Influencing factors of pancreatic fistula after pancreaticoduodenectomy and significance of pancreatic fistula risk score system on selection of main pancreatic duct drainage after pancreaticoduodenectomy_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

ZHANG Wei ¹ , WEN Xin ¹ , CAO Kuan ¹ , SHAN Wengang ¹ , MA Hao ² , ZHANG Bin ¹ , WEN Quan ¹ ,  WANG Renhao ¹

1. Department of Hepatobiliary Surgery, Digestive Disease Research Center, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221000, P. R. China;
2. The First Department of Surgery, People’s Hospital of Taierzhuang District, Zaozhuang City, Zaozhuang, Shandong 277400, P. R. China;

Corresponding?author：

WANG Renhao, Email: drwangrenhao@163.com

Keywords：

pancreatic fistula; pancreaticoduodenectomy; fistula risk score; drainage

DOI：

10.7507/1007-9424.201808014

Video：

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Objective To explore the influencing factors of pancreatic fistula after pancreaticoduodenectomy (PD), and to compare the incidence of pancreatic fistula after pancreaticoduodenectomy with internal drainage of main pancreatic duct and external drainage according to the pancreatic fistula risk score (FRS) system, to provide the basis for the best drainage scheme in clinic. Methods The clinical data of 76 patients with PD who treated in the Affiliated Hospital of Xuzhou Medical University from January 2016 to December 2017 were analyzed retrospectively, to explore the risk factors of pancreatic fistula. Single factor analysis was based on group chi-square test or Fisher exact probability method, and multivariate analysis was based on unconditioned logistic regression model. According to the results of FRS, the difference of pancreatic fistula in different risk groups was explored. The statistical method was chi-square test. Results The incidence of pancreatic fistula after PD was 31. 5% in 76 patients.Univariate analysis showed that the diameter of the main pancreatic duct and the texture of the pancreas were the related factors affecting the occurrence of pancreatic fistula after PD (P<0.05), and the soft pancreas was the independent risk factor for the occurrence of pancreatic fistula after PD (OR=3.886, P=0.011). There was no significant difference in the incidence of postoperative pancreatic fistula between the internal drainage group and the external drainage group (P>0.05). There was no pancreatic fistula occurred in the patients with negligible risk. The incidence of postoperative pancreatic fistula in patients with high risk of external drainage group was only 12.5%, comparing with patients in internal drainage group (63.6%), the difference was statistically significant (P=0.026). There was no significant difference in the incidence of postoperative pancreatic fistula between patients in the external drainage group with moderate risk and low risk compared with the corresponding patients in the internal drainage group (P>0.05). Conclusions Pancreatic texture was an independent risk factor for pancreatic fistula after PD. External drainage maybe more effective than internal drainage in preventing pancreatic fistula after PD in patients with high risk of FRS.

Citation： ZHANG Wei, WEN Xin, CAO Kuan, SHAN Wengang, MA Hao, ZHANG Bin, WEN Quan, WANG Renhao. Influencing factors of pancreatic fistula after pancreaticoduodenectomy and significance of pancreatic fistula risk score system on selection of main pancreatic duct drainage after pancreaticoduodenectomy. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2019, 26(1): 42-48. doi: 10.7507/1007-9424.201808014 Copy

