Risk Factors and Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy: Single-center Experience

Abstract

Pancreatic fistula (PF) remains the most frequent complication after pancreaticoduodenectomy (PD). This study was undertaken to explore the risk factors of postoperative PF following PD and discuss the management of PF in our center. A single-center respective study, involving 241 patients who underwent PD between September 2015 and June 2018, was conducted. Differences in the demographic data, preoperative, intraoperative and postoperative variables between the group with PF [International Study Group on Pancreatic Surgery (ISGPS) grade B/C] and the group without PF (no PF and ISGPS grade BL) were evaluated. The diagnosis and grading of PF were in strict accordance with ISGPS. Risk factors were analyzed by univariate analysis and multivariate logistic regression analysis. The results showed that postoperative PF occurred in 50 (20.7%) of the patients; 25 (10.4%) patients had a PF type BL, 46 (19.1%) patients developed a PF type B and 4 (1.6%) had a PF type C. Univariate analysis showed that fasting blood glucose (P=0.02), pancreatic texture (P< 0.001) and pancreatic duct diameter (P=0.01) were correlated with PF. Multivariate logistic regression analysis identified one independent risk factor for postoperative PF: soft pancreatic texture (OR=3.251, P=0.002). Among the cases, there were three postoperative deaths, giving a 60-day hospital mortality rate of 1.2% (3/241), and the mortality related to PF was 4.0% (2/50). One of the patients died from multiple organ failure caused by postoperative abdominal hemorrhage. In conclusion, soft pancreatic texture is an independent risk factor for PF. Surgeons should be well aware of this risk factor when performing a PD.

Keywords

pancreaticoduodenectomy / pancreatic fistulae / risk factors / complication / pancreatic texture

References

[1] CharlesG. Carcinoma of duodenum: one-stage radical pancreaticoduodenectomy, preserving the external pancreatic secretion. Ann Surg, 1943, 118(5): 838-842

[2] CameronJL, RiallTS, ColemanJ, et al.. One thousand consecutive pancreaticoduodenectomies. Ann Surg, 2006, 244(1): 10-15

[3] DeOliveiraML, WinterJM, SchaferM, et al.. Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg, 2006, 244(6): 931-937 discussion 937–939

[4] HamanakaY, NishiharaK, HamasakiT, et al.. Pancreatic juice output after pancreatoduodenectomy in relation to pancreatic consistency, duct size, and leakage. Surgery, 1996, 119(3): 281-287

[5] van Berge HenegouwenMI, De WitLT, Van GulikTM, et al.. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg, 1997, 185(1): 18-24

[6] TaniM, OnishiH, KinoshitaH, et al.. The evaluation of duct-to-mucosal pancreaticojejunostomy in pancreaticoduodenectomy. World J Surg, 2005, 29(1): 76-79

[7] BassiC, FalconiM, MolinariE, et al.. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg, 2005, 242(6): 767-771 discussion 771–773

[8] PanSB, GengW, ZhouDC, et al.. One-layer versus two-layer duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: study protocol for a randomized controlled trial. Trials, 2016, 17(1): 407

[9] FujiiT, SugimotoH, YamadaS, et al.. Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study. J Gastrointest Surg, 2014, 18(6): 1108-1115

[10] WinterJM, CameronJL, CampbellKA, et al.. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg, 2006, 10(9): 1280-90 discussion 1290

[11] BassiC, FalconiM, MolinariE, et al.. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial. Surgery, 2003, 134(5): 766-771

[12] PengSY, WangJW, LauWY, et al.. Conventional Versus Binding Pancreaticojejunostomy After Pancreaticoduodenectomy. Ann Surg, 2007, 245(5): 692

[13] ShanYS, SyED, LinPW. Role of somatostatin in the prevention of pancreatic stump-related morbidity following elective pancreaticoduodenectomy in high-risk patients and elimination of surgeon-related factors: prospective, randomized, controlled trial. World J Surg, 2003, 27(6): 709-714

[14] YangF, JinC, FuD. Pasireotide for postoperative pancreatic fistula. N Engl J Med, 2014, 371(9): 875

