The Effect of Preoperative Biliary and Pancreatic Drainage on Postoperative Pancreatic Fistula: A Retrospective Cohort Study

Abstract

Background Surgeons and endoscopists welcome routine preoperative biliary drainage prior to pancreaticoduodenectomy despite evidence that it increases complications. Its effect on postoperative pancreatic fistula is variably reported in literature. Simultaneous biliary and pancreatic drainage is rarely performed for very selected indications and its effects on postoperative pancreatic fistula are largely unknown. Our aim was to analyze the same while eliminating confounding factors. Methods Retrospective single center cohort study of patients who underwent pancreaticoduodenectomy over the past 10 years for carcinoma obstructing the lower common bile duct. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, and no stenting prior to pancreaticoduodenectomy were the three study cohort groups and their records were scrutinized for the incidence of postoperative pancreatic fistula. Results Sixty-two patients underwent biliary stenting alone, 5 patients underwent both biliary and pancreatic stenting, and 237 patients were not stented in the adenocarcinoma group without chronic pancreatitis. The pancreatic fistula rate was similar in the patients who underwent biliary stenting alone when compared with the group which was not stented. (24/62 versus 67/237, odds ratio [OR] =0.619, confidence interval (CI) =0.345–1.112, p = 0.121). However, the patients who underwent both biliary and pancreatic stenting had a significant increase in postoperative pancreatic fistula compared with the not stented ( p = 0.003). By univariate and multivariate analysis using Firth logistic regression, pancreatic texture (OR = 1.205, CI = 0.103–2.476, p = 0.032) and the presence of a biliary and pancreatic stent (OR = 2.695, CI = 0.273–7.617, p = 0.027) were the significant factors affecting pancreatic fistula. Conclusion Preoperative biliary drainage alone has no significant influence on postoperative pancreatic fistula except when combined with pancreatic stenting. We need more such studies from other centers to confirm that the rare event of preoperative biliary and pancreatic stenting has indeed this harmful effect on healing of postoperative pancreatic anastomosis.

Impact of Preoperative Endoscopic Biliary Drainage on Postoperative Outcome after Pancreaticoduodenectomy

“…Singhirunnusorn et al, proved a no significant difference in mild and major complications of patients with PBD (42% and 37%, respectively) in comparison to (35% and 32.8% respectively) in patients without PBD. They also reported no significant difference in hospital mortality, and each complication alone like biliary fistula, pancreatic fistula, WI, and reoperation (22,23). In contrast to our study with a significant difference in major complications, but maybe the definition of major complications that made these changes of results between the different studies.…”

The Effect of Preoperative Biliary Drainage with or without Pancreatic Stenting on Complications after Pancreatoduodenectomy: A Retrospective Cohort Study

“…There were few studies to evaluate the influence of pancreatic duct stenting during PBD on the complications of pancreaticoduodenectomy. A retrospective study by John et al in 2018 showed that simultaneous cholangiopancreatic duct drainage increased the incidence of postoperative pancreatic leakage [ 21 ]. This study enrolled only 5 cases of simultaneous cholangiopancreatic duct drainage, which was regarded as a rare event during data analysis and Firth logistic regression.…”

Centralisation of Pancreatoduodenectomy in India: Where Do We Stand?

“…A total of 36 unique series [9–44] from 24 institutes across India were identified after excluding 18 series [45–62] due to overlap of cases from the same author and institution. Figure 1 depicts the consort chart of the study methodology.…”

“…Incidence of post‐operative pancreatic fistula (POPF) in included studies ranged from 4 to 61.5%, with only 3 studies reporting POPF rates 41% [10], 54.3% [44] and 61.5% [20]. Apart from that, all other articles reported POPF incidence in the range of 4–15%, except six where the range was 20–35% [21, 28, 30, 37, 38, 43]. Only 19 out 36 studies reported incidence of clinically significant/relevant POPF with a range 0.6–18%.…”

“…Surgeons and primary care physicians also stand to benefit from development of centres of excellence for PD Kaman et al [19] Sunil et al [34] Vinchurkar et al [36] Govil et al [42] Patra et al [10] Singhal et al [13] Shah et al [14] Samaddar et al [17] Kaman et al [18] Jakhmola et al [21] Reddy et al [26] Govil et al [27] Pal et al [28] Mishra et al [31] Tampi et al [32] Krishna et al [35] Pamecha et al [38] Jain et al [39] Chowdappa et al [40] Nikhil et al [43] Gupta et al [44] Ray et al [9] Barreto et al [11] Perwaiz et al [12] Palanivelu et al [16] Kurumboor et al [20] Rammohan et al [22] Sivaraj et al [23] Rajarathinam et al [24] Shrikhande et al [25] Gangavatiker et al [29] Singh et al [30] Mansukhani et al [33] Manipadam et al [37] Tewari et al [ as they can focus more intently on problems that are more commonly encountered in their practice than invest their time in a disease that is infrequent. The surgeons at dedicated units develop better understanding of the disease process, anatomy and anatomic anomalies, thereby achieving more proficiency, and become better equipped to take complex clinical decisions.…”