1.	El Nakeeb A, Salah T, Sultan A, et al. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J Surg, 2013, 37(6): 1405-1418.
2.	Büchler MW, Wagner M, Schmied BM, et al. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg, 2003, 138(12): 1310-1314.
3.	Roberts KJ, Hodson J, Mehrzad H, et al. A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy. HPB (Oxford), 2014, 16(7): 620-628.
4.	Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery, 2017, 161(3): 584-591.
5.	Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery, 2005, 138(1): 8-13.
6.	Callery MP, Pratt WB, Kent TS, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg, 2013, 216(1): 1-14.
7.	趙玉沛. 胰腺術后外科常見并發癥診治及預防的專家共識 (2017). 協和醫學雜志, 2017, 8(2): 139-146.
8.	Mitra A, D’Souza A, Goel M, et al. Surgery for pancreatic and periampullary carcinoma. Indian J Surg, 2015, 77(5): 371-380.
9.	Poon RT, Lo SH, Fong D, et al. Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg, 2002, 183(1): 42-52.
10.	Lin JW, Cameron JL, Yeo CJ, et al. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg, 2004, 8(8): 951-959.
11.	胡丙洋, 冷建軍, 萬濤, 等. 511 例胰十二指腸切除術患者胰瘺危險因素分析. 中華肝膽外科雜志, 2015, 21(6): 377-381.
12.	翁昊, 束翌俊, 包潤發, 等. 術前胰腺平掃 CT 值可預測胰十二指腸切除術后胰瘺危險性. 中華普通外科雜志, 2014, 29(1): 21-24.
13.	劉穎斌, 王許安, 黃叢云. 胰十二指腸切除術后胰腺殘端消化道重建的歷史回顧. 中華消化外科雜志, 2018, 17(7): 671-676.
14.	何鐵英, 晏冬, 王喜艷, 等. 胰十二指腸切除術應用胰管支撐管的 Meta 分析. 中華消化外科雜志, 2012, 11(4): 339-342.
15.	Xiong JJ, Ahaf K, Mukherjee R, et al. Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement durng pancreaticoduodenectomy. Br J Surg, 2012, 99(8): 1050-1061.
16.	Wang Q, He XR, Tian JH, et al. Pancreatic duct stents at pancreaticoduodenectomy: a meta-analysis. Dig Surg, 2013, 30(4-6): 415-424.
17.	Ke FY, Wu XS, Zhang Y, et al. Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis. Chin J Cancer Res, 2015, 27(4): 397-407.
18.	Patel K, Teta A, Sukharamwala P, et al. External pancreatic duct stent reduces pancreatic fistula: a meta-analysis and systematic review. Int J Surg, 2014, 12(8): 827-832.
19.	王剛, 孫備, 姜洪池, 等. 胰十二指腸切除術后早期胰管支撐管內引流及外引流的療效比較. 中華外科雜志, 2014, 52(5): 333-337.
20.	姜凱, 陳照軍, 陳永衛, 等. 胰十二指腸切除術置放胰管引流合理性的流體動力學模擬研究. 解放軍醫學雜志, 2014, 39(3): 184-187.
21.	Winter JM, Cameron JL, Campbell KA, et al. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg, 2006, 10(9): 1280-1290.
22.	Tani M, Kawai M, Hirono S, et al. A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy. Am J Surg, 2010, 199(6): 759-764.
23.	吳國忠, 姜杰, 龐紹春. 完全性胰液外引流預防胰十二指腸切除術后胰瘺的機理分析. 中國現代手術學雜志, 2011, 15(4): 262-263.
24.	胡平海, 金焰, 喬鷗. 胰管支撐外引流管在胰十二指腸切除術胰腸吻合中的臨床效果分析. 中國現代普通外科進展, 2015, 18(10): 799-801.
25.	Pessaux P, Sauvanet A, Mariette C, et al. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg, 2011, 253(5): 879-885.
26.	胡澤民, 余元龍, 周載平, 等. 胰十二指腸切除術 132 例嚴重并發癥的防治. 中華普通外科學文獻: 電子版, 2010, 4(3): 224-227.
27.	Zhao Y, Zhang J, Lan Z, et al. Are internal or external pancreatic duct stents the preferred choice for patients undergoing pancreaticoduodenectomy? A meta-analysis. Biomed Res Int, 2017, 2017: 1367238.
28.	Ecker BL, McMillan MT, Asbun HJ, et al. Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg, 2018, 267(4): 608-616.
29.	McMillan MT, Malleo G, Bassi C, et al. Drain management after pancreatoduodenectomy: reappraisal of a prospective randomized trial using risk stratification. J Am Coll Surg, 2015, 221(4): 798-809.

