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.	赵玉沛. 胰腺术后外科常见并发症诊治及预防的专家共识 (2017). 协和医学杂志, 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, 冷建军, 万涛, 等. 511 例胰十二指肠切除术患者胰瘘危险因素分析. 中华肝胆外科杂志, 2015, 21(6): 377-381.
12.	翁昊, 束翌俊, 包润发, 等. 术前胰腺平扫 CT 值可预测胰十二指肠切除术后胰瘘危险性. 中华普通外科杂志, 2014, 29(1): 21-24.
13.	刘颖斌, 王许安, 黄丛云. 胰十二指肠切除术后胰腺残端消化道重建的历史回顾. 中华消化外科杂志, 2018, 17(7): 671-676.
14.	何铁英, 晏冬, 王喜艳, 等. 胰十二指肠切除术应用胰管支撑管的 Meta 分析. 中华消化外科杂志, 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.	王刚, 孙备, 姜洪池, 等. 胰十二指肠切除术后早期胰管支撑管内引流及外引流的疗效比较. 中华外科杂志, 2014, 52(5): 333-337.
20.	姜凯, 陈照军, 陈永卫, 等. 胰十二指肠切除术置放胰管引流合理性的流体动力学模拟研究. 解放军医学杂志, 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.	吴国忠, 姜杰, 庞绍春. 完全性胰液外引流预防胰十二指肠切除术后胰瘘的机理分析. 中国现代手术学杂志, 2011, 15(4): 262-263.
24.	胡平海, 金焰, 乔鸥. 胰管支撑外引流管在胰十二指肠切除术胰肠吻合中的临床效果分析. 中国现代普通外科进展, 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.	胡泽民, 余元龙, 周载平, 等. 胰十二指肠切除术 132 例严重并发症的防治. 中华普通外科学文献: 电子版, 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. 赵玉沛. 胰腺术后外科常见并发症诊治及预防的专家共识 (2017). 协和医学杂志, 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, 冷建军, 万涛, 等. 511 例胰十二指肠切除术患者胰瘘危险因素分析. 中华肝胆外科杂志, 2015, 21(6): 377-381.
12. 翁昊, 束翌俊, 包润发, 等. 术前胰腺平扫 CT 值可预测胰十二指肠切除术后胰瘘危险性. 中华普通外科杂志, 2014, 29(1): 21-24.
13. 刘颖斌, 王许安, 黄丛云. 胰十二指肠切除术后胰腺残端消化道重建的历史回顾. 中华消化外科杂志, 2018, 17(7): 671-676.
14. 何铁英, 晏冬, 王喜艳, 等. 胰十二指肠切除术应用胰管支撑管的 Meta 分析. 中华消化外科杂志, 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. 王刚, 孙备, 姜洪池, 等. 胰十二指肠切除术后早期胰管支撑管内引流及外引流的疗效比较. 中华外科杂志, 2014, 52(5): 333-337.
20. 姜凯, 陈照军, 陈永卫, 等. 胰十二指肠切除术置放胰管引流合理性的流体动力学模拟研究. 解放军医学杂志, 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. 吴国忠, 姜杰, 庞绍春. 完全性胰液外引流预防胰十二指肠切除术后胰瘘的机理分析. 中国现代手术学杂志, 2011, 15(4): 262-263.
24. 胡平海, 金焰, 乔鸥. 胰管支撑外引流管在胰十二指肠切除术胰肠吻合中的临床效果分析. 中国现代普通外科进展, 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. 胡泽民, 余元龙, 周载平, 等. 胰十二指肠切除术 132 例严重并发症的防治. 中华普通外科学文献: 电子版, 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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