Comparison of two anastomosis techniques in terms of postoperative pancreatic fistula development: A retrospective cohort study

Postoperative pancreatic fistula and anastomosis techniques

Authors

Keywords:

pancreaticoduodenectomy, pancreaticojejunostomy, pancreatic fistula, postoperative complications, jejunum, serosa

Abstract

Background/Aim: Postoperative pancreatic fistula (POPF) development is a common complication after pancreaticoduodenectomy. Various surgical anastomosis techniques have been proposed to mitigate this risk. This study compares two techniques: the two-layer duct-to-mucosa pancreaticojejunostomy (TLPJ) and the modified layer-to-layer end-to-side duct-to-mucosa pancreaticojejunostomy with jejunal serosa resection (MLLPJ).

Methods: A retrospective cohort study was conducted on patients who underwent pancreaticoduodenectomy between January 2012 and December 2020. The primary outcome was the rate of biochemical leak and clinically relevant POPF (grades B and C POPFs).

Results: The rate of biochemical leak was significantly higher in the TLPJ group than in the MLLPJ group (54.5% vs. 4.0%, P<0.001). Clinically relevant POPFs developed in 5.2% of all patients, with rates of 6.1% in the TLPJ group and 4.0% in the MLLPJ group. Patients with longer surgery durations, increased bleeding, and a soft pancreas texture had significantly higher risk of developing clinically relevant POPFs (P=0.009, P=0.039, and P=0.022, respectively).

Conclusion: The MLLPJ anastomosis technique demonstrated a significant reduction in biochemical leak rates. However, the choice between TLPJ and MLLPJ did not significantly impact the rates of clinically relevant POPFs. Other factors, such as surgery duration, bleeding volume, and pancreas texture, were identified as significant risk factors for the development of these fistulas.

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References

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394-424. doi: 10.3322/caac.21492. DOI: https://doi.org/10.3322/caac.21492

Chen BP, Bennett S, Bertens KA, Balaa FK, Martel G. Use and acceptance of the International Study Group for Pancreatic Fistula (ISGPF) definition and criteria in the surgical literature. HPB (Oxford). 2018 Jan;20(1):69-75. doi: 10.1016/j.hpb.2017.08.022. DOI: https://doi.org/10.1016/j.hpb.2017.08.022

Fu SJ, Shen SL, Li SQ, Hu WJ, Hua YP, Kuang M, et al. Risk factors and outcomes of postoperative pancreatic fistula after pancreatico-duodenectomy: an audit of 532 consecutive cases. BMC Surg. 2015 Mar 26;15:34. doi: 10.1186/s12893-015-0011-7. DOI: https://doi.org/10.1186/s12893-015-0011-7

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 Mar;161(3):584-91. doi: 10.1016/j.surg.2016.11.014. DOI: https://doi.org/10.1016/j.surg.2016.11.014

Ke Z, Cui J, Hu N, Yang Z, Chen H, Hu J, et al. Risk factors for postoperative pancreatic fistula: Analysis of 170 consecutive cases of pancreaticoduodenectomy based on the updated ISGPS classification and grading system. Medicine (Baltimore). 2018 Aug;97(35):e12151. doi: 10.1097/MD.0000000000012151. DOI: https://doi.org/10.1097/MD.0000000000012151

Pedrazzoli S. Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore). 2017 May;96(19):e6858. doi: 10.1097/MD.0000000000006858. DOI: https://doi.org/10.1097/MD.0000000000006858

Satoi S, Yamamoto T, Yanagimoto H, Yamaki S, Kosaka H, Hirooka S, et al. Does modified Blumgart anastomosis without intra-pancreatic ductal stenting reduce post-operative pancreatic fistula after pancreaticojejunostomy? Asian J Surg. 2019 Jan;42(1):343-9. doi: 10.1016/j.asjsur.2018.06.008. DOI: https://doi.org/10.1016/j.asjsur.2018.06.008

Liang H, Wu JG, Wang F, Chen BX, Zou ST, Wang C, et al. Choice of operative method for pancreaticojejunostomy and a multivariable study of pancreatic leakage in pancreaticoduodenectomy. World J Gastrointest Surg. 2021 Nov 27;13(11):1405-13. doi: 10.4240/wjgs.v13.i11.1405. DOI: https://doi.org/10.4240/wjgs.v13.i11.1405

Fujii T, Sugimoto H, Yamada S, Kanda M, Suenaga M, Takami H, et al. Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study. J Gastrointest Surg. 2014 Jun;18(6):1108-15. doi: 10.1007/s11605-014-2523-3. DOI: https://doi.org/10.1007/s11605-014-2523-3

Su AP, Zhang Y, Ke NW, Lu HM, Tian BL, Hu WM, et al. Triple-layer duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa decreased pancreatic fistula after pancreaticoduodenectomy. J Surg Res. 2014 Jan;186(1):184-91. doi: 10.1016/j.jss.2013.08.029. DOI: https://doi.org/10.1016/j.jss.2013.08.029

Hashimoto D, Hirota M, Yagi Y, Baba H. End-to-side pancreaticojejunostomy without stitches in the pancreatic stump. Surg Today. 2013 Jul;43(7):821-4. doi: 10.1007/s00595-012-0371-x. DOI: https://doi.org/10.1007/s00595-012-0371-x

