Advertisement

Pancreaticogastrostomy as a fistula mitigating strategy for a high-risk pancreatic anastomosis following pancreaticoduodenectomy

Published:October 08, 2022DOI:https://doi.org/10.1016/j.hpb.2022.10.003

      Abstract

      Background

      Clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) has been associated with soft gland texture and/or small pancreatic duct. We hypothesized that selective use of pancreaticogastrostomy (PG) over pancreaticojejunostomy (PJ) in those scenarios would decrease the rate of CR-POPF.

      Methods

      Review of prospective database of all PD’s performed at a single institution between 2009 and 2019 was performed. The pancreatic remnant was deemed “high risk” if soft gland and/or small duct were present.

      Results

      PJ was performed in 199 (147 “low-risk” and 52 “high-risk”) cases, and 110 patients (all “high-risk”) had a PG. Overall CR-POPF rate was 11.9% with no difference between the groups. Risk-stratified analysis within PJ group showed CR-POPF rate of 5.4% versus 36% in “low-risk” versus “high risk” scenarios, respectively; the use of PG significantly decreased CR-POPF rate (9.1%, p < 0.0001). Gastrointestinal bleeding was more likely to occur following PG than PJ. Soft gland texture and gastrointestinal bleeding were the strongest predictors of CR-POPF in PJ and PG groups, respectively.

