Skip to main content
SpringerLink
Log in

The Effect of Pancreaticojejunostomy Technique on Fistula Formation Following Pancreaticoduodenectomy in the Soft Pancreas

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Introduction

A soft pancreas has been associated with an increased risk of post-operative pancreatic fistula formation. Few studies have evaluated the effect of anastomotic technique (duct to mucosa vs invagination) on fistula formation. This study aims to compare the effect of anastomotic technique on fistula formation among patients with a soft pancreas in a large multiinstitutional database.

Methods

The targeted pancreas module of the American College of Surgeons–National Surgical Quality Improvement Program (NSQIP) Database was used. All patients with a soft pancreas who underwent pancreaticoduodenectomy from 2014 to 2015 were identified. Demographic data, comorbid conditions, operative variables, and 30-day outcomes were compared using univariate and multivariable analyses.

Results

A total of 975 patients met inclusion criteria. Eight-hundred fifty four (88%) underwent a duct to mucosa pancreaticojejunostomy technique and 121 (12%) underwent invagination. Patients who underwent invagination had higher 30-day mortality (5.8% vs 1.4%, p < 0.01), higher fistula formation (38% vs 25%, p < 0.01), and more often had percutaneous drain placement post-operatively (27% vs 14%, p < 0.01). Following multivariable analysis, invagination remained associated with pancreatic fistula formation (OR 2.5, CI 1.4–4.3) and post-operative percutaneous drain placement (OR 1.8, CI 1.1–2.9).

Conclusion

Invagination technique for pancreaticojejunostomy in patients with a soft pancreas is associated with increased rates of pancreatic fistula. Surgeons should consider utilizing a duct to mucosa technique when feasible to decrease morbidity following pancreaticoduodenectomy in this patient population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Fu S-J, Shen S-L, Li S-Q, et al. Risk factors and outcomes of postoperative pancreatic fistula after pancreatico-duodenectomy: an audit of 532 consecutive cases. BMC Surg. 2015;15(1):34. https://doi.org/10.1186/s12893-015-0011-7.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery. 2005;138(1):8–13. https://doi.org/10.1016/j.surg.2005.05.001.

    Article  PubMed  Google Scholar 

  3. Gouma DJ, van Geenen RC, van Gulik TM, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg. 2000;232(6):786–795. https://doi.org/10.1097/00000658-200012000-00007.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Greenblatt DY, Kelly KJ, Rajamanickam V, et al. Preoperative Factors Predict Perioperative Morbidity and Mortality After Pancreaticoduodenectomy. Ann Surg Oncol. 2011;18(8):2126–2135. https://doi.org/10.1245/s10434-011-1594-6.

    Article  PubMed  Google Scholar 

  5. Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg. 2004;8(8):951–959. https://doi.org/10.1016/j.gassur.2004.09.044.

    Article  PubMed  Google Scholar 

  6. Mathur A, Pitt HA, Marine M, et al. Fatty pancreas: a factor in postoperative pancreatic fistula. Ann Surg. 2007;246(6):1058–1064. https://doi.org/10.1097/SLA.0b013e31814a6906.

    Article  PubMed  Google Scholar 

  7. 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(5):738–747. https://doi.org/10.1016/j.jamcollsurg.2008.12.031.

    Article  PubMed  Google Scholar 

  8. Hua J, He Z, Qian D, Meng H, Zhou B, Song Z. Duct-to-Mucosa Versus Invagination Pancreaticojejunostomy Following Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis. J Gastrointest Surg. 2015;19(10):1900–1909. https://doi.org/10.1007/s11605-015-2913-1.

    Article  PubMed  Google Scholar 

  9. Sun X, Zhang Q, Zhang JY, et al. Meta-analysis of invagination and duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: An update. Int J Surg. 2016;36(2016):240–247. https://doi.org/10.1016/j.ijsu.2016.11.008.

    Article  PubMed  Google Scholar 

  10. Bai X, Zhang Q, Gao S, et al. Duct-to-Mucosa vs Invagination for Pancreaticojejunostomy after Pancreaticoduodenectomy: A Prospective, Randomized Controlled Trial from a Single Surgeon. J Am Coll Surg. 2016;222(1):10–18. https://doi.org/10.1016/j.jamcollsurg.2015.10.003.

    Article  PubMed  Google Scholar 

  11. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. http://www.kdigo.org/clinical_practice_guidelines/pdf/CKD/KDIGO_2012_CKD_GL.pdf. Accessed 1 Sep 2018

  12. Fragulidis GP, Arkadopoulos N, Vassiliou I, et al. Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump. Pancreas. 2009;38(7):e177–82. https://doi.org/10.1097/MPA.0b013e3181b57705.

    Article  PubMed  Google Scholar 

  13. Wellner UF, Kayser G, Lapshyn H, et al. A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively. HPB (Oxford). 2010;12(10):696–702. https://doi.org/10.1111/j.1477-2574.2010.00239.x.

    Article  Google Scholar 

  14. Manabu K, Satoshi K, Hiroki Y, Keita W, Keiji S, Fuyuhiko M. Predictive risk factors for clinically relevant pancreatic fistula analyzed...: EBSCOhost. J Hepatobiliary Pancreat Sci. 2011;18:601–608. https://doi.org/10.1007/s00534-011-0373-x.

    Article  Google Scholar 

  15. Pratt WB, Callery MP, Vollmer CMJ. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg. 2008;32(3):419–428. https://doi.org/10.1007/s00268-007-9388-5.

    Article  PubMed  Google Scholar 

  16. Hu BY, Wan T, Zhang WZ, Dong JH. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol. 2016;22(34):7797–7805. https://doi.org/10.3748/wjg.v22.i34.7797.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg. 1995;221(6):635–638. https://doi.org/10.1097/00000658-199506000-00003.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Suzuki Y, Fujino Y, Tanioka Y, et al. Selection of pancreaticojejunostomy techniques according to pancreatic texture and duct size. Arch Surg. 2002;137(9):1044–7; discussion 1048. https://doi.org/10.1001/archsurg.137.9.1044.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, George Washington University Medical Center, Washington, DC, USA

    Lisbi Rivas, Sara L. Zettervall, Tammy Ju, Samantha Olafson, Jeremy Holzmacher, Paul P. Lin & Khashayar Vaziri

Authors
  1. Lisbi Rivas
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sara L. Zettervall
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tammy Ju
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Samantha Olafson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jeremy Holzmacher
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Paul P. Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Khashayar Vaziri
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lisbi Rivas.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Lisbi Rivas and Sara L. Zettervall are first co-authors.

All authors listed above made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data. The authors all participated in drafting the work or revising it critically for important intellectual content and final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rivas, L., Zettervall, S.L., Ju, T. et al. The Effect of Pancreaticojejunostomy Technique on Fistula Formation Following Pancreaticoduodenectomy in the Soft Pancreas. J Gastrointest Surg 23, 2211–2215 (2019). https://doi.org/10.1007/s11605-019-04164-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-019-04164-6

Keywords

Search

Navigation