Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015.

Objective To review prospective randomized controlled trials to determine whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is associated with lower risks of mortality and pancreatic fistula after pancreaticoduodenectomy (PD). Background Previous studies comparing reconstruction by PG and PJ reported conflicting results regarding the relative risks of mortality and pancreatic fistula after these procedures. Methods MEDLINE, the Cochrane Trials Register, and EMBASE were searched for prospective randomized controlled trials comparing PG and PJ after PD, published up to November 2013. Meta-analysis was performed using Review Manager 5.0. Results Seven trials were selected, including 562 patients who underwent PG and 559 who underwent PJ. The pancreatic fistula rate was significantly lower in the PG group than in the PJ group (63/562, 11.2% vs 84/559, 18.7%; odds ratio = 0.53; 95% confidence interval, 0.38-0.75; P = 0.0003). The overall mortality rate was 3.7% (18/489) in the PG group and 3.9% (19/487) in the PJ group (P = 0.68). The biliary fistula rate was significantly lower in the PG group than in the PJ group (8/400, 2.0% vs 19/392, 4.8%; odds ratio = 0.42; 95% confidence interval, 0.18-0.93; P = 0.03). Conclusions In PD, reconstruction by PG is associated with lower postoperative pancreatic and biliary fistula rates.

https://www.cinj.org/sites/cinj/files/documents/Pancreaticogastrostomy%20Is%20Superior%20to%20Pancreaticojejunostomy%20for%20Prevention%20of%20Pancreatic%20Fistula%20After%20Pancreaticoduodenectomy%20%28An%20Updated%20Meta-analysis%20of%20Randomized%20Controlled%20Trials%29.pdf

Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials.

Background

Surgical reconstruction following pancreaticoduodenectomy (PD) is associated with significant morbidity and mortality. Because of great variability in definitions of specific complications, it remains unclear whether there is a difference in complication rates following the two commonest types of reconstruction, pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ). Published consensus definitions for postoperative pancreatic fistula (POPF) have led to a series of randomized clinical trials (RCTs) uniquely placed to address this question.



Methods

A literature search was carried out to identify all RCTs comparing postoperative complications of PG versus PJ reconstruction following PD published between January 1995 and December 2013. Pooled odds ratios (ORs) with 95 percent confidence intervals (c.i.) were calculated using fixed-effect or random-effects models.



Results

In total, seven RCTs with 1121 patients were included. Four of these trials applied definitions as published by the International Study Group on Pancreatic Fistula (ISGPF). Using ISGPF definitions, the incidence of POPF was lower in patients undergoing PG than in those having PJ (OR 0·50, 95 per cent c.i. 0·34 to 0·73; P < 0·001). Using definitions applied by each individual study, PG was associated with significantly lower rates of POPF (OR 0·51, 0·36 to 0·71; P < 0·001), intra-abdominal fluid collection (OR 0·50, 0·34 to 0·74; P < 0·001) and biliary fistula (OR 0·42, 0·18 to 0·93; P = 0·03) than PJ.



Conclusion

Meta-analysis of four RCTs based on ISGPF criteria, and seven RCTs using non-standard criteria, revealed that PG reduced the incidence of POPF after PD compared with PJ.

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Meta-analysis of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy

Objective:To analyze the actual long-term outcome after the Whipple's surgery of pancreatic adenocarcinoma and to identify the characteristics shared by long-term surivors.Methods:Sixty-six patients with the disgnosis of pancreatic adenocarcinoma who received Whipple's surgery between January 1996 and December 2001 were entered into a prospective database.Their actual survival outcome and the clinicopathologic characteristics were compared retrospectively.Results:Median follow-up of survivors who had Whipple's surgery was 25 months.Actuarial 5-year survival was 18.3%.Tumors with lymph node involvement,portal vein invasion,and tumor size greater than 2.5 cm were predictors of a significantly worse survival in both univariate and multivariate analysis.Conclusion:This paper emphasizes the grim prognosis of pancreatic adenocarcinoma.Biologic characteristics remain important predictors of survival for patients with resected pancreatic cancer.

