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

Abstract

Background Despite the fact that primary percutaneous catheter drainage has become standard practice, some patients with pancreatic fistula after pancreatoduodenectomy ultimately undergo a relaparotomy. The aim of this study was to compare completion pancreatectomy with a pancreas-preserving procedure in patients undergoing relaparotomy for pancreatic fistula after pancreatoduodenectomy. Methods This retrospective cohort study of nine institutions included patients who underwent relaparotomy for pancreatic fistula after pancreatoduodenectomy from 2005–2018. Furthermore, a systematic review and meta-analysis were performed according to the PRISMA guidelines. Results From 4877 patients undergoing pancreatoduodenectomy, 786 (16 per cent) developed a pancreatic fistula grade B/C and 162 (3 per cent) underwent a relaparotomy for pancreatic fistula. Of these patients, 36 (22 per cent) underwent a completion pancreatectomy and 126 (78 per cent) a pancreas-preserving procedure. Mortality was higher after completion pancreatectomy (20 (56 per cent) versus 40 patients (32 per cent); P = 0.009), which remained after adjusting for sex, age, BMI, ASA score, previous reintervention, and organ failure in the 24 h before relaparotomy (adjusted odds ratio 2.55, 95 per cent c.i. 1.07 to 6.08). The proportion of additional reinterventions was not different between groups (23 (64 per cent) versus 84 patients (67 per cent); P = 0.756). The meta-analysis including 33 studies evaluating 745 patients, confirmed the association between completion pancreatectomy and mortality (Mantel–Haenszel random-effects model: odds ratio 1.99, 95 per cent c.i. 1.03 to 3.84). Conclusion Based on the current data, a pancreas-preserving procedure seems preferable to completion pancreatectomy in patients in whom a relaparotomy is deemed necessary for pancreatic fistula after pancreatoduodenectomy.

Surgical management of severe pancreatic fistula after pancreatoduodenectomy: a comparison of early versus late rescue pancreatectomy

“…See Table 4 for the outcomes. In the present study, 21% of patients with POPF grade B/C underwent a rescue pancreatectomy, which is in line with the identified literature (6–30%) [ 9 , 22 , 24 , 27 , 32 ]. Whereas the need for rescue pancreatectomy has decreased over the years by improvement of minimally invasive management [ 12 ], the rescue pancreatectomy rate at Karolinska University Hospital did not decrease significantly.…”

“…In the PORSCH trial, still 8% of the patients who underwent a PD in the intervention group needed a relaparotomy. A retrospective analysis from the Dutch Pancreatic Cancer Group revealed that rescue pancreatectomy was associated with higher mortality in comparison to pancreas-preserving surgery, strengthened by the literature [ 9 ]. Furthermore, mortality was similar between simple surgical drainage and other pancreas-preserving surgical interventions, whereby clinical condition and additional intervention rates were similar [ 36 ].…”

“…Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤ 11 versus > 11 days), based on recent literature (i.e. studies with inclusion periods from 2000 and onwards) [9,[22][23][24][25][26][27][28]. See Supplementary Digital Content 1 for the literature search strategy and Table 4 for the studies that are used to calculate the average timing of rescue pancreatectomy.…”

“…Rescue pancreatectomy is considered as a last-resort treatment whereby the pancreatic remnant as the cause of abdominal sepsis is removed [ 7 , 8 ]. This intervention is associated with high mortality rates up to 56% [ 9 ]. Moreover, the life-long metabolic insufficiencies that negatively impacts the quality of life further strengthens the general reluctance to perform rescue pancreatectomy in these critically ill patients [ 10 , 11 ].…”

Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy

“…In the present study, although few patients were included, 2 patients who underwent completion pancreatectomy experienced in-hospital mortality (100%). A recently published meta-analysis reported that a pancreas-preserving procedure seems preferable to completion pancreatectomy in patients in whom relaparotomy is deemed necessary for POPF after PD [ 21 ]. Emergency completion pancreatectomy is also a technically difficult procedure because of active bleeding, severe adhesions around the splenic vessels, and necrotized friable remnant pancreas and adjacent organs.…”