A Meta-Analysis and Systematic Review of Pancreatic Duct Stent

Abstract

IntroductionThe National Cancer Institute has estimated that there will be as many as 45,220 new cases of pancreatic cancer in the U.S. in 2012 and that as many as 38,460 patients will die of the disease this year alone [1]. Pancreaticoduodenectomy (PD) remains the sole potentially curative intervention for several types of peri-ampullary and pancreatic carcinomas and pathologies. Postoperative Pancreatic Fistula Formation (POPF) as a result of pancreaticojejunostomy (PJ) anastomotic failure remains one of the most serious and dreaded complications following PD. POPF is believed to be a consequence of pancreatic exocrine secretion seepage across a compromised anastomotic site, with the most likely mechanism being autodigestion and destruction of the tissue surrounding the PJ anastomotic site leading to dehiscence and seepage into the abdominal cavity. The release of these activated pancreatic juices then cause peripancreatic collections, intra-abdominal abscesses, hemorrhage, and POPF [2].Protection of this anastomotic site has therefore been the focus of many modifications to the original Whipple procedure. Stent placement across the PJ anastomsis has been proposed to protect the integrity of the site by diverting the potentially caustic exocrine secretions of the pancreatic remnant away from the delicate anastomotic site. In addition, such stents have been theorized to promote precise placement of anastomotic sutures, facilitate decompression of the pancreatic remnant, and maintain patency of the pancreatic duct postoperatively [3,4].Two similar though uniquely different procedures have been integrated into the traditional PD procedure with varying reports of actual efficacy; an internal and an external pancreatic duct stent. The internal stent technique is generally performed by inserting a 6 cm stent into the pancreatic duct such that one-half of its length remains within the duct itself, bridges across the anastomotic site, and empties into the jejunal lumen. In contrast, the external stent utilizes a longer stent placed similarly within the pancreatic duct stump, bridges across the anastomotic site into the jenual lumen, but the tail of which is exited through a small enterotomy site in the free end of the jejunal loop. This is then closed with a purse-string suture, externalized via a stab incision in the anterior abdominal wall, and closed by suturing the serosa of the jejunum to the peritoneum of the abdominal wall. In both cases migration of the catheter is prevented with an absorbable suture attachment to the jejunal mucosal surface [4][5][6][7][8][9]. The final PJ reconstruction is then carried out with an end-to-side, duct-to-mucosa anastomosis using 1-or 2-layer interrupted fine sutures [6].Previous meta analysis performed by Markar et al. [10] examined the combined effect of placement of either stent type on clinical outcome following PJ. Based on the integrated data sets, these authors identified a non-statistically significant trend towards reduced pancreatic fistula with the use of either sten...