Prognostic Indicators for Survival after Resection of Pancreatic Adenocarcinoma

Postoperative pancreatic fistula is a significant contributor to morbidity following proximal and distal pancreatic resections. In recent decades, the incidence of fistula has ranged from 2 to 33 %; however, the consistent identification of risk factors has been difficult due to significant variability in the definition of pancreatic fistula. The purpose of this study was to use the highest level evidence available in the literature to present risk factors thus far identified as significant predictors of fistula occurrence. Another endpoint will address those risk factors which have been shown to have a clinical impact on the patient. This review will conclude by discussing comprehensive risk models that interpret the aggregate fistula risk for a patient based on the presence of weighted risk factors. The contemporary surgical literature suggests many risk factors for fistula development, which can be categorized as either endogenous, operative, or perioperative. The advent of the International Study Group of Pancreatic Fistula (ISGPF) scheme created universal definitions for fistula that delineate between biochemical and clinically relevant fistulas. This classification system has allowed for the elucidation of risk factors for clinically impactful fistula and enabled the development of risk scores for predicting fistula occurrence after major pancreatic resections, which are useful in clinical management and comparative research.

Predictive factors for pancreatic fistula following pancreatectomy

Background and Objectives: The method of pancreatic reconstruction after pancreaticoduodenectomy (PD) is closely associated with postoperative morbidity, mortality, and patient's quality of life. The objective of this study is to evaluate which anastomosis approach - pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ) is a better option of choice in terms of postoperative complications. Methods: Articles comparing PG and PJ that were published by July 2011 were retrieved and subjected to a systematic review and meta-analysis. Results: Four randomized controlled trials (RCTs) and 22 observational clinical studies (OCSs) were included. RCTs showed that the PG group had significantly lower incidence rates of postoperative intra-abdominal fluid collection (p = 0.003, relative risk (RR) 0.50, 95% CI 0.31-0.79) and multiple intra-abdominal complications (p = 0.0007, RR 0.26, 95% CI 0.12-0.56) than the PJ group. OCSs demonstrated significant differences between PG and PJ in terms of frequencies of postoperative biliary fistula, intra-abdominal fluid collection, pancreatic fistula, morbidity, and mortality. The overall analysis revealed significant differences in frequencies of intra-luminal hemorrhage (p = 0.03, OR 2.82, 95% CI 1.08-7.33) and grade B/C pancreatic fistula (p = 0.002, OR 0.42, 95% CI 0.24-0.73) between the two groups. Conclusions: Current literature has no adequate evidence to prove that PG is superior to PJ for patients undergoing PD in terms of postoperative complications. A standardized classification of pancreatic fistula and other intra-abdominal complications may enable an objective, valid comparison between PG and PJ.

Pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a systematic review and meta-analysis.

Aim: To investigate the ways in which to decrease the morbidity of pancreatic fistula after pancreaticoduodenectomy and corresponding therapy.

Methods:  Double-layered end-to-side duct-to-mucosa anastomosis was applied in 105 cases of pancreaticoduodenectomy and pancreaticoenteric reconstruction, postoperative pancreatic fistula cases were treated aggressively by early surgery, effective drainage and enteral nutrition.

Results:  Ten cases of pancreatic fistula occurred among 105 operative cases and required reoperation. The rest of the cases recovered uneventfully, except for five cases of in-hospital death.

Conclusion:  Aggressively early surgery, effective drainage, comprehensive treatment and continual improvement of operative technique are the key to dealing with postoperative pancreatic fistula.

Wei Han

Papers

Pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a systematic review and meta-analysis.

The analysis of diagnosis and treatment for pancreatic fistula after pancreaticoduodenectomy for 105 periampullary carcinoma cases