 2002 and 31 December 2022) were retrospectively assessed and compared. (3) Results: 29 CP were analyzed: WJ-12 patients (41.4%) and PJ-17 patients (58.6%). The operative time was significantly higher in the WJ vs. PJ group of patients (195 min vs. 140 min, p = 0.012). Statistically higher rates of patients within the high-risk fistula group were observed in the PJ vs. WJ group (52.9% vs. 0%, p = 0.003). However, no differences were observed between the groups regarding the overall, severe, and specific postpancreatectomy morbidity rates (p values ≥ 0.170). (4) Conclusions: The WJ and PJ anastomoses after CP were comparable in terms of morbidity rates. However, a PJ anastomosis appeared to fit better for patients with high-risk fistula scores. Thus, a personalized, patient-adapted technique for the distal pancreatic stump anastomosis with the jejunum after CP should be considered. At the same time, future research should explore gastric anastomoses' emerging role.
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Affiliation(s)
- Traian Dumitrascu
- Center of General Surgery and Liver Transplant, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania
| | - Irinel Popescu
- Center of General Surgery and Liver Transplant, Fundeni Clinical Institute, Titu Maiorescu University, 022328 Bucharest, Romania
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He YG, Yang XM, Peng XH, Li J, Huang W, Jian GC, Wu J, Tang YC, Wang L, Huang XB. Association of a Modified Blumgart Anastomosis With the Incidence of Pancreatic Fistula and Operation Time After Laparoscopic Pancreatoduodenectomy: A Cohort Study. Front Surg 2022; 9:931109. [PMID: 35832498 PMCID: PMC9271827 DOI: 10.3389/fsurg.2022.931109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/07/2022] [Indexed: 01/04/2023] Open
Abstract
Objective To explore the association between a modified Blumgart anastomosis technique and the operative time and surgical complications. Methods This is a retrospective cohort study that analyzed the data of patients who underwent laparoscopic pancreaticoduodenectomy from January 2015 to March 2021. The primary outcome was to explore the association between the modified Blumgart anastomosis technique and operative time. Results A total of 282 patients were enrolled. There were 177 cases of pancreatic duct-to-mucosa anastomosis in the traditional surgery group, and 105 cases of the modified three-step Blumgart anastomosis in the modified group. There were no statistically significant differences in the general and intraoperative characteristics found between the two groups (P > 0.05). The surgical method was an independent predictor of operative time. Overall complications postsurgery were less common in the modified group than in the traditional group. The incidence of postoperative pancreatic fistula was higher in the traditional group than in the modified group (45 cases (25.4%) and 11 cases (10.5%), respectively). Fourteen cases (7.9%) in the traditional group and four case (3.8%) in the modified group had postoperative pancreatic fistula of grades B + C. The two groups had statistically significant differences (P < 0.05). The results of the linear regression showed that the type of surgical method was associated with operation time (95% CI, −73.074 to −23.941, β: −0.438, P < 0.001). Conclusion This modified three-step Blumgart pancreaticojejunostomy was associated with the operation time.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Liang Wang
- Correspondence: Xiaobing Huang Liang Wang
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Hai H, Li Z, Zhang Z, Cheng Y, Liu Z, Gong J, Deng Y. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2022; 3:CD013462. [PMID: 35289922 PMCID: PMC8923262 DOI: 10.1002/14651858.cd013462.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain. OBJECTIVES To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques. SEARCH METHODS We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021). SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes. MAIN RESULTS We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.