      Conclusion

      Selective use of PG after PD in “high-risk” scenarios mitigates the risk of CR-POPF. Increased rate of gastrointestinal bleeding calls for further refinement of the technique and heightened postoperative vigilance.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to HPB
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hunt V.C.
        Surgical management of carcinoma of the ampulla of vater and of the periampullary portion of the duodenum.
        Ann Surg. 1941; 114: 570-602
        • Whipple A.O.
        A reminiscence: pancreaticduodenectomy.
        Rev Surg. 1963; 20: 221-225
        • Whipple A.O.
        • Parsons W.B.
        • Mullins C.R.
        Treatment of carcinoma of the ampulla of vater.
        Ann Surg. 1935; 102: 763-779
        • Bassi C.
        • Dervenis C.
        • Butturini G.
        • Fingerhut A.
        • Yeo C.
        • Izbicki J.
        • et al.
        Postoperative pancreatic fistula: an international study group (ISGPF) definition.
        Surgery. 2005; 138: 8-13
        • Cameron J.L.
        • Riall T.S.
        • Coleman J.
        • Belcher K.A.
        One thousand consecutive pancreaticoduodenectomies.
        Ann Surg. 2006; 244: 10-15
        • Marcus S.G.
        • Cohen H.
        • Ranson J.H.
        Optimal management of the pancreatic remnant after pancreaticoduodenectomy.
        Ann Surg. 1995; 221 (; discussion 45-8): 635-645
        • Mirrielees J.A.
        • Weber S.M.
        • Abbott D.E.
        • Greenberg C.C.
        • Minter R.M.
        • Scarborough J.E.
        Pancreatic fistula and delayed gastric emptying are the highest-impact complications after whipple.
        J Surg Res. 2020; 250: 80-87
        • Hank T.
        • Sandini M.
        • Ferrone C.R.
        • Rodrigues C.
        • Weniger M.
        • Qadan M.
        • et al.
        Association between pancreatic fistula and long-term survival in the era of neoadjuvant chemotherapy.
        JAMA Surg. 2019; 154: 943-951
        • Chen H.W.
        • Lai E.C.
        • Su S.Y.
        • Cai Y.F.
        • Zhen Z.J.
        • Lau W.Y.
        Modified technique of pancreaticojejunal anastomosis with invagination following pancreaticoduodenectomy: a cohort study.
        World J Surg. 2008; 32: 2695-2700
        • Grobmyer S.R.
        • Kooby D.
        • Blumgart L.H.
        • Hochwald S.N.
        Novel pancreaticojejunostomy with a low rate of anastomotic failure-related complications.
        J Am Coll Surg. 2010; 210: 54-59
        • Khan A.W.
        • Agarwal A.K.
        • Davidson B.R.
        Isolated Roux Loop duct-to-mucosa pancreaticojejunostomy avoids pancreatic leaks in pancreaticoduodenectomy.
        Dig Surg. 2002; 19: 199-204
        • Peng S.Y.
        • Wang J.W.
        • Lau W.Y.
        • Cai X.J.
        • Mou Y.P.
        • Liu Y.B.
        • et al.
        Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial.
        Ann Surg. 2007; 245: 692-698
        • Poon R.T.
        • Fan S.T.
        • Lo C.M.
        • Ng K.K.
        • Yuen W.K.
        • Yeung C.
        • et al.
        External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial.
        Ann Surg. 2007; 246 (; discussion 33-5): 425-433
        • Shimada K.
        • Sano T.
        • Sakamoto Y.
        • Kosuge T.
        Safe management of the pancreatic remnant with prolamine duct occlusion after extended pancreaticoduodenectomy.
        Hepato-Gastroenterology. 2005; 52: 1874-1877
        • Winter J.M.
        • Cameron J.L.
        • Campbell K.A.
        • Chang D.C.
        • Riall T.S.
        • Schulick R.D.
        • 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 (; discussion 90): 1280-1290
        • Lin J.W.
        • Cameron J.L.
        • Yeo C.J.
        • Riall T.S.
        • Lillemoe K.D.
        Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula.
        J Gastrointest Surg. 2004; 8: 951-959
        • Pratt W.B.
        • Callery M.P.
        • Vollmer Jr., C.M.
        Risk prediction for development of pancreatic fistula using the ISGPF classification scheme.
        World J Surg. 2008; 32: 419-428
        • Shubert C.R.
        • Wagie A.E.
        • Farnell M.B.
        • Nagorney D.M.
        • Que F.G.
        • Reid Lombardo K.M.
        • et al.
        Clinical risk score to predict pancreatic fistula after pancreatoduodenectomy: independent external validation for open and laparoscopic approaches.
        J Am Coll Surg. 2015; 221: 689-698
        • El Nakeeb A.
        • Sultan A.M.
        • Atef E.
        • Salem A.
        • Abu Zeid M.
        • Abu El Eneen A.
        • et al.
        Tailored pancreatic reconstruction after pancreaticoduodenectomy: a single-center experience of 892 cases.
        Hepatobiliary Pancreat Dis Int. 2017; 16: 528-536
        • Jin K.M.
        • Liu W.
        • Wang K.
        • Bao Q.
        • Wang H.W.
        • Xing B.C.
        The individualized selection of pancreaticoenteric anastomosis in pancreaticoduodenectomy.
        BMC Surg. 2020; 20: 140
        • Aranha G.V.
        • Aaron J.M.
        • Shoup M.
        Critical analysis of a large series of pancreaticogastrostomy after pancreaticoduodenectomy.
        Arch Surg. 2006; 141 (; discussion 9-80): 574-579
        • Icard P.
        • Dubois F.
        Pancreaticogastrostomy following pancreatoduodenectomy.
        Ann Surg. 1988; 207: 253-256
        • Mackie J.A.
        • Rhoads J.E.
        • Park C.D.
        Pancreaticogastrostomy: a further evaluation.
        Ann Surg. 1975; 181: 541-545
        • Keck T.
        • Wellner U.F.
        • Bahra M.
        • Klein F.
        • Sick O.
        • Niedergethmann M.
        • et al.
        Pancreatogastrostomy versus pancreatojejunostomy for RECOnstruction after PANCreatoduodenectomy (RECOPANC, DRKS 00000767): perioperative and long-term results of a multicenter randomized controlled trial.
        Ann Surg. 2016; 263: 440-449
        • Topal B.
        • Fieuws S.
        • Aerts R.
        • Weerts J.
        • Feryn T.
        • Roeyen G.
        • et al.
        Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial.
        Lancet Oncol. 2013; 14: 655-662
        • Yeo C.J.
        • Cameron J.L.
        • Maher M.M.
        • Sauter P.K.
        • Zahurak M.L.
        • Talamini M.A.
        • et al.
