Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy

Motoi, Fuyuhiko; Egawa, Shinichi; Rikiyama, Toshiki; Katayose, Yu; Unno, Michiaki

doi:10.1002/bjs.8654

Cited by 189 publications

(140 citation statements)

References 26 publications

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“…At present it appears that this effect is not replicated among patients with a dilated (>3 mm) pancreatic duct. Although the univariable analysis of several studies have identified soft pancreatic texture as risk factor for the development of POPF [4,[6][7], stenting does not appear to mitigate this risk in any significant manner.…”

Section: Discussionmentioning

confidence: 93%

“…Subsequent screening resulted in four prospective randomized trials examining only external pancreatic stents following PD [6][7]9,14]. Of note, the present study excluded two trials previously included by Markar et al [10]; 1) the 2009 prospective trial conducted by Smyrniotis et al [5] on the basis that this study examined internal stents only, and 2) the 2006 trial conducted by Winter et al [4] on the basis that internal stents were included and because these authors utilized an alternating method of allocating patients to either treatment or control arms, which may have inadvertently introduced selection bias as described by Doll [15].…”

Section: Resultsmentioning

confidence: 99%

“…All four trials reported on the incidence of POPF formation following PD with versus without external pancreatic duct stent placement [6][7]9,14]. There was a statistically significant difference in the overall incidence of any grade POPF formation among these cohorts (OR 0.37, 95% CI=0.23 to 0.58, P=0.0001) as well as a statistically significant difference in the incidence of clinically significant (grade B or C) POPF (OR 0.50, 95% CI=0.30 to 0.84, P=0.0009) favoring external stent placement (Table 2).…”

Section: Resultsmentioning

confidence: 99%

“…In a 2012 randomized control trial, Motoi et al found that the incidence of clinically significant POPF (Figure 3) was decreased in the presence of an externalized pancreatic duct stent (6.4% stented vs. 21.7% non-stented, P=0.04) [7]. Furthermore, researchers noted that among patients with a non-dilated pancreatic duct stump (≤ 3 mm) the incidence of clinically relevant POPF was significantly lower in the external stent group versus non-stented group (9.5% stented vs. 40% non-stented, P=0.033).…”

Section: Discussionmentioning

confidence: 99%

“…This is then closed with a purse-string suture, externalized via a stab incision in the anterior abdominal wall, and closed by suturing the serosa of the jejunum to the peritoneum of the abdominal wall. In both cases migration of the catheter is prevented with an absorbable suture attachment to the jejunal mucosal surface [4][5][6][7][8][9]. The final PJ reconstruction is then carried out with an end-to-side, duct-to-mucosa anastomosis using 1-or 2-layer interrupted fine sutures [6].…”

Section: Introductionmentioning

confidence: 99%

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A Meta-Analysis and Systematic Review of Pancreatic Duct Stent

Prashant¹,

Thoens²,

Mauricio³

et al. 2014

Pancreat Disord Ther

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IntroductionThe National Cancer Institute has estimated that there will be as many as 45,220 new cases of pancreatic cancer in the U.S. in 2012 and that as many as 38,460 patients will die of the disease this year alone [1]. Pancreaticoduodenectomy (PD) remains the sole potentially curative intervention for several types of peri-ampullary and pancreatic carcinomas and pathologies. Postoperative Pancreatic Fistula Formation (POPF) as a result of pancreaticojejunostomy (PJ) anastomotic failure remains one of the most serious and dreaded complications following PD. POPF is believed to be a consequence of pancreatic exocrine secretion seepage across a compromised anastomotic site, with the most likely mechanism being autodigestion and destruction of the tissue surrounding the PJ anastomotic site leading to dehiscence and seepage into the abdominal cavity. The release of these activated pancreatic juices then cause peripancreatic collections, intra-abdominal abscesses, hemorrhage, and POPF [2].Protection of this anastomotic site has therefore been the focus of many modifications to the original Whipple procedure. Stent placement across the PJ anastomsis has been proposed to protect the integrity of the site by diverting the potentially caustic exocrine secretions of the pancreatic remnant away from the delicate anastomotic site. In addition, such stents have been theorized to promote precise placement of anastomotic sutures, facilitate decompression of the pancreatic remnant, and maintain patency of the pancreatic duct postoperatively [3,4].Two similar though uniquely different procedures have been integrated into the traditional PD procedure with varying reports of actual efficacy; an internal and an external pancreatic duct stent. The internal stent technique is generally performed by inserting a 6 cm stent into the pancreatic duct such that one-half of its length remains within the duct itself, bridges across the anastomotic site, and empties into the jejunal lumen. In contrast, the external stent utilizes a longer stent placed similarly within the pancreatic duct stump, bridges across the anastomotic site into the jenual lumen, but the tail of which is exited through a small enterotomy site in the free end of the jejunal loop. This is then closed with a purse-string suture, externalized via a stab incision in the anterior abdominal wall, and closed by suturing the serosa of the jejunum to the peritoneum of the abdominal wall. In both cases migration of the catheter is prevented with an absorbable suture attachment to the jejunal mucosal surface [4][5][6][7][8][9]. The final PJ reconstruction is then carried out with an end-to-side, duct-to-mucosa anastomosis using 1-or 2-layer interrupted fine sutures [6].Previous meta analysis performed by Markar et al. [10] examined the combined effect of placement of either stent type on clinical outcome following PJ. Based on the integrated data sets, these authors identified a non-statistically significant trend towards reduced pancreatic fistula with the use of either sten...

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Section: Discussionmentioning

confidence: 93%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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A Meta-Analysis and Systematic Review of Pancreatic Duct Stent

Prashant¹,

Thoens²,

Mauricio³

et al. 2014

Pancreat Disord Ther

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Pancreaticojejunostomy With Externalized Stent vs Pancreaticogastrostomy With Externalized Stent for Patients With High-Risk Pancreatic Anastomosis

et al. 2020

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IMPORTANCEThe operative scenarios with the highest postoperative pancreatic fistula (POPF) risk represent situations in which fistula prevention and mitigation strategies have the strongest potential to affect surgical outcomes after pancreaticoduodenectomy. Evidence from studies providing risk stratification is lacking.OBJECTIVE To investigate whether pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG), both with externalized transanastomotic stent, is the best reconstruction method for patients at high risk of POPF after pancreaticoduodenectomy.

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Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy

Dong

Wang

et al. 2016

Cochrane Database of Systematic Reviews

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Main results We included eight studies (1018 participants). The average age of the participants ranged from 56 to 68 years. Most of the studies were conducted in single centers in Japan (four studies), China (two studies), France (one study), and the USA (one study). The risk of bias was low or unclear for most domains across the studies. Stents versus no stents Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy (Review)

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Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy

Abstract: External duct stenting reduced the risk of clinically relevant POPF after PD and subsequent duct-to-mucosa PJ.

Cited by 189 publications

References 26 publications

A Meta-Analysis and Systematic Review of Pancreatic Duct Stent

A Meta-Analysis and Systematic Review of Pancreatic Duct Stent

Pancreaticojejunostomy With Externalized Stent vs Pancreaticogastrostomy With Externalized Stent for Patients With High-Risk Pancreatic Anastomosis

Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy

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