Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis.

IMPORTANCE

Postoperative pancreatic fistula is among the most notorious complications after pancreatoduodenectomy.¹ Primary percutaneous catheter drainage has become standard practice in the management of a clinically relevant pancreatic fistula. However, percutaneous catheter drainage is not successful in all patients and a small subset ultimately undergo a relaparotomy.² Only few studies have been performed on the clinical outcomes of different surgical strategies in patients with pancreatic fistula after pancreatoduodenectomy.³         

QUESTION

Should a completion pancreatectomy or a pancreas-preserving procedure be the preferred surgical strategy in patients undergoing relaparotomy for pancreatic fistula after pancreatoduodenectomy?

FINDINGS

Recently, we compared 36 patients undergoing completion pancreatectomy and 126 patients undergoing a pancreas-preserving intervention during the first relaparotomy for pancreatic fistula after pancreatoduodenectomy.⁴ Mortality was higher after completion pancreatectomy (odds ratio after correction for confounders 2.55, 95% confidence interval 1.07-6.08). The proportion of additional reinterventions (64% vs 67%, P=0.76) and length of hospital stay was not different between groups Additionally, we conducted a systematic review and meta-analysis on mortality and found a similar association (745 patients, odds ratio 1.99, 95% confidence interval 1.03-3.84).

MEANING

Completion pancreatectomy as surgical strategy was independently associated with a doubling of mortality, as compared to a pancreas-preserving procedure. There was no difference in the proportion of additional reinterventions or duration of hospital stay. Therefore, we believe that, after failure of percutaneous drainage, a pancreas-preserving procedure seems to be the preferred surgical strategy whenever possible during relaparotomy for pancreatic fistula after pancreatoduodenectomy.

FUTURE

The Dutch Pancreatic Cancer Group is currently analysing the data of the nationwide PORSCH trial which investigates if the implementation of an standardised best practice algorithm for early recognition and minimally invasive management of postoperative pancreatic fistula may improve the rates of severe complications and mortality.⁵ These results are important since the recognition and treatment of pancreatic fistula is standardised: i.e. the indication to perform CT-scan, its subsequent assessment and consequences (no action, antibiotics, percutaneous drainage, consulting expert panel). This best practice algorithm has adequate external validity and excludes most heterogeneity. A recent paper on postoperative pancreatic fistula from international pancreatic experts highlighted the importance of a dedicated team including interventional radiology, interventional endoscopy and critical care support to avoid unnecessary laparotomies.⁶ Therefore, future studies and multidisciplinary efforts are pivotal to improves outcomes for patients with pancreatic fistula.