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The pancreaticojejunal anastomotic stent: Friend or foe?

Published on May 1, 2013in Surgery3.476
· DOI :10.1016/j.surg.2012.11.007
Teviah Sachs13
Estimated H-index: 13
(BIDMC: Beth Israel Deaconess Medical Center),
Wande B. Pratt17
Estimated H-index: 17
(BIDMC: Beth Israel Deaconess Medical Center)
+ 2 AuthorsCharles M. Vollmer40
Estimated H-index: 40
(UPenn: University of Pennsylvania)
Sources
Abstract
Background The efficacy of pancreaticojejunal (P-J) anastomotic stents in preventing clinically relevant postoperative pancreatic fistulas (CR-POPF) after pancreatic resection is poorly understood. We sought to compare the outcomes of stented and nonstented patients in light of recognized risk-factors for the development of CR-POPF and to determine whether outcomes differed once there was a change in practice where use of stents was abandoned. Methods A total of 444 patients underwent proximal pancreatic resection with P-J reconstruction from 2001 to 2011. At the surgeon's discretion, a PJ stent (5- or 8-Fr Silastic tube) was placed in 59 patients (13.3%; 46 internal, 13 external). Demographics, comorbidities, and adjusted outcomes were evaluated between groups of nonstented (n = 385) and stented patients; these outcomes included a subgroup analysis of internally and externally stented patients. Risk factors for CR-POPF (International Study Group on Pancreatic Fistula grade B/C) development have been previously defined as soft gland, small duct size, high-risk pathology, or excessive blood loss (>1,000 mL). Outcomes were interpreted in reference to the risk factor profile (the number of absolute risk factors present; 0–4), and to the fistula risk score, a prospectively validated score which accurately predicts the risk and impact of pancreatic fistula based on these variables. Results Preoperative demographics of age, sex, body mass index, American Society of Anesthesiologists class, and physiologic and operative severity score for the enumeration of mortality and morbidity (ie, POSSUM) score were equivalent between cohorts. The CR-POPF risk-factor profile and fistula risk score were greater in stented patients (P Conclusion The use of P-J stents does not decrease the incidence or severity of CR-POPF after proximal pancreatic resection, both overall and for high-risk scenarios. In some patients, P-J stents may lead to short- and long-term adverse outcomes.
  • References (21)
  • Citations (29)
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References21
Newest
#1Sheraz R. MarkarH-Index: 30
#2Soumil VyasH-Index: 10
Last. MassimoMalagoH-Index: 49
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Background The aim of this meta-analysis is to evaluate the effect of stenting the pancreatic duct during pancreaticojejunostomy formation on perioperative outcomes.
15 CitationsSource
#1Despoina Daskalaki (University of Verona)H-Index: 3
#2Giovanni Butturini (University of Verona)H-Index: 36
Last. Claudio Bassi (University of Verona)H-Index: 80
view all 6 authors...
Aim Postoperative pancreatic fistula (POPF) has a wide range of clinical and economical implications due to the difference of the associated complications and management. The aim of this study is to verify the applicability of the International Study Group of Pancreatic Fistula (ISGPF) definition and its capability to predict hospital costs.
43 CitationsSource
#1Masajitani (Wakayama Medical University)H-Index: 28
#2Manabu Kawai (Wakayama Medical University)H-Index: 28
Last. Hirokiyamaue (Wakayama Medical