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Affiliation(s)
- Hua Hai
- Department of Operating Room, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuyin Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziwei Zhang
- Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Outcome of pancreatic anastomoses during pancreatoduodenectomy in two national audits. Surgery 2021; 170:1799-1806. [PMID: 34373107 DOI: 10.1016/j.surg.2021.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Evidence on the optimal pancreatic anastomosis during pancreatoduodenectomy is inconclusive. Large multicenter and nationwide registries may provide additional insights. The study compared the practice and outcome of different pancreatic anastomoses during pancreatoduodenectomy, focusing on the rate of postoperative pancreatic fistula, in two large audits of pancreatic surgery. METHODS Posthoc analysis of patients after pancreatoduodenectomy in the Dutch Pancreatic Cancer Audit and the German DGAV StuDoQ|Pancreas registries (January 2014 to December 2017). Postoperative pancreatic fistula (International Study Group of Pancreatic Surgery B/C), postpancreatectomy hemorrhage (International Study Group of Pancreatic Surgery B/C) and Clavien-Dindo ≥3 complications rates were compared for the three most common anastomoses: duct-to-mucosa pancreatojejunostomy, non-duct-to-mucosa pancreatojejunostomy, and non-duct-to-mucosa pancreatogastrostomy. Multivariable adjustment for potential confounders was performed. RESULTS Overall, 6,149 patients were included. The most common anastomosis was duct-to-mucosa pancreatojejunostomy (duct-to-mucosa pancreatojejunostomy 59.8%, non-duct-to-mucosa pancreatojejunostomy 21.1%, non-duct-to-mucosa pancreatogastrostomy 12.4%). The overall postoperative pancreatic fistula rate was 14%: duct-to-mucosa pancreatojejunostomy 12.9%, non-duct-to-mucosa pancreatojejunostomy 14.4% (P = .162), non-duct-to-mucosa pancreatogastrostomy 18.3% (P < .001). The rate of postpancreatectomy hemorrhage was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 6.9%, non-duct-to-mucosa pancreatojejunostomy 10% (P < .001), non-duct-to-mucosa pancreatogastrostomy 17.9% (P < .001). The rate of Clavien-Dindo ≥3 complications was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 28%, non-duct-to-mucosa pancreatojejunostomy 32.7% (P = .002), non-duct-to-mucosa pancreatogastrostomy 43.1% (P < .001). In the multivariable analysis, the risk of postoperative pancreatic fistula did not differ significantly between the three anastomoses. The risk of hemorrhage (odds ratio 2.4, 95% confidence interval 1.6-3.5, P < .001) and Clavien-Dindo ≥3 (odds ratio 1.6, 95% confidence interval 1.2-2.1, P = .001) remained significantly higher only for non-duct-to-mucosa pancreatogastrostomy. CONCLUSION Data from two national audits showed no difference in the risk-adjusted postoperative pancreatic fistula rate among the three most used pancreatic anastomoses during pancreatoduodenectomy. Pancreatogastrostomy was inferior to pancreatojejunostomy regarding bleeding and overall major complications.
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Li Y, Hua R. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: a network meta-analysis. Minerva Surg 2021; 77:65-71. [PMID: 34160171 DOI: 10.23736/s2724-5691.21.08802-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile. EVIDENCE ACQUISITION A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistula(ISGPF) definition of POPF. The main outcomes were POPF and clinically relevant POPF. RESULTS Three techniques of pancreatic anastomosis following PD were directly compared in 16 RCTs comprising 2365 patients. EVIDENCE SYNTHESIS Overall, 929 patients underwent duct-to-mucosa pancreaticojejunostomy(PJ DTM), 760 patients invagination pancreaticojejunostomy(PJ Inv), and 676 patients underwent pancreatogastrostomy(PG). The results of comparisons of POPF, clinically relevant POPF, biliary leakage, delayed gastric emptying(DGE), in hospital mortality, internal hemorrhage, reoperation in our network meta-analysis suggested there were no significant differences among the 3 procedures. CONCLUSIONS There are no significant differences among PJ DTM, PJ Inv and PG in the prevention of POPF, clinically relevant POPF, biliary leakage, DGE, internal hemorrhage and reoperation. However, further randomized controlled trials should be undertaken to ascertain these findings.
