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Pancreaticogastrostomy Following Pancreaticoduodenectomy Is Associated With Low Re-Operation and Pancreatic Fistula RATES
Jennifer K. Plichta*, Gerard Abood, Eileen O'Halloran, Sam Pappas, Gerard V. Aranha
Department of Surgery, Loyola University Medical Center, Maywood, IL
Introduction: Significant morbidity and mortality following pancreaticoduodenectomy (PD) has been attributed to the potential development of a pancreatic fistula, which has been shown to be as high as 40% in some studies. Our aim was to review the development of post-operative pancreatic fistulas from a consecutive series of PD with pancreaticogastrostomy (PG) patients.
Methods: Retrospective review of a prospective database identified 435 patients who underwent PD with PG between 1996 and 2013. Of these patients, pancreatic texture and duct size data were available for 239 patients. Clinical and pathological data for this subset were reviewed, and statistical analyses using univariate models were performed.
Results: The median age was 66±12 years, with 56% males. Median intra-operative blood loss was 750ml, intra-operative transfusions was 0 units, operative time was 6h, and post-operative length of stay was 8 days. Pathology revealed: 96 pancreatic cancers, 35 ampullary cancers, 14 duodenal cancers, 12 bile duct (CBD) cancers, and 82 other lesions (including IPMN, pancreatitis, neuroendocrine tumors, and others). The post-operative complication rate was 36% (n=86), most commonly pancreatic fistula (11%, n=27), delayed gastric emptying (DGE, 10%, n=24), and wound infection (4.6%, n=11). Three patients (1.3%) required re-operation (1 for a type C fistula and 2 for bleeding), no associated deaths for these patients. However, there were 5 peri-operative mortalities (2%). The development of a post-operative pancreatic fistula was associated with a soft pancreas and pancreatic duct size <3mm. Other factors, including age, pre-operative weight loss, use of intra-operative octreotide, estimated blood loss, intra-operative transfusions, and operative time, were not correlated with fistula formation. Specifically, the pancreatic fistula rate for patients with a soft pancreas was 18%, compared to 6.5% in patients with a firm or hard pancreas. Patients with a pancreatic duct <3mm had a 17% rate of fistula formation, compared to 2.3% in those with a duct >3mm. The rates of pancreatic fistula formation were not significant for benign vs. malignant lesions in general. However, patients with duodenal adenocarcinoma had a statistically significant higher fistula formation rate. The fistula rates for select groups are summarized in Table 1.
Conclusions: Our study demonstrates that PG appears to be associated with overall low fistula formation rates, although the rates are increased with a soft pancreas, pancreatic duct size <3mm, and certain types of peri-ampullary tumors. Overall, it is also associated with low post-operative mortality, re-operation, and fistula.
Pancreatic Fistula Rates
| Pancreatic Fistula Rate | P value | | Overall | 11% | n/a | | Soft pancreas | 18% | 0.006 | | Pancreatic duct <3mm | 17% | 0.001 | | Pancreatic adenocarcinoma | 6.2% | 0.043 | | Ampullary adenocarcinoma | 20% | 0.078 | | Duodenal adenocarcinoma | 29% | 0.035 | | Bile duct adenocarcinoma | 8.3% | 0.739 |
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