Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy

Abstract

Background:The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy.Methods: Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay.Results: Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0⋅077). Duration of drain insertion (6 versus 7 days respectively; P = 0⋅027) and postoperative hospital stay (19 versus 24 days; P = 0⋅015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0⋅010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38⋅5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0⋅028) and postoperative hospital stay (42 versus 54⋅5 days respectively; P = 0⋅028). Conclusion:This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).

Randomized clinical trial of the effect of a fibrin sealant patch on pancreatic fistula formation after pancreatoduodenectomy

“…The outcome measures of the present trial were adapted retrospectively according to the new definition of POPF, but the incidence of biochemical leakage was kept in the report in order to provide a complete picture of the tightening capacity of fibrin sealant patches. The proportion of patients with biochemical leakage was significantly higher here than reported previously, whereas the incidence of grade B and C POPF was not. The authors are not able to provide a conclusive explanation for this as the participating centres have a high annual caseload of pancreatic resections, with pancreatojejunostomy performed according to general standards, with little variation.…”

Novel single‐layer continuous suture of pancreaticojejunostomy for robotic pancreaticoduodenectomy

“…The pancreatic texture was assessed and classified as soft or hard by an experienced surgeon (Dr Liu Rong) during operation according to a previous study . The main pancreatic duct (MPD) was considered small if it measured less than 3 mm during operation as described by Senda et al .…”

“…To reduce POPF incidence after PD, numerous pancreatic anastomotic methods have been proposed and studied, and pancreaticojejunostomy (PJ) is the most commonly performed anastomosis among them . Although various anastomotic techniques have been devised to improve the outcome of PD, the best anastomotic technique for PJ to minimize POPF is still controversial . In this study, we present novel single‐layer continuous suture (SCS), a safe and effective technique for PJ for RPD based on our experience in a high‐volume robotic center.…”

Magnetic compression anastomosis for biliojejunostomy and pancreaticojejunostomy in Whipple's procedure: An initial clinical study

“…Although the operative mortality after pancreaticoduodenectomy has decreased to < 5%, the incidence of postoperative morbidity remains as high as 60% . Of the many complications after pancreaticoduodenectomy, postoperative pancreatic fistula is the most common and severe one, the incidence of which ranges from 5–30%. This is associated with many other clinically relevant problems including sepsis, hemorrhage, and death .…”

“…7 Surgeon's experience and techniques independently influenced the overall and anastomosis relevant morbidity. Herein, various surgical procedures have been devised to improve the outcome of pancreaticojejunostomy 1,4 and biliojejunostomy. 7 However, in lower-volume and mediumvolume centers, the incidence of postoperative morbidity and mortality is still relatively high.…”