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Affiliation(s)
- Yujie Li
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China.,Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Rong Hua
- Department of Pancreaticobiliary Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China -
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Wongta K, Tangsirapat V. Surgical outcomes of combined modified Blumgart pancreaticojejunostomy and long internal pancreatic duct stent for pancreaticoduodenectomy. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shinde RS, Acharya R, Chaudhari VA, Bhandare MS, Shrikhande SV. Pancreaticojejunostomy for Pancreatico-enteric Anastomosis after Pancreaticoduodenectomy: one procedure with multiple techniques. SURGERY IN PRACTICE AND SCIENCE 2020. [DOI: 10.1016/j.sipas.2020.100019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Kone LB, Maker VK, Banulescu M, Maker AV. A propensity score analysis of over 12,000 pancreaticojejunal anastomoses after pancreaticoduodenectomy: does technique impact the clinically relevant fistula rate? HPB (Oxford) 2020; 22:1394-1401. [PMID: 32019740 DOI: 10.1016/j.hpb.2020.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/24/2019] [Accepted: 01/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) remains a major cause of morbidity in patients undergoing pancreatic surgery. Controversy exists as to whether there is any difference in CR-POPF with a Duct-to-Mucosa (DTM) versus an Invagination (IG) pancreaticojejunostomy (PJ). METHODS Demographic, perioperative, intraoperative, and postoperative data were captured from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2014-2017 databases. Potential confounders were included in a logistic regression and a propensity score model. The primary outcome was CR-POPF. RESULTS A total of 12,361 pancreaticojejunal anastomoses were performed with 11,168 patients undergoing DTM (90%) and 1193 undergoing IG (10%) after pancreaticoduodenectomy. Amongst all patients, there was no significant difference in CR-POPF between DTM and IG on multivariate (OR = 0.95, p = 0.64) or propensity score analysis (OR = 0.99, p = 0.93). After stratification by pancreatic gland texture and duct size, there was a decrease in CR-POPF with DTM amongst patients with duct size greater than 6 mm on multivariate analysis (OR = 0.35, p = 0.009) and propensity score analysis (OR = 0.40, p = 0.018). There were no significant differences in any other strata. CONCLUSION DTM or IG technique are not associated with CR-POPF for patients with average size pancreatic ducts; however, DTM is preferable in patients with large pancreatic duct diameter (>6 mm).
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Affiliation(s)
- Lyonell B Kone
- Department of Surgery, Division of Surgical Oncology, University of Illinois, Chicago, IL, USA; Creticos Cancer Center, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Vijay K Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois, Chicago, IL, USA; Creticos Cancer Center, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mihaela Banulescu
- Creticos Cancer Center, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois, Chicago, IL, USA; Creticos Cancer Center, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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11
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Ratnayake CBB, Wells CI, Kamarajah SK, Loveday B, Sen G, French JJ, White S, Pandanaboyana S. Critical appraisal of the techniques of pancreatic anastomosis following pancreaticoduodenectomy: A network meta-analysis. Int J Surg 2020; 73:72-77. [PMID: 31843679 DOI: 10.1016/j.ijsu.2019.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/22/2019] [Accepted: 12/09/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile. METHODS A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistula (ISGPF) definition of POPF. The primary outcome was clinically relevant POPF. RESULTS Five techniques of pancreatic anastomosis following PD were directly compared in 15 RCTs comprising 2428 patients. Panreatojejunostomy (PJ) end-to-side invagination vs. PJ end-to-side duct-to-mucosa was the most frequent comparison (n = 7). Overall, 971 patients underwent PJ end-to-side duct-to-mucosa, 791 patients PJ end-to-side invagination, 505 patients pancreatogastrostomy (PG) end-to-side invagination, 98 patients PG end-to-side duct-to-mucosa, and 63 patients PJ end-to-side single layer. PG duct-to-mucosa was associated with the lowest rates of clinically relevant POPF, delayed gastric emptying, intra-abdominal abscess, all postoperative morbidity and postoperative mortality, the shortest operative time and postoperative hospital stay and the lowest volume of intra-operative blood loss. CONCLUSION Duct-to-mucosa pancreaticogastrostomy was associated with the lowest rates of clinically relevant POPF and had the best outcome profile among all techniques of pancreatico-anastomosis following PD.
