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Externalized Stents for Pancreatoduodenectomy Provide Value Only in High-Risk Scenarios

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Evidence suggests externalized trans-anastomotic stents may be beneficial as a fistula mitigation strategy for pancreatoduodenectomy (PD); however, previous studies have not been rigorously risk-adjusted.

Methods

From 2001 to 2015, PDs were performed at three institutions, with externalized stents placed at the surgeon’s discretion. The Fistula Risk Score (FRS) and the Modified Accordion Severity Grading System were used to analyze occurrence and severity of clinically relevant postoperative pancreatic fistula (CR-POPF) across various risk scenarios.

Results

Of 729 PDs, externalized stents were placed during 129 (17.7 %). Overall, CR-POPFs occurred in 77 (10.6 %) patients. The median FRS of patients who received externalized stents was significantly higher compared with patients who did not (6 vs. 3, p < 0.0001). Patients with negligible, low, or moderate CR-POPF risk (FRS 0–6) did not demonstrate improved outcomes with externalized stents; however, among high-risk patients (FRS 7–10), stents were associated with significantly reduced rates of CR-POPF (14.0 vs. 36.4 %, p = 0.031), severe complications (p = 0.039), and hospital stay (p = 0.014) compared with no stents. The average complication burden of CR-POPF was significantly lower for patients with externalized stents (p = 0.035).

Conclusion

This multicenter study, the largest comparative analysis of externalized trans-anastomotic stents versus no stent for PD, demonstrates a risk-stratified benefit to externalized stents.

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Abbreviations

POPF:

Postoperative pancreatic fistula

PD:

Pancreatoduodenectomy

CR-POPF:

Clinically relevant postoperative pancreatic fistula

RCT:

Randomized controlled trial

PDAC:

Pancreatic ductal adenocarcinoma

FRS:

Fistula Risk Score

ISGPF:

International Study Group on Pancreatic Fistula

ACB:

Average Complication Burden

SD:

Standard deviation

IQR:

Interquartile range

OR:

Odds ratio

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Author Contributions

Conception/design (MM, SB, MC, JC, CV); data acquisition (MM, BE, SK, MS); data interpretation (MM, SB, MC, JC, JD, BE, DF, TK, ML, RR, CV); drafting (MM, CV); critical revisions (SB, MC, JC, JA, BE, DF, TK, ML, RR, MS, CV); final approval (all authors)

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Authors and Affiliations

  1. Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA

    Matthew T. McMillan, Brett L. Ecker, Jeffrey A. Drebin, Douglas L. Fraker, Major K. Lee, Robert E. Roses, Michael H. Sprys & Charles M. Vollmer Jr.

  2. Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA

    Stephen W. Behrman

  3. Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Mark P. Callery & Tara S. Kent

  4. Department of Surgery, University of Alabama School of Medicine, Birmingham, AL, USA

    John D. Christein

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  1. Matthew T. McMillan
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  2. Brett L. Ecker
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  3. Stephen W. Behrman
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  4. Mark P. Callery
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  9. Major K. Lee
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  10. Robert E. Roses
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  11. Michael H. Sprys
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  12. Charles M. Vollmer Jr.
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Correspondence to Charles M. Vollmer Jr..

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McMillan, M.T., Ecker, B.L., Behrman, S.W. et al. Externalized Stents for Pancreatoduodenectomy Provide Value Only in High-Risk Scenarios. J Gastrointest Surg 20, 2052–2062 (2016). https://doi.org/10.1007/s11605-016-3289-6

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  • DOI: https://doi.org/10.1007/s11605-016-3289-6

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