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.

Predictive nomogram for postoperative pancreatic fistula following pancreaticoduodenectomy: a retrospective study

Background

Postoperative pancreatic fistula (POPF) represents the most common complication following pancreaticoduodenectomy (PD). Predictive models are needed to select patients with a high risk of POPF. This study was aimed to establish an effective predictive nomogram for POPF following PD.

Methods

Consecutive patients who had undergone PD between January 2016 and May 2020 at a single institution were analysed retrospectively. A predictive nomogram was established based on a training cohort, and Lasso regression and multivariable logistic regression analysis were used to evaluate predictors. The predictive abilities of the predicting model were assessed for internal validation by the area under the receiver operating characteristic curve (AUC) and calibration plot using bootstrap resampling. The performance of the nomogram was compared with that of the currently used a-FRS model.

Results

A total of 459 patients were divided into a training cohort (n = 302) and a validation cohort (n = 157). No significant difference was observed between the two groups with respect to clinicopathological characteristics. The POPF rate was 16.56%. The risk factors of POPF POPF were albumin difference, drain amylase value on postoperative day 1, pancreas texture, and BMI, which were all selected into a nomogram. Nomogram application revealed good discrimination (AUC = 0.87, 95% CI: 0.81–0.94, P <  0.001) as well as calibration abilities in the validation cohort. The predictive value of the nomogram was better than that of the a-FRS model (AUC: 0.87 vs 0.62, P <  0.001).

Conclusions

This predictive nomogram could be used to evaluate the individual risk of POPF in patients following PD, and albumin difference is a new, accessible predictor of POPF after PD.

Trial registration

This study was registered in the Chinese Clinical Trial Register (ChiCTR2000034435).

Intraoperative Shear Wave Elastography as a Quantitative Predictor of Pancreatic Fibrosis and Exocrine Function

BACKGROUND/AIM

Soft pancreatic texture is a risk factor for postoperative pancreatic fistula (POPF). However, conventional evaluation of pancreatic texture is largely dependent on subjective assessment and lacks quantitative parameters. The study aimed to use ultrasonic shear wave elastography (SWE) to evaluate pancreatic stiffness to determine if the intraoperative SWE measurement could be a quantitative predictor for POPF.

PATIENTS AND METHODS

Fifteen patients scheduled for pancreaticoduodenectomy were included. Both pre- and intra-operative measurement of the pancreatic SWE index (SWEI) were evaluated. Relationships between intraoperative and preoperative SWEI, pathological fibrosis of the resected pancreatic specimen, postoperative exocrine function of the remnant pancreas, and the incidence of POPF were evaluated.

RESULTS

The intraoperative SWEI was correlated with the preoperative SWEI, pathological fibrosis of pancreatic tissue, and pancreatic exocrine function.

CONCLUSION

Intraoperative SWE measurement of pancreatic elasticity may be useful as a quantitative method for evaluating pancreatic fibrosis and exocrine function.

Pancreatic fistulas following distal pancreatectomy are unrelated to the texture quality of the pancreas

PURPOSE

The relevance of pancreatic texture for pancreatic fistula (POPF) formation after distal pancreatectomy (DP) remains ill defined. Recent POPF definition adjustments and common subjective pancreatic texture assessment are further drawbacks in the investigation of pancreatic texture as a factor for POPF development after DP.

METHODS

The predictive value of pancreatic texture by histologic assessment was investigated for POPF formation after DP, respecting the updated 2016 fistula definition. Histologic evaluation at the resection margin included amount of steatosis, degree of fibrosis, and pancreatic duct size.

RESULTS

A total of 102 patients who underwent DP were included. Thirty-six patients developed POPF. There was no difference in histologic variables in patients with and without POPF. In the univariate analysis, none of the three histologic features showed significant correlation with POPF formation. The ROC (receiver operating characteristic) curve demonstrated poor utility for the grade of steatosis 0.481 ± 0.058 (p = 0.75) and grade of fibrosis 0.466 ± 0.058 (p = 0.57) as predictive factors for POPF formation.

CONCLUSION

Results indicate that pancreatic texture does not predict POPF formation following DP. This is particularly relevant in the context of the increasing use of robotic and laparoscopic approaches for DPs with limited clinical pancreatic texture assessment by palpation.

Albumin difference as a new predictor of pancreatic fistula following distal pancreatectomy: a retrospective study of 211 consecutive patients

PURPOSE

The level of albumin declines after surgery, and whether the difference between preoperative and postoperative albumin levels on postoperative day 1 has an effect on the development of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) is unclear. Our aim was to evaluate the effect of albumin difference on POPF.

METHODS

A retrospective analysis of consecutive patients who had undergone DP between January 2016 and October 2018 at a single institution was conducted. Patient demographic data and perioperative data were analysed using univariate and multivariate models. Pancreatic fistula was defined by the 2016 International Study Group of Pancreatic Surgery criteria. All patients were followed for up to 90 days.

RESULTS

A total of 211 consecutive patients were identified. The POPF rate was 15.64%, and no 90-day mortality was observed. Five predictors were independently associated with POPF: albumin difference (OR 6.60, 95% CI 2.36-18.45, P < 0.001), pancreatic texture (OR 4.15, 95% CI 1.62-10.63, P = 0.003), operative time (OR 3.13, 95% CI 1.19-8.24, P = 0.021), intraoperative fluid transfusion (OR 4.85, 95% CI 1.70-13.79, P = 0.003), and cardiovascular disease (OR 5.38, 95% CI 1.99-14.55, P = 0.001).

CONCLUSIONS

Although DP can be performed with a low rate of mortality, POPF remains a common complication. Albumin difference is a new, accessible predictor for POPF following DP.