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Affiliation(s)
- Chathura B B Ratnayake
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Benjamin Loveday
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Surgery, The Royal Melbourne Hospital, Melbourne, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Gourab Sen
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Jeremy J French
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Steve White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Sanjay Pandanaboyana
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK.
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12
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Cheng Y, He S, Xia J, Ding X, Liu Z, Gong J. Duct-to-mucosa pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Hippokratia 2019. [DOI: 10.1002/14651858.cd013462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Sirong He
- Chongqing Medical University; Department of Immunology, College of Basic Medicine; No. 1 Yixue Road Chongqing China 450000
| | - Jie Xia
- Chongqing Medical University; The Key Laboratory of Molecular Biology on Infectious Diseases; Chongqing China 450000
| | - Xiong Ding
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
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13
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Xiang Y, Wu J, Lin C, Yang Y, Zhang D, Xie Y, Yao X, Zhang X. Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature. Expert Rev Gastroenterol Hepatol 2019; 13:797-806. [PMID: 31282769 DOI: 10.1080/17474124.2019.1640601] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Postoperative pancreatic fistula is the most troublesome complication after pancreaticoduodenectomy, and is an on-going area of concern for pancreatic surgeons. The specific pancreatic reconstruction technique is an important factor influencing the development of postoperative pancreatic fistula after pancreaticoduodenectomy. Areas covered: In this paper, we briefly introduced the definition and relevant influencing factors of postoperative pancreatic fistula. We performed a search of all meta-analyses published in the last 5 years and all published randomized controlled trials comparing different pancreatic anastomotic techniques, and we evaluated the advantages and disadvantages of different techniques. Expert opinion: No individual anastomotic method can completely avoid postoperative pancreatic fistula. Selecting specific techniques tailored to the patient's situation intraoperatively may be key to reducing the incidence of postoperative pancreatic fistula.
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Affiliation(s)
- Yien Xiang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Jiacheng Wu
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Chao Lin
- b Department of Hepatobiliary and Pancreatic Surgery, Jilin University Third Affiliated Hospital , Changchun , Jilin , CN
| | - Yongsheng Yang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Dan Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Yingjun Xie
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xiaoxiao Yao
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xuewen Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
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14
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Wu T, Guo Y, Bi J, Liu S, Guo Y, Bao S. Modified duct-to-mucosa versus conventional pancreaticoenterostomy for pancreaticoduodenectomy: a retrospective cohort study based on propensity score matching analysis. World J Surg Oncol 2019; 17:5. [PMID: 30611270 PMCID: PMC6320616 DOI: 10.1186/s12957-018-1557-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/27/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the most common neopathy after pancreatoduodenectomy (PD). An ideal pancreaticoenterostomy (PE) which can effectively reduce the incidence of CR-POPF and its potential neopathy is needed. We aimed to assess the efficacy of our modified duct-to-mucosa PE in the PD. METHOD From January 2011 to December 2017, 233 consecutive patients with PD were retrospectively included from Shenzhen People's Hospital. After propensity score matching (PSM), there were 82 patients in both the modified duct-to-mucosa PE group (group A) and the conventional end-to-side inserting PE group (group B), respectively. The clinical course and the incidence of postoperative neopathy were compared between groups. Logistic regression method was utilized to analyze the association between PE approach and CR-POPF. RESULTS The PE time was shorter in group A (9.3 ± 1.8 min vs. 21.5 ± 2.8 min, P < 0.001). The group A had significantly lower incidence of severe neopathy (Clavien-Dindo grade > II) [7.3% (5/82) vs. 17.1% (14/82), P = 0.028] and incidence of CR-POPF [1.2% (1/82) vs. 19.5% (12/82), P < 0.001] than the group B. Our modified duct-to-mucosa PE technique was associated with a reduced risk for CR-POPF (OR, 0.11 [95% CI, 0.02-0.57]; P = 0.009) as compared with the conventional end-to-side inserting PE. CONCLUSION Compared with conventional end-to-side inserting PE, our modified duct-to-mucosa PE technique can effectively reduce the incidences of postoperative neopathy and CR-POPF. TRIAL REGISTRATION Researchregistry3877 . Registered 24 March 2018. Retrospectively registered.
