Abstract
Background: Postoperative Pancreatic Fistula (POPF) formation is an important complication following pancreatic resections. International Study Group on Pancreatic Fistula (ISGPF) has defined POPF as ‘an abnormal communication between pancreatic ductal epithelium and another epithelial surface, containing pancreas derived enzyme-rich fluid.’ Although Pancreatic Fistula (PF) is generally treated conservatively (grade A), some cases may require interventional procedures (grade B) or maybe life-threatening and necessitate emergency reoperation (grade C).
This study aims to compare the incidence of POPF after pancreatico-duodenectomy (PD) following duct-to-mucosa and dunking methods.
Materials and Methods: A total number of 48 patients diagnosed with periampullary carcinoma attending to OPD, King George Hospital from August 2017 to August 2018 are included. All the patients were subjected to routine blood investigations and imaging studies. Cases were randomized based on block randomization. Postoperatively biochemical and imaging studies done for leak identification. Patients who didn’t give their consent and who succumbed immediately postoperatively were excluded.
Results: Of the 48 cases who underwent PD, 24 underwent pancreaticojejunostomy using duct to mucosa method, rest with invagination or dunking method. Three cases developed POPF following surgery (6.23%). Of these, two (8.33%) following duct-to-mucosa and one (4.16%) following the invagination method. All three managed conservatively. No mortality due to POPF.
Conclusion: POPF continues to be the nemesis of pancreatic resection. Many technical variations have been developed with the hope of decreasing the incidence of POPF. In a nutshell, a successful pancreatico-enteric anastomosis requires a tension-free anastomosis with adequately placed and tied sutures, preserved blood supply to the pancreatic remnant and jejunum, and unobstructed flow from the pancreas into the gastrointestinal tract, whatever the chosen technique may be.
Keywords: Postoperative Pancreatic fistula-pancreaticojejunostomy-Whipple’s procedure.
References
- Seetharam P, Rodrigues GS. Postoperative pancreatic fistula: A surgeon’s nightmare! An insight with a detailed literature review. JOP J Pancreas. 2015;16(2):115–124.
- Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. surgery. 2005;138(1):8–13.
- Berger AC, Howard TJ, Kennedy EP, Sauter PK, Bower-Cherry M, Dutkevitch S, et al. Does Type of Pancreaticojejunostomy after Pancreaticoduodenectomy Decrease Rate of Pancreatic Fistula? A Randomized, Prospective, Dual-Institution Trial. J Am Coll Surg. 2009 May 1;208(5):738–47.
- Senda Y, Shimizu Y, Natsume S, Ito S, Komori K, Abe T, et al. Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy. BJS Br J Surg. 2018;105(1):48–57.
- Han J, Wang X, Quan Z, Zhu W. Duct-to-mucosa anastomosis and incidence of pancreatic fistula following pancreaticoduodenectomy. J Med Postgrad [Internet]. 2003 Jan 1 [cited 2020 Jan 12];0(09). Available from: http://wprim.whocc.org.cn/admin/article/articleDetail?WPRIMID=595878&articleId=595878
- Langrehr JM, Bahra M, Jacob D, Glanemann M, Neuhaus P. Prospective randomized comparison between a new mattress technique and Cattell (duct-to-mucosa) pancreaticojejunostomy for pancreatic resection. World J Surg. 2005;29(9):1111–1119.
- Bassi C, Falconi M, Molinari E, Mantovani W, Butturini G, Gumbs AA, et al. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial. Surgery. 2003;134(5):766–771.
- Chou: Postoperative morbidity and mortality of pancreatic... - Google Scholar [Internet]. [cited 2020 Jan 11]. Available from: https://scholar.google.com/scholar_lookup?title=Post-operative%20morbidity%20and%20mortality%20of%20pancreaticoduodenectomy%20for%20periampullary%20cancer&publication_year=1996&author=F.F.%20Chou&author=S.M.%20Sheen-Chen&author=Y.S.%20Chen&author=M.C.%20Chen&author=C.L.%20Chen
- Singh AN, Pal S, Mangla V, Kilambi R, George J, Dash NR, et al. Pancreaticojejunostomy: Does the technique matter? A randomized trial. J Surg Oncol. 2018 Mar;117(3):389–96.
- Bai X, Zhang Q, Gao S, Lou J, Li G, Zhang Y, 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 Jan;222(1):10–8.
- 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 Oct 1;19(10):1900–9.
- Callery MP, Castillo-Angeles M, Kent TS. Prevention and Management of Complications of Pancreatic Surgery. In: Shackelford’s Surgery of the Alimentary Tract, 2 Volume Set. Elsevier; 2019. p. 1239–1248.
- McMillan MT, Vollmer CM. Predictive factors for pancreatic fistula following pancreatectomy. Langenbecks Arch Surg. 2014;399(7):811–824.
- Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer Jr CM. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg. 2007;245(3):443.
- Callery MP, Pratt WB, Vollmer CM. Prevention and management of pancreatic fistula. J Gastrointest Surg. 2009;13(1):163–173.
- Miller BC, Christein JD, Behrman SW, Drebin JA, Pratt WB, Callery MP, et al. A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy. J Gastrointest Surg. 2014;18(1):172–180.
- Menahem B, Guittet L, Mulliri A, Alves A, Lubrano J. Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials. LWW; 2015.
- Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg. 1995;221(6):635.
- Batignani G, Fratini G, Zuckermann M, Bianchini E, Tonelli F. Comparison of Wirsung-jejunal duct-to-mucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy. 2005;
Corresponding Author
Dr Chintagada Jayaraj
Professor & Head of the Department of Surgery, Andhra Medical College, Visakhapatnam, India
DOI: https://dx.doi.org/10.18535/jmscr/v8i1.106
