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The Impact of Internal or External Transanastomotic Pancreatic Duct Stents Following Pancreaticojejunostomy. Which One Is Better? A Meta-analysis

  • Review Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

The use of pancreatic duct stent to improve postoperative outcomes of pancreatic anastomosis remains a matter of debate, and the value of stenting when performing anastomosis for normal pancreas (soft and duct less than 3 mm) needs further study. The aim of the present meta-analysis was to evaluate the perioperative outcomes of patients with stenting during pancreatic anastomosis and compare the effect of external stent with that of internal stent indirectly.

Methods

A systematic literature search (EMBASE, MEDLINE, PubMed, The Cochrane Library, and Web of Science) was performed to identify studies evaluating external stent or internal stent. Included literature was assessed and extracted by two independent reviewers. A meta-analysis including comparative studies providing data on patients with and without external stenting or internal stenting during pancreaticojejunostomy anastomosis was performed.

Results

Thirteen articles including 1,867 patients were identified for inclusion: five randomized controlled trials study and eight observational clinical studies. Meta-analyses revealed that use of external stent was associated with a significantly decreased risk for pancreatic fistula in total (odds ratio (OR) 0.47; 95 % confidence interval (CI) 0.31–0.71; P = 0.0004; I 2 = 3 %), pancreatic fistula in normal pancreas(OR 0.5; 95 % CI 0.30–0.82; P = 0.007; I 2 = 5 %), and overall morbidity(OR 0.64; 95 % CI 0.45–0.90; P = 0.01; I 2 = 0 %); however, the meta-analysis showed that there were no significant differences between internal stenting and non-stenting groups as regards perioperative outcomes and that in fact it may increase pancreatic fistula rate in normal pancreas(OR 1.97; 95 % CI 1.05–3.69; P = 0.03; I 2 = 0 %).

Conclusions

The results of this analysis demonstrate a trend toward reduced pancreatic fistula with the use of external pancreatic stents in pancreaticojejunostomy. An internal stent does not impact development of fistula and that in fact it was not useful in a soft pancreas. Our conclusion may be limited to stenting during the duct-to-mucosa pancreaticojejunostomy anastomosis, and the value of stenting during invagination anastomosis needs further study.

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References

  1. Fernandez-delCastillo C, Rattner DW, Warshaw AL. Standards for pancreatic resection in the 1990s. Arch Surg. 1995;130: 295–300.

    Article  PubMed  CAS  Google Scholar 

  2. Lieberman MD, Kilburn H, Lindsey M, et al. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg. 1995;222: 638–645.

    Article  PubMed  CAS  Google Scholar 

  3. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s. Ann Surg. 1997;226: 248–260.

    Article  PubMed  CAS  Google Scholar 

  4. Gouma DJ, Geenen RC, Gulik TM et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of the hospital volume. Ann Surg. 2000; 232(6): 786–795.

    Article  PubMed  CAS  Google Scholar 

  5. Buechler MW, Friess H, Wagner M, et al. Pancreatic fistula after pancreatic head resection. Br J Surg. 2000;87: 883–889.

    Article  Google Scholar 

  6. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364: 2128–2137

    Article  PubMed  CAS  Google Scholar 

  7. Begg CB, Cramer LD, Hoskins WJ, et al. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998; 280: 1747–1751.

    Article  PubMed  CAS  Google Scholar 

  8. Bassi C, Dervenis C, Butturini G, et al. International Study Group on Pancreatic Fistula. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138: 8–13.

    Article  PubMed  Google Scholar 

  9. Hashimoto Y, Traverso LW. Incidence of pancreatic anastomotic failure and delayed gastric emptying after pancreatoduodenectomy in 507 consecutive patients: use of a Web-based calculator to improve homogeneity of definition. Surgery. 2010;147(4):503–515.

    Article  PubMed  Google Scholar 

  10. Poon RT, Lo SH, Fong D, et al. Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg. 2002;183: 42–52.

    Article  PubMed  Google Scholar 

  11. Hosotani R, Doi R, Imamura M: Duct-to-mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatoduodenectomy. World J Surg. 2002;26:99–104.

    Article  PubMed  Google Scholar 

  12. Takeuchi K, Tsuzuki Y, Ando T, et al. Distal pancreatectomy: is staple closure beneficial? ANZ J Surg. 2003;73: 922–925.

    Article  PubMed  Google Scholar 

  13. Suc B, Msika S, Fingerhut A, et al; French Associations for Surgical Research. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of complications after pancreatic resection: prospective randomized trial. Ann Surg. 2003;237: 57–65.

    Google Scholar 

  14. Kapoor VK, Sharma A, Behari A, et al. Omental flaps in pancreaticoduodenectomy. JOP. 2006;7: 608–615.

    PubMed  Google Scholar 

  15. Kawai M, Tani M, Terasawa H, et al: Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients. Ann Surg. 2006;244: 1–7.

