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REDUCTION IN THE RATE AND SEVERITY OF POSTOPERATIVE PANCREATIC FISTULA CAN BE ACHIEVED BY SELECTIVE USE OF PANCREATICOGASTROSTOMY
George Kazantsev*, Austin L. Spitzer, Peter Peng, Rene Ramirez, CK Chang
Surgery, Kaiser Permanente, Oakland, CA
Postoperative pancreatic fistula (POPF) continues to dominate the spectrum of complications of pancreaticoduodenectomy. We have previously presented retrospective data indicating that pancreaticogastrostomy (PG) may lead to substantial decrease in POPF rate compared to pancreaticojejunostomy (PJ), especially in patients with so called “high-risk pancreatic remnant”. Below we present more compelling evidence that selective application of PG leads to reduction in the rate and severity of POPF.
A retrospective chart review of all cases of PD performed between 2009 and 2016 was conducted with respect to type of the procedure, diagnosis, clinical and biochemical parameters, intraoperative gland assessment (soft vs. hard), duct size (<3mm was considered small) and postoperative outcomes. The pancreatic remnant was classified as “high-risk” if at least one risk factor (soft gland, small duct) was present. POPF was evaluated according to ISGPF classification.
A total of 141 patients underwent PD at a single institution for malignant (74.5%) and benign disease (25.5%). Pylorus preservation was achieved in 73.8% and vascular resection/reconstruction was required in 14.9% of cases. PG was done in 49 (34.8%) and PJ in 92 (70.6%) patients. The choice of procedure was up to the individual surgeon. All PGs were done for high-risk remnant while PJ was performed in both groups. Two early deaths occurred (1.4%), neither related to POPF. Clinically relevant POPF (Grade B and C) developed in 15 patients (10.8%); no significant difference between PG and PJ was observed (8.3% vs. 11.1%). Subgroup analysis revealed that the majority of leaks after PJ occurred in patients with high risk remnants: 32% vs. 4.5%, p=0.005. In contrast, PG performed in a similar group of patients, was associated with significantly lower POPF rate: 8.3% vs. 32%, p=0.016, see Table). All cases of POPF in PG group were Grade B only; 3 Grade C and 5 Grade B leaks occurred in “high risk” PJ subgroup. Gland texture, risk group affiliation, BMI, but not the duct size or blood loss, were strong predictors of POPF on univariate analysis. Gland texture appeared to be the strongest predictor on multivariate analysis. Based on observed leak rates, use of PG in all “high-risk” cases could potentially lead to 75% reduction in the rate of POPF.
We conclude that PJ remains the procedure of choice in patients with low-risk gland remnant (hard pancreas, large duct) as the rate of POPF is low. In patients with “high-risk”( soft pancreas and/or small duct) remnant PG offers substantial reduction in the rate and severity of POPF compared to PJ and should be the preferred method of reconstruction in these cases. More prospectively collected data is required to test this hypothesis, but the retrospective results hold promise.
Incidence of clinically significant POPF depending on the type of pancreatic remnant and anastomosis type.
| Procedure | # | POPF(%) | P value | | PJ, low risk | 66 | 3(4.5%) | 0.005* | | PJ, high risk | 25 | 8(32%) | | | PG, high risk | 48 | 4(8.3%) | 0.016** |
*PJ, low risk vs. PJ, high risk; **PJ, high risk vs. PG (no PG done for low risk)
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