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Affiliation(s)
- Tianchong Wu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Yuehua Guo
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Jiangang Bi
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Shuwang Liu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Yusheng Guo
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China
| | - Shiyun Bao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Medical College, Shenzhen People's Hospital, Jinan University, Shenzhen, 518020, Guangdong Province, China.
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15
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Affiliation(s)
- William E Fisher
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Elkins Pancreas Center, Baylor College of Medicine, 6620 Main Street, Suite 1425, Houston, TX 77030, USA.
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16
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Wang W, Zhang Z, Gu C, Liu Q, Liang Z, He W, Chen J, Lai J. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: A network meta-analysis of randomized control trials. Int J Surg 2018; 57:111-116. [PMID: 29777880 DOI: 10.1016/j.ijsu.2018.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 03/03/2018] [Accepted: 04/02/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND A number of pancreatic anastomosis methods for pancreaticoduodenectomy including pancreaticogastrostomy(PG), duct-to-mucosa pancreaticojejunostomy(duct-to-mucosa PJ), invagination pancreaticojejunostomy(invagination PJ) and binding pancreaticojejunostomy(BPJ), but the optimal choice remains unclear. We performed a network meta-analysis to synthesize direct and indirect evidence to identify the optimal choice for pancreatic anastomosis after pancreaticoduodenectomy METHODS: We searched the Embase, PubMed and Cochrane library databases for randomized control trials. The relative risk (RR) and its 95% confidence interval (CI) were calculated. The primary outcome is postoperative pancreatic fistula (POPF). RESULT In total, 16 RCT studies, including a total of 2396 patients, met our criteria. The results showed that PG is not superior to invagination PJ (RR 0.70 95%CI: 0.35-1.39) and duct-to-mucosa PJ (RR 0.58 95%CI: 0.30-1.10) according to the ISGPS definition. Furthermore PG cannot reduce the POPF rates than invagination PJ (RR 0.51 95%CI: 0.2-1.21) and duct-to-mucosa PJ (RR 0.46 95%CI: 0.16-1.14) according to the soft pancreatic texture. BPJ might reduce the incidence of POPF than duct-to-mucosa PJ (RR 0.00 95%CI: 0.00-0.04), invagination PJ (RR 0.00 95%CI: 0.00-0.03), PG (RR 0.00 95%CI: 0.00-0.03), but the results have major limitations with only one RCT reported BPJ and different definition of POPF. CONCLUSION There are no significant differences among BPJ, duct-to-mucosa PJ, invagination PJ and PG in the prevention of POPF, overall morbidity, mortality and DGE. However, further randomized controlled trials should be undertaken to ascertain these findings, especially for BPJ.
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Affiliation(s)
- Weidong Wang
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Zhaohui Zhang
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China
| | - Chichang Gu
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Qingbo Liu
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China
| | - Zhiqiang Liang
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Wei He
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Jianping Chen
- Second Department of General Surgery, Shunde Hospital, Southern Medical University, China
| | - Jiaming Lai
- Department of Pancreatico-Biliary Surgery, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China.
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17
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Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a review of traditional and emerging concepts. Clin Exp Gastroenterol 2018; 11:105-118. [PMID: 29588609 PMCID: PMC5858541 DOI: 10.2147/ceg.s120217] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF.
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Affiliation(s)
- Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, Australia
| | - Saxon J Connor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Australian Pancreatic Centre, Sydney, Australia
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