1. El Nakeeb A, Salah T, Sultan A, et al. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J Surg, 2013, 37(6): 1405-1418.
2. Büchler MW, Wagner M, Schmied BM, et al. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg, 2003, 138(12): 1310-1314.
3. Roberts KJ, Hodson J, Mehrzad H, et al. A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy. HPB (Oxford), 2014, 16(7): 620-628.
4. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery, 2017, 161(3): 584-591.
5. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery, 2005, 138(1): 8-13.
6. Callery MP, Pratt WB, Kent TS, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg, 2013, 216(1): 1-14.
7. 趙玉沛. 胰腺術后外科常見并發癥診治及預防的專家共識 (2017). 協和醫學雜志, 2017, 8(2): 139-146.
8. Mitra A, D’Souza A, Goel M, et al. Surgery for pancreatic and periampullary carcinoma. Indian J Surg, 2015, 77(5): 371-380.
9. Poon RT, Lo SH, Fong D, et al. Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg, 2002, 183(1): 42-52.
10. Lin JW, Cameron JL, Yeo CJ, et al. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg, 2004, 8(8): 951-959.
11. 胡丙洋, 冷建軍, 萬濤, 等. 511 例胰十二指腸切除術患者胰瘺危險因素分析. 中華肝膽外科雜志, 2015, 21(6): 377-381.
12. 翁昊, 束翌俊, 包潤發, 等. 術前胰腺平掃 CT 值可預測胰十二指腸切除術后胰瘺危險性. 中華普通外科雜志, 2014, 29(1): 21-24.
13. 劉穎斌, 王許安, 黃叢云. 胰十二指腸切除術后胰腺殘端消化道重建的歷史回顧. 中華消化外科雜志, 2018, 17(7): 671-676.
14. 何鐵英, 晏冬, 王喜艷, 等. 胰十二指腸切除術應用胰管支撐管的 Meta 分析. 中華消化外科雜志, 2012, 11(4): 339-342.
15. Xiong JJ, Ahaf K, Mukherjee R, et al. Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement durng pancreaticoduodenectomy. Br J Surg, 2012, 99(8): 1050-1061.
16. Wang Q, He XR, Tian JH, et al. Pancreatic duct stents at pancreaticoduodenectomy: a meta-analysis. Dig Surg, 2013, 30(4-6): 415-424.
17. Ke FY, Wu XS, Zhang Y, et al. Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis. Chin J Cancer Res, 2015, 27(4): 397-407.
18. Patel K, Teta A, Sukharamwala P, et al. External pancreatic duct stent reduces pancreatic fistula: a meta-analysis and systematic review. Int J Surg, 2014, 12(8): 827-832.
19. 王剛, 孫備, 姜洪池, 等. 胰十二指腸切除術后早期胰管支撐管內引流及外引流的療效比較. 中華外科雜志, 2014, 52(5): 333-337.
20. 姜凱, 陳照軍, 陳永衛, 等. 胰十二指腸切除術置放胰管引流合理性的流體動力學模擬研究. 解放軍醫學雜志, 2014, 39(3): 184-187.
21. Winter JM, Cameron JL, Campbell KA, et al. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg, 2006, 10(9): 1280-1290.
22. Tani M, Kawai M, Hirono S, et al. A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy. Am J Surg, 2010, 199(6): 759-764.
23. 吳國忠, 姜杰, 龐紹春. 完全性胰液外引流預防胰十二指腸切除術后胰瘺的機理分析. 中國現代手術學雜志, 2011, 15(4): 262-263.
24. 胡平海, 金焰, 喬鷗. 胰管支撐外引流管在胰十二指腸切除術胰腸吻合中的臨床效果分析. 中國現代普通外科進展, 2015, 18(10): 799-801.
25. Pessaux P, Sauvanet A, Mariette C, et al. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg, 2011, 253(5): 879-885.
26. 胡澤民, 余元龍, 周載平, 等. 胰十二指腸切除術 132 例嚴重并發癥的防治. 中華普通外科學文獻: 電子版, 2010, 4(3): 224-227.
27. Zhao Y, Zhang J, Lan Z, et al. Are internal or external pancreatic duct stents the preferred choice for patients undergoing pancreaticoduodenectomy? A meta-analysis. Biomed Res Int, 2017, 2017: 1367238.
28. Ecker BL, McMillan MT, Asbun HJ, et al. Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg, 2018, 267(4): 608-616.
29. McMillan MT, Malleo G, Bassi C, et al. Drain management after pancreatoduodenectomy: reappraisal of a prospective randomized trial using risk stratification. J Am Coll Surg, 2015, 221(4): 798-809.

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CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Influencing factors of pancreatic fistula after pancreaticoduodenectomy and significance of pancreatic fistula risk score system on selection of main pancreatic duct drainage after pancreaticoduodenectomy

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