External stenting of pancreaticojejunostomy anastomosis and pancreatic duct after pancreaticoduodenectomy

Abstract

Pancreatic fistula is a major cause of morbidity and mortality after pancreaticoduodenectomy. External drainage of pancreaticojejunostomy anastomosis with a stent is used to reduce the rate of pancreatic fistula. This study compares the rates of pancreatic fistula between external stent drainage versus no-stent drainage for pancreaticojejunal anastomosis following pancreaticoduodenectomy. A total of 53 patients undergoing pancreaticoduodenectomy for various benign and malignant pathologies were included in the study. An external stent was inserted across the anastomosis to drain the pancreatic duct in 26 patients and 27 patients received no stent. The primary end point was pancreatic fistula. All surgeries were done by a single surgeon with expertise in hepatobiliary pancreatic surgery at a single institute. The two groups were comparable in demographic data, underlying pathologies, presenting complaints, presence of comorbid illnesses and proportion of patients with preoperative biliary drainage, pancreatic consistency and duct diameter. The pancreatic fistula rates were similar in both the groups (11.5 vs. 14.8 %, P = 0.725). The morbidity and surgical re-exploration rate were statistically not significant between the two groups (65.4 vs. 51.9 %, P = 0.318 and 11.5 vs. 7.4 %, P = 0.60). Postoperative stay was also similar with a mean of 14 days in both the groups (P = 0.66). The mortality rate was statistically not significant in the two groups (3.8 vs. 7.4 %, P = 0.575). External drainage of pancreaticojejunostomy anastomosis and the pancreatic duct with a stent does not decrease the rate of postoperative pancreatic fistula after pancreaticoduodenectomy.

USE of Biodegradable STENTS in Pancreaticoduodenectomy: Initial Experience

“…Finally, stents provide a low resistance pathway for the pancreatic secretions towards the jejunum, decreasing leak around the anastomosis. 7,40,41 PJ stents can be internal or external, and we have been using both techniques, according to surgeon preference. Internal stents have one end in the pancreatic duct and the other in the jejunum, and rely on peristalsis for migration into the bowel and expulsion; they may be fixed with a fast absorbable stitch to prevent early expulsion.…”

“…Many studies have proved its benefit, especially in high-risk patients, while others have shown no effect. 7,19,41,48,49 Part of the argument against using stents is the morbidity associated with plastic stents, including stent occlusion and migration, which can result in pancreatic duct obstruction and pancreatitis. 31,40,49 Another frequent concern with internal stents is stent retention, which can lead to recurrent pancreatitis, the formation of stones, pancreatic insufficiency, and strictures of the pancreatic duct or the anastomosis.…”

Digestive tract reconstruction in pancreaticoduodenectomy in University Hospitals of China: a national questionnaire survey

“…[23] However, not all reports have concluded that stents are effective in reducing POPF incidence and other complications. Kaman et al [24] concluded that external drainage stents do not reduce the incidence of POPF compared with not using stents, and a meta-analysis by Zhou et al [25] showed that internal drainage stents not only did not reduce the incidence of POPF but increased the risk of POPF in the soft pancreas. An RCT in 2018 suggested that there was no difference between internal and external drainage stents, regardless of immediate or long-term complications, [26] and that there was a lack of a uniform understanding of stent tube placement and indications in China.…”

The prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy in patients with FRS ≥ 4: a retrospective cohort study

“…A large number of studies, including prospective randomized trials as well as meta-analyses, have shown that external pancreatic duct stents significantly decrease the rate of pancreatic fistula and shorten the length of hospital stay [6][7][8]. Paradoxically, several studies have shown that external pancreatic duct stents have no effect and may even increase the incidence of postoperative pancreatic fistula [9][10][11]. In a meta-analysis, Dong et al [12] observed that the use of an external pancreatic duct stent was associated with a significantly lower incidence of pancreatic fistula in patients at high risk for pancreatic fistula compared with an internal stent, but there was no definitive conclusion because of the low quality of the evidence [8].…”