    Article  PubMed  Google Scholar 

  16. Peng SY, Mou YP, Liu YB, et al. Binding pancreaticojejunostomy: 150 consecutive cases without leakage. J Gastrointest Surg. 2003;7(7): 898–900.

    Article  PubMed  Google Scholar 

  17. Buc E, Flamein R, Golffier C, et al. Peng’s binding pancreaticojejunostomy after pancreaticoduodenectomy: a French prospective study. J Gastrointest Surg. 2010;14(4): 705–10.

    Article  PubMed  Google Scholar 

  18. Juni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA. 1999;282(11): 1054–1060.

    Article  PubMed  CAS  Google Scholar 

  19. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2. (Updated September, 2009). The Cochrane Collaboration; 2009. Available at: http://www.cochrane-handbook.org. Accessed October 2009.

  20. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004;328: 1490.

    Article  PubMed  Google Scholar 

  21. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336: 924–926.

    Article  PubMed  Google Scholar 

  22. Rahbari NN, Aigner M, Thorlund K, et al. Meta-analysis shows that detection of circulating tumor cells indicates poor prognosis in patients with colorectal cancer. Gastroenterology. 2010;138: 1714–1726.

    Article  PubMed  Google Scholar 

  23. Mollberg N, Rahbari NN, Koch M, et al. Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg. 2011 Dec;254(6):882–93.

    Article  PubMed  Google Scholar 

  24. Suc B, Msika S, Fingerhut A, et al. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intraabdominal complications after pancreatic resection-prospective randomized trial. Ann. Surg. 2003;237: 57–65.

    Article  PubMed  Google Scholar 

  25. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ. 2003;327: 557–560.

    Article  PubMed  Google Scholar 

  26. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–188.

    Article  PubMed  CAS  Google Scholar 

  27. Egger M, DaveySmith G, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315: 629–634.

    Article  PubMed  CAS  Google Scholar 

  28. Shukla PJ, Barreto SG, Fingerhut A. Do transanastomotic pancreatic ductal stents after pancreatic resections improve outcomes? Pancreas. 2010;39(5): 561–566.

    Article  PubMed  Google Scholar 

  29. Poon RT, Fan ST. Decreasing the pancreatic leak rate after pancreaticoduodenectomy. Adv Surg. 2008;42: 33–48.

    Article  PubMed  Google Scholar 

  30. Zhou Y, Yang C, Wang S, et al. Does external pancreatic duct stent decrease pancreatic fistula rate after pancreatic resection?: a meta-analysis. Pancreatology. 2011;11(3):362–370.

    Article  PubMed  Google Scholar 

  31. Markar SR, Vyas S, Karthikesalingam A, et al. The Impact of Pancreatic Duct Drainage Following Pancreaticojejunostomy on Clinical Outcome. J Gastrointest Surg. 2012 Mar 1. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22383216.

  32. 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):1280–90.

    Article  PubMed  Google Scholar 

  33. Lai EC, Chung NT, Yang GP, Li MK. Internal pancreatic ductal stenting to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a comparative study. Hepatogastroenterology. 2011;58(105): 163–7.

    PubMed  Google Scholar 

  34. Smyrniotis V, Arkadopoulos N, Kyriazi MA, et al. Does internal stenting of the pancreaticojejunostomy improve outcomes after pancreatoduodenectomy? A prospective study. Langenbecks Arch Surg. 2010;395(3): 195–200.

    Article  PubMed  Google Scholar 

  35. Suzuki S, Kaji S, Koike N, et al. Pancreaticojejunostomy of duct to mucosa anastomosis can be performed more safely without than with a stenting tube. Am J Surg. 2009;198(1): 51–4.

    Article  PubMed  Google Scholar 

  36. Mok KT, Wang BW, Liu SI. Management of pancreatic remnant with strategies according to the size of pancreatic duct after pancreaticoduodenectomy. Br J Surg. 1999;86(8):1018–9.

    Article  PubMed  CAS  Google Scholar 

  37. Grace PA, Pitt HA, Tompkins RK, et al. Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg. 1986;151(1):141–149.

    Article  PubMed  CAS  Google Scholar 

  38. Moriya T, Clark CJ, Kirihara Y, et al. Stenting and the rate of pancreatic fistula following pancreaticoduodenectomy. Arch Surg. 2012 Jan;147(1): 35–40.

  39. Poon RT, Fan ST, Lo CM, et al. External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg. 2007;246: 425–433.

    Article  PubMed  Google Scholar 

  40. 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: 879–885.