        A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy.
        Ann Surg. 1995; 222 (; discussion 8-92): 580-588
        • Daamen L.A.
        • Smits F.J.
        • Besselink M.G.
        • Busch O.R.
        • Borel Rinkes I.H.
        • van Santvoort H.C.
        • et al.
        A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy.
        HPB. 2018; 20: 777-785
        • Lyu Y.
        • Li T.
        • Cheng Y.
        • Wang B.
        • Chen L.
        • Zhao S.
        Pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: an up-to-date meta-analysis of RCTs applying the ISGPS (2016) criteria.
        Surg Laparosc Endosc Percutaneous Tech. 2018; 28: 139-146
        • Qin H.
        • Luo L.
        • Zhu Z.
        • Huang J.
        Pancreaticogastrostomy has advantages over pancreaticojejunostomy on pancreatic fistula after pancreaticoduodenectomy. A meta-analysis of randomized controlled trials.
        Int J Surg. 2016; 36: 18-24
        • Wang X.X.
        • Yan Y.K.
        • Dong B.L.
        • Li Y.
        • Yang X.J.
        Pancreatic outflow tract reconstruction after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials.
        World J Surg Oncol. 2021; 19: 203
        • Charlson M.
        • Szatrowski T.P.
        • Peterson J.
        • Gold J.
        Validation of a combined comorbidity index.
        J Clin Epidemiol. 1994; 47: 1245-1251
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Wente M.N.
        • Bassi C.
        • Dervenis C.
        • Fingerhut A.
        • Gouma D.J.
        • Izbicki J.R.
        • et al.
        Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS).
        Surgery. 2007; 142: 761-768
        • Wente M.N.
        • Veit J.A.
        • Bassi C.
        • Dervenis C.
        • Fingerhut A.
        • Gouma D.J.
        • et al.
        Postpancreatectomy hemorrhage (PPH): an international study group of pancreatic surgery (ISGPS) definition.
        Surgery. 2007; 142: 20-25
        • Bassi C.
        • Marchegiani G.
        • Dervenis C.
        • Sarr M.
        • Abu Hilal M.
        • Adham M.
        • et al.
        The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years after.
        Surgery. 2017; 161: 584-591
        • Salvia R.
        • Lionetto G.
        • Perri G.
        • Malleo G.
        • Marchegiani G.
        Total pancreatectomy and pancreatic fistula: friend or foe?.
        Updates Surg. 2021; 73: 1231-1236
        • Cattell R.B.
        A technic for pancreatoduodenal resection.
        Surg Clin. 1948; 28: 761-775
        • Shrikhande S.V.
        • Sivasanker M.
        • Vollmer C.M.
        • Friess H.
        • Besselink M.G.
        • Fingerhut A.
        • et al.
        Pancreatic anastomosis after pancreatoduodenectomy: a position statement by the international study group of pancreatic surgery (ISGPS).
        Surgery. 2017; 161: 1221-1234
        • Waugh J.M.
        • Clagett O.T.
        Resection of the duodenum and head of the pancreas for carcinoma; an analysis of thirty cases.
        Surgery. 1946; 20: 224-232
        • McMillan M.T.
        • Malleo G.
        • Bassi C.
        • Sprys M.H.
        • Vollmer Jr., C.M.
        Defining the practice of pancreatoduodenectomy around the world.
        HPB : the official journal of the International Hepato Pancreato Biliary Association. 2015; 17: 1145-1154
        • Eguia E.
        • O'Halloran E.A.
        • Borge M.A.
        • Micetich K.
        • Aranha G.V.
        Four hundred fifty-three consecutive pancreaticoduodenectomies with pancreaticogastrostomy.
        Am J Surg. 2019; 218: 355-361
        • Figueras J.
        • Sabater L.
        • Planellas P.
        • Munoz-Forner E.
        • Lopez-Ben S.
        • Falgueras L.
        • et al.
        Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy on the rate and severity of pancreatic fistula after pancreaticoduodenectomy.
        Br J Surg. 2013; 100: 1597-1605
        • El Nakeeb A.
        • Hamdy E.
        • Sultan A.M.
        • Salah T.
        • Askr W.
        • Ezzat H.
        • et al.
        Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study.
        HPB. 2014; 16: 713-722
        • Fernandez-Cruz L.
        • Cosa R.
        • Blanco L.
        • Lopez-Boado M.A.
        • Astudillo E.
        Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreatojejunostomy: a prospective randomized study.
        Ann Surg. 2008; 248: 930-938
        • Wellner U.F.
        • Sick O.
        • Olschewski M.
        • Adam U.
        • Hopt U.T.
        • Keck T.
        Randomized controlled single-center trial comparing pancreatogastrostomy versus pancreaticojejunostomy after partial pancreatoduodenectomy.
        J Gastrointest Surg. 2012; 16: 1686-1695
        • Williamsson C.
        • Stenvall K.
        • Wennerblom J.
        • Andersson R.
        • Andersson B.
        • Tingstedt B.
        Predictive factors for postoperative pancreatic fistula-A Swedish nationwide register-based study.
        World J Surg. 2020; 44: 4207-4213
        • Callery M.P.
        • Pratt W.B.
        • Kent T.S.
        • Chaikof E.L.
        • Vollmer Jr., C.M.
        A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy.
        J Am Coll Surg. 2013; 216: 1-14
        • Ecker B.L.
        • McMillan M.T.
        • Asbun H.J.
        • Ball C.G.
        • Bassi C.
        • Beane J.D.
        • et al.
        Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy.
        Ann Surg. 2018; 267: 608-616
        • Ansorge C.
        • Strommer L.
        • Andren-Sandberg A.
        • Lundell L.
        • Herrington M.K.
        • Segersvard R.
        Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy.
        Br J Surg. 2012; 99: 1076-1082
        • Komokata T.
        • Nuruki K.
        • Tada N.
        • Imada R.
        • Aryal B.
        • Kaieda M.
        • et al.
        An invaginated pancreaticogastrostomy following subtotal stomach-preserving pancreaticoduodenectomy: a prospective observational study.
        Asian J Surg. 2021; 44: 1510-1514
        • Standop J.
        • Schafer N.
        • Overhaus M.
        • Schmitz V.
        • Ladwein L.
        • Hirner A.
        • et al.
        Endoscopic management of anastomotic hemorrhage from pancreatogastrostomy.
        Surg Endosc. 2009; 23: 2005-2010