[15] KakitaA, TakahashiT, YoshidaM, et al.. A simpler and more reliable technique of pancreatojejunal anastomosis. Surg Today, 1996, 26(7): 532-535

[16] PengS, MouY, CaiX, et al.. Binding pancreaticojejunostomy is a new technique to minimize leakage. Am J Surg, 2002, 183(3): 283-285

[17] BuchlerM, FriessH, KlempaI, et al.. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am J Surg, 1992, 163(1): 125-30 discussion 130–131

[18] MontorsiM, ZagoM, MoscaF, et al.. Efficacy of octreotide in the prevention of pancreatic fistula after elective pancreatic resections: a prospective, controlled, randomized clinical trial. Surgery, 1995, 117(1): 26-31

[19] LermiteE, PessauxP, BrehantO, et al.. Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy. J Am Coll Surg, 2007, 204(4): 588-596

[20] LiuQY, ZhangWZ, XiaHT, et al.. Analysis of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy. World J Gastroenterol, 2014, 20(46): 17491-17497

[21] HuBY, WanT, ZhangWZ, et al.. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol, 2016, 22(34): 7797-7805

[22] PrattWB, CalleryMP, VollmerCMJr. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg, 2008, 32(3): 419-28

[23] MuscariF, SucB, KirzinS, et al.. Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients. Surgery, 2006, 139(5): 591-598

[24] LinJW, CameronJL, YeoCJ, et al.. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg, 2004, 8(8): 951-959

[25] BassiC, DervenisC, ButturiniG, et al.. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery, 2005, 138(1): 8-13

[26] BassiC, MarchegianiG, DervenisC, et al.. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery, 2017, 161(3): 584-591

[27] ShrikhandeSV, D’SouzaMA. Pancreatic fistula after pancreatectomy: evolving definitions, preventive strategies and modern management. World J Gastroenterol, 2008, 14(38): 5789-5796

[28] BarretoG, D’SouzaMA, ShuklaPJ, et al.. The gray zone between postpancreaticoduodenectomy collections and pancreatic fistula. Pancreas, 2008, 37(4): 422-425

[29] Munoz-BongrandN, SauvanetA, DenysA, et al.. Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy. J Am Coll Surg, 2004, 199(2): 198-203

[30] StojadinovicA, BrooksA, HoosA, et al.. An evidence-based approach to the surgical management of resectable pancreatic adenocarcinoma. J Am Coll Surg, 2003, 196(6): 954-64

[31] GouillatC, ChipponiJ, BaulieuxJ, et al.. Randomized controlled multicentre trial of somatostatin infusion after pancreaticoduodenectomy. Br J Surg, 2001, 88(11): 1456-1462

[32] ConlonKC, LabowD, LeungD, et al.. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg, 2001, 234(4): 487-93 discussion 493–494

[33] CullenJJ, SarrMG, IlstrupDM. Pancreatic anastomotic leak after pancreaticoduodenectomy: incidence, significance, and management. Am J Surg, 1994, 168(4): 295-298

[34] YekebasEF, WolframL, CataldegirmenG, et al.. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg, 2007, 246(2): 269-280

[35] RezvaniM, O’MoorePV, PezziCM. Late pancreaticojejunostomy stent migration and hepatic abscess after Whipple procedure. J Surg Educ, 2007, 64(4): 220-223

[36] AndrianelloS, PeaA, PulvirentiA, et al.. Pancreaticojejunostomy after pancreaticoduodenectomy: Suture material and incidence of post-operative pancreatic fistula. Pancreatology, 2016, 16(1): 138-141

[37] KatsaragakisS, LarentzakisA, PanousopoulosSG, et al.. A new pancreaticojejunostomy technique: a battle against postoperative pancreatic fistula. World J Gastroenterol, 2013, 19(27): 4351-4355

[38] ShrikhandeSV, BarretoSG, SomashekarBA, et al.. Evolution of pancreatoduodenectomy in a tertiary cancer center in India: Improved results from service reconfiguration. Pancreatology, 2013, 13(1): 63-71

