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.
References
McMillan MT, Vollmer CM, Jr., Asbun HJ, Ball CG, Bassi C, Beane JD, Berger AC, Bloomston M, Callery MP, Christein JD, Dixon E, Drebin JA, Castillo CF, Fisher WE, Fong ZV, Haverick E, House MG, Hughes SJ, Kent TS, Kunstman JW, Malleo G, McElhany AL, Salem RR, Soares K, Sprys MH, Valero V, 3rd, Watkins AA, Wolfgang CL, Behrman SW. The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy. J Gastrointest Surg 2016;20(2): 262-276.
Smits FJ, van Santvoort HC, Besselink MG, Batenburg MCT, Slooff RAE, Boerma D, Busch OR, Coene P, van Dam RM, van Dijk DPJ, van Eijck CHJ, Festen S, van der Harst E, de Hingh I, de Jong KP, Tol J, Borel Rinkes IHM, Molenaar IQ, Dutch Pancreatic Cancer G. Management of Severe Pancreatic Fistula After Pancreatoduodenectomy. JAMA Surg 2017;152(6): 540-548.
Zhou YM, Zhou X, Wan T, Xu D, Si XY. An evidence-based approach to the surgical interventions for severe pancreatic fistula after pancreatoduodenectomy. Surgeon 2018;16(2): 119-124.
J V Groen, F J Smits, D Koole, M G Besselink, O R Busch, M den Dulk, C H J van Eijck, B Groot Koerkamp, E van der Harst, I H de Hingh, T M Karsten, V E de Meijer, B K Pranger, I Q Molenaar, B A Bonsing, H C van Santvoort, J S D Mieog, the Dutch Pancreatic Cancer Group, Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis, British Journal of Surgery, Volume 108, Issue 11, November 2021, Pages 1371–1379, https://doi.org/10.1093/bjs/znab273
Smits FJ, Henry AC, van Eijck CH, Besselink MG, Busch OR, Arntz M, Bollen TL, van Delden OM, van den Heuvel D, van der Leij C, van Lienden KP, Moelker A, Bonsing BA, Borel Rinkes IHM, Bosscha K, van Dam RM, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IH, Kazemier G, Liem M, van der Kolk BM, de Meijer VE, Patijn GA, Roos D, Schreinemakers JM, Wit F, van Werkhoven CH, Molenaar IQ, van Santvoort HC, for the Dutch Pancreatic Cancer G. Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster-randomized trial. Trials 2020;21(1): 389.
Casciani F, Bassi C, Vollmer CM, Jr. Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula. Surgery 2021.
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