A propensity score analysis of over 12,000 pancreaticojejunal anastomoses after pancreaticoduodenectomy: does technique impact the clinically relevant fistula rate?

Abstract

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) remains a major cause of morbidity in patients undergoing pancreatic surgery. Controversy exists as to whether there is any difference in CR-POPF with a Duct-to-Mucosa (DTM) versus an Invagination (IG) pancreaticojejunostomy (PJ).Methods: Demographic, perioperative, intraoperative, and postoperative data were captured from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2014-2017 databases. Potential confounders were included in a logistic regression and a propensity score model. The primary outcome was CR-POPF.Results: A total of 12,361 pancreaticojejunal anastomoses were performed with 11,168 patients undergoing DTM (90%) and 1193 undergoing IG (10%) after pancreaticoduodenectomy. Amongst all patients, there was no significant difference in CR-POPF between DTM and IG on multivariate (OR = 0.95, p = 0.64) or propensity score analysis (OR = 0.99, p = 0.93). After stratification by pancreatic gland texture and duct size, there was a decrease in CR-POPF with DTM amongst patients with duct size greater than 6 mm on multivariate analysis (OR = 0.35, p = 0.009) and propensity score analysis (OR = 0.40, p = 0.018). There were no significant differences in any other strata.Conclusion: DTM or IG technique are not associated with CR-POPF for patients with average size pancreatic ducts; however, DTM is preferable in patients with large pancreatic duct diameter (>6 mm).

Risk factors of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A systematic review and meta-analysis

“…Vuorela et al [ 48 ] found that pasireotide could reduce the occurrence of CR-POPF in high-risk patients with small pancreatic duct, soft pancreatic texture, biliary, or neuroendocrine tumors. The study by Lyonell et al [ 49 ] showed that duct-to-mucosa or invagination techniques were not statistically associated with CR-POPF for patients with mean size of pancreatic duct, but duct-to-mucosa was preferable for patients with pancreatic duct diameter of >6 mm.…”

Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis

“…POPF can lead to intra-abdominal abscess, sepsis and haemorrhage and to life-threatening conditions with mortality up to 40% 5 . Therefore, numerous methods have been used to decrease POPF in previous studies, including use of octreotide 6 or fibrin sealants to pancreatic remnant 7 , occlusion of the pancreatic duct 8 , pancreatic duct stenting 9 , modification of the pancreaticojejunostomy(PJ) anastomosis (end-to-end versus end-to-side 10 , invagination versus duct-to-mucosa 11 , interrupted suture versus continuous suture 12 ) and pancreaticogastrostomy (PG) 13 . However, the reconstruction technique was perhaps the most important factor to reduce POPF.…”

“…pancreaticojejunostomy(PJ) anastomosis (end-to-end versus end-to-side 10 , invagination versus duct-to-mucosa 11 , interrupted suture versus continuous suture 12 ) and pancreaticogastrostomy (PG) 13 . However, the reconstruction technique was perhaps the most important factor to reduce POPF.…”

Perioperative Broad-spectrum Antibiotics are Associated With Decreased Surgical Site Infections Compared to 1st–3rd Generation Cephalosporins After Open Pancreaticoduodenectomy in Patients With Jaundice or a Biliary Stent

“…9,[22][23][24] Vascular resection versus no vascular resection was compared given the known overall increased risk of postoperative complications. 25,26 In addition, given the correlation between clinically relevant postoperative pancreatic fistula (CR-POPF) and SSI, 27 a modified fistula risk score (FRS) 28 and CR-POPF outcome were created as previously described, 29 and included in the analysis.…”