Hayashibe A, Kameyama M. Duct-to-mucosa pancreaticojejunostomies with a hard pancreas and dilated pancreatic duct and duct-to-mucosa pancreaticojejunostomies with a soft pancreas and non-dilated duct. HPB (Oxford). 2008;10(1):54-7. doi: 10.1080/13651820701883130. DOI: https://doi.org/10.1080/13651820701883130

Hayashibe A, Kameyama M. The clinical results of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy in consecutive 55 cases. Pancreas. 2007 Oct;35(3):273-5. doi: 10.1097/MPA.0b013e3180676dc2. DOI: https://doi.org/10.1097/MPA.0b013e3180676dc2

Hayashibe A, Sakamoto K, Shinbo M, Makimoto S, Nakamoto T. The surgical procedure and clinical results of the duct to mucosa pancreaticojejunostomies with resection of jejunal serosa. Int J Surg. 2005;3(3):188-92. doi: 10.1016/j.ijsu.2005.07.001. DOI: https://doi.org/10.1016/j.ijsu.2005.07.001

Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V. Fast-track recovery programme after pancreatico- duodenectomy reduces delayed gastric emptying. Br J Surg. 2008 Nov;95(11):1387-93. doi: 10.1002/bjs.6324. DOI: https://doi.org/10.1002/bjs.6324

Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205-13. doi: 10.1097/01.sla.0000133083.54934.ae. DOI: https://doi.org/10.1097/01.sla.0000133083.54934.ae

Halle-Smith JM, Pande R, Hall L, Hodson J, Roberts KJ, Arshad A, et al. Perioperative interventions to reduce pancreatic fistula following pancreatoduodenectomy: meta-analysis. Br J Surg. 2022 Aug 16;109(9):812-21. doi: 10.1093/bjs/znac074. DOI: https://doi.org/10.1093/bjs/znab430.261

Hai H, Li Z, Zhang Z, Cheng Y, Liu Z, Gong J, et al. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev. 2022 Mar 15;3(3):CD013462. doi: 10.1002/14651858.CD013462.pub2. DOI: https://doi.org/10.1002/14651858.CD013462.pub2

Fernández-Cruz L, Belli A, Acosta M, Chavarria EJ, Adelsdorfer W, López-Boado MA, et al. Which is the best technique for pancreaticoenteric reconstruction after pancreaticoduodenectomy? A critical analysis. Surg Today. 2011 Jun;41(6):761-6. doi: 10.1007/s00595-011-4515-1. DOI: https://doi.org/10.1007/s00595-011-4515-1

Zeng ZL, Sun Y, Xue D, Liu PL, Chen WM, Zhang L. Effect of six-stitch pancreaticojejunostomy on pancreatic fistula: A propensity score-matched comparative cohort study. Hepatobiliary Pancreat Dis Int. 2020 Jun;19(3):277-83. doi: 10.1016/j.hbpd.2020.04.006. DOI: https://doi.org/10.1016/j.hbpd.2020.04.006

Kone LB, Maker VK, Banulescu M, Maker AV. A propensity score analysis of over 12,000 pancreaticojejunal anastomoses after pancreaticoduodenectomy: does technique impact the clinically relevant fistula rate? HPB (Oxford). 2020 Oct;22(10):1394-401. doi: 10.1016/j.hpb.2020.01.002. DOI: https://doi.org/10.1016/j.hpb.2020.01.002

Ibrahim S, Tay KH, Launois B, Ta NC. Triple-layer duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy. Dig Surg. 2006;23(5-6):296-302. doi: 10.1159/000096244. DOI: https://doi.org/10.1159/000096244

Van Buren G 2nd, Bloomston M, Hughes SJ, Winter J, Behrman SW, Zyromski NJ, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg. 2014 Apr;259(4):605-12. doi: 10.1097/SLA.0000000000000460. DOI: https://doi.org/10.1097/SLA.0000000000000460

McMillan MT, Allegrini V, Asbun HJ, Ball CG, Bassi C, Beane JD, et al. Incorporation of Procedure-specific Risk Into the ACS-NSQIP Surgical Risk Calculator Improves the Prediction of Morbidity and Mortality After Pancreatoduodenectomy. Ann Surg. 2017 May;265(5):978-86. doi: 10.1097/SLA.0000000000001796. DOI: https://doi.org/10.1097/SLA.0000000000001796

Caruso F, Alessandri G, Cesana G, Castello G, Uccelli M, Ciccarese F, et al. Laparoscopic pancreaticoduodenectomy for tumors of the head of pancreas; 10 cases for a single center experience. Eur Rev Med Pharmacol Sci. 2017 Oct;21(17):3745-53.

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Published

2023-08-22

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Research Article

How to Cite

1.
Çiçek Okuyan G, Talu M. Comparison of two anastomosis techniques in terms of postoperative pancreatic fistula development: A retrospective cohort study: Postoperative pancreatic fistula and anastomosis techniques. J Surg Med [Internet]. 2023 Aug. 22 [cited 2024 May 25];7(8):468-72. Available from: https://jsurgmed.com/article/view/7888