    Article  PubMed  Google Scholar 

  41. Kuroki T, Tajima Y, Kitasato A, et al. Stenting versus non-stenting in pancreaticojejunostomy: a prospective study limited to a normal pancreas without fibrosis sorted by using dynamic MRI. Pancreas. 2011;40: 25–29.

    Article  PubMed  Google Scholar 

  42. Motoi F, Egawa S, Rikiyama T, et al. Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. Br J Surg. 2012;99(4):524–531.

    Article  PubMed  CAS  Google Scholar 

  43. Tani M, Onishi H, Kinoshita H, et al. The evaluation of duct-to-mucosal pancreaticojejunostomy in pancreaticoduodenectomy. World J Surg. 2005 Jan;29(1): 76–79.

  44. Roder JD, Stein HJ, Böttcher KA, et al. Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy: a prospective study. Ann Surg. 1999;229: 41–48.

    Article  PubMed  CAS  Google Scholar 

  45. Imaizumi T, Hatori T, Tobita K, et al. Pancreaticojejunostomy using duct-to-mucosa anastomosis without a stenting tube. J Hepatobiliary Pancreat Surg. 2006;13(3): 194–201.

    Article  PubMed  Google Scholar 

  46. Sriussadaporn S, Pak-Art R, Sriussadaporn S, et al. Pancreaticoduodenectomy with external drainage of the pancreatic remnant. Asian J Surg. 2008;31: 167–173.

    Article  PubMed  Google Scholar 

  47. Satoi S, Toyokawa H, Yanagimoto H, et al. Is a nonstented duct-to-mucosa anastomosis using the modified Kakita method a safe procedure? Pancreas. 2010;39: 165–170.

    Article  PubMed  Google Scholar 

  48. Park JS, Hwang HK, Kim JK, et al. Clinical validation and risk factors for delayed gastric emptying based on the International Study Group of Pancreatic Surgery (ISGPS) Classification. Surgery. 2009;146; 882–887.

    Article  PubMed  Google Scholar 

  49. Malleo G, Crippa S, Butturini G, et al. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB (Oxford). 2010; 12: 610–618.

    Article  Google Scholar 

  50. Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg. 2000;232: 419–429.

    Article  PubMed  CAS  Google Scholar 

  51. Sato N, Yamaguchi K, Chijiiwa K, et al. Risk analysis of pancreatic fistula after pancreatic head resection. Arch Surg. 1998;133: 1094–1098.

    Article  PubMed  CAS  Google Scholar 

  52. Cheng Q, Zhang B, Zhang Y, et al. Predictive factors for complications after pancreaticoduodenectomy. J Surg Res. 2007;139: 22–29.

    Article  PubMed  Google Scholar 

  53. Berger AC, Howard TJ, Kennedy EP, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg 2009; 208: 738–747.

    Article  PubMed  Google Scholar 

  54. Choe YM, Lee KY, Oh CA, et al. Risk factors affecting pancreatic fistulas after pancreaticoduodenectomy. World J Gastroenterol. 2008;14: 6970–6974.

    Article  PubMed  Google Scholar 

  55. Satoi S, Toyokawa H, Yanagimoto H, et al. A new guideline to reduce postoperative morbidity after pancreaticoduodenectomy. Pancreas. 2008;37: 128–133.

    Article  PubMed  Google Scholar 

  56. Ohwada S, Tanahashi Y, Ogawa T, et al. In situ vs. ex situ pancreatic duct stents of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy with billroth I-type reconstruction. Arch Surg. 2002;137: 1289–1293.

    Article  PubMed  Google Scholar 

  57. 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: 759–764.

    Article  PubMed  Google Scholar 

  58. Kamoda Y, Fujino Y, Matsumoto I, et al. Usefulness of performing a pancreaticojejunostomy with an internal stent after a pancreatoduodenectomy. Surg Today. 2008;38: 524–528.

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors thank Shuji Suzuki for explaining the health system and medical policy in Japan.

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Authors and Affiliations

  1. Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan-Jiang Xi Road, GuangZhou, 510120, China

    Yu Zhou, Quanbo Zhou, Zhihua Li, Qing Lin, Yuanfeng Gong & Rufu Chen

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  1. Yu Zhou
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  2. Quanbo Zhou
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  3. Zhihua Li
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  4. Qing Lin
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Correspondence to Rufu Chen.

Additional information

Yu Zhou, Quanbo Zhou, and Zhihua Li contributed equally to this study.

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Zhou, Y., Zhou, Q., Li, Z. et al. The Impact of Internal or External Transanastomotic Pancreatic Duct Stents Following Pancreaticojejunostomy. Which One Is Better? A Meta-analysis. J Gastrointest Surg 16, 2322–2335 (2012). https://doi.org/10.1007/s11605-012-1987-2

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  • DOI: https://doi.org/10.1007/s11605-012-1987-2

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