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ARE ALL PANCREATIC FISTULAS CREATED EQUAL? AN ANALYSIS OF FISTULA RATES AND SEVERITY BASED ON OPERATIVE MANAGEMENT FOR HEAD-PREDOMINANT CHRONIC PANCREATITIS AND PERIAMPULLARY MALIGNANCIES
Brent T. Xia*, Vikrom K. Dhar, Nick C. Levinsky, Young Kim, Syed Ahmad
Surgery, University of Cincinnati, Cincinnati, OH
Introduction: Although pancreaticoduodenectomy (PD) has been the traditional surgical approach for patients with head-predominant chronic pancreatitis (CP) who fail conservative management, drainage procedures and duodenal-preserving head resection have demonstrated to be equally as effective in relieving pain and improving quality of life. However, little is known about the postoperative pancreatic fistula rates of these procedures, and its impact on morbidity in comparison to that of PDs performed for malignancies.
Methods: Perioperative data for patients who underwent PD, Berne, and Frey procedures for head-predominant CP, and PDs for periampullary malignancies from 2005 to 2015 were assessed. The International Study Group on Pancreatic Fistula definition was utilized to identify and grade postoperative pancreatic fistulas (POPF). The Clavien-Dindo classification was utilized to grade surgical complications.
Results: The most common etiologies of CP were alcohol (n=46, 43.4%), idiopathic (n=35, 33.0%), and pancreatic divisum (n=14, 13.2%). The majority of patients underwent resective procedures, consisting of PD (n=44, 41.5%), and Berne (n=18, 17.0%). The Frey drainage procedure was utilized in 44 patients (41.5%). The PD, Berne and Frey patient cohorts were well matched with regards to age, gender, body-mass index, duration of disease, and pre-narcotic requirements (all P>0.05). The overall POPF rate was 5.7% (n=6), and consisted of 33.3% (n=2) grade A, 50% (n=3) grade B, and 16.7% (n=1) grade C fistulas. Despite worse perioperative metrics with regards to operative time, estimated blood loss, and length of stay (all P<0.01) in the PD cohort, there were no differences in the POPF rates (PD vs. Berne vs. Frey; 4.5% vs. 5.6% vs. 6.8%; P=0.74). Overall, POPFs were neither associated with increased length of stay (P=0.91) nor greater complication grades (P=0.20). Among 216 patients who underwent PD for periampullary malignancies, the POPF rate (n=28, 13%) was significantly higher than that of the CP cohort (P=0.04). Although the distribution of grade A (n=6, 21.4%), B (n=16, 57.2%) and C (n=6, 21.4%) fistulas were similar to that of the CP cohort (P=0.84), POPFs in the periampullary malignancy cohort were associated with increased length of stay (15.8 vs. 11.7 days, P<0.01) and higher complication grades (P<0.01).
Conclusions: Postoperative pancreatic fistulas occur less frequently and with less morbidity in patients with head-predominant chronic pancreatitis compared to patients with periampullary malignancies. Although pancreaticoduodenectomy is associated with worse perioperative metrics compared to the Berne and Frey procedures for patients with chronic pancreatitis, there is no difference in the postoperative rate of pancreatic fistulas.
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