[39] WeberCE, BockEA, HurtukMG, et al.. Clinical and pathologic features influencing survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. J Gastrointest Surg, 2014, 18(2): 340-347

[40] AddeoP, DelperoJR, PayeF, et al.. Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association. HPB (Oxford), 2014, 16(1): 46-55

[41] TakanoS, ItoY, WatanabeY, et al.. Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy. Br J Surg, 2000, 87(4): 423-427

[42] OussoultzoglouE, BachellierP, BigourdanJM, et al.. Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy. Arch Surg, 2004, 139(3): 327-335

[43] MenahemB, GuittetL, MulliriA, et al.. Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials. Ann Surg, 2015, 261(5): 882-887

[44] DuffasJP, SucB, MsikaS, et al.. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg, 2005, 189(6): 720-729

[45] BuccolieroF, PansiniGC, MascoliF, et al.. Somatostatin in duodenocephalopancreatectomy for neoplastic pathology. Minerva Chir, 1992, 47(8): 713-716

[46] LowyAM, LeeJE, PistersPW, et al.. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg, 1997, 226(5): 632-641

[47] ConnorS, AlexakisN, GardenOJ, et al.. Meta-analysis of the value of somatostatin and its analogues in reducing complications associated with pancreatic surgery. Br J Surg, 2005, 92(9): 1059-1067

[48] GagnerM, PompA. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc, 1994, 8(5): 408-410

[49] KendrickML, van HilstJ, BoggiU, et al.. Minimally invasive pancreatoduodenectomy. HPB (Oxford), 2017, 19(3): 215-224

[50] TranTB, DuaMM, WorhunskyDJ, et al.. The First Decade of Laparoscopic Pancreaticoduodenectomy in the United States: Costs and Outcomes Using the Nationwide Inpatient Sample. Surg Endosc, 2016, 30(5): 1778-1783

[51] WangM, ZhangH, WuZ, et al.. Laparoscopic pancreaticoduodenectomy: single-surgeon experience. Surg Endosc, 2015, 29(12): 3783-3794

[52] CroomeKP, FarnellMB, QueFG, et al.. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches?. Ann Surg, 2014, 260(4): 633-638 discussion 638–640

[53] SongKB, KimSC, HwangDW, et al.. Matched Case-Control Analysis Comparing Laparoscopic and Open Pylorus-preserving Pancreaticoduodenectomy in Patients with Periampullary Tumors. Ann Surg, 2015, 262(1): 146-155

[54] NassourI, WangSC, ChristieA, et al.. Minimally Invasive Versus Open Pancreaticoduodenectomy: A Propensity-matched Study from a National Cohort of Patients. Ann Surg, 2018, 268(1): 151-157

[55] DokmakS, FtericheFS, AussilhouB, et al.. Laparoscopic pancreaticoduodenectomy should not be routine for resection of periampullary tumors. J Am Coll Surg, 2015, 220(5): 831-838

[56] de CastroSM, BuschOR, van GulikTM, et al.. Incidence and management of pancreatic leakage after pancreatoduodenectomy. Br J Surg, 2005, 92(9): 1117-1123

[57] PoonRT, LoSH, FongD, et al.. Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg, 2002, 183(1): 42-52

[58] FrymermanAS, SchuldJ, ZiehenP, et al.. Impact of postoperative pancreatic fistula on surgical outcome-the need for a classification-driven risk management. J Gastrointest Surg, 2010, 14(4): 711-718

[59] SuzukiY, FujinoY, TaniokaY, et al.. Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size. Arch Surg, 2002, 137(9): 1044-1047 discussion 1048

[60] SatoN, YamaguchiK, ChijiiwaK, et al.. Risk analysis of pancreatic fistula after pancreatic head resection. Arch Surg, 1998, 133(10): 1094-1098

[61] SatoN, YamaguchiK, YokohataK, et al.. Preoperative exocrine pancreatic function predicts risk of leakage of pancreaticojejunostomy. Surgery, 1998, 124(5): 871-876

[62] StrasbergSM, DrebinJA, SoperNJ. Evolution and current status of the Whipple procedure: an update for gastroenterologists. Gastroenterology, 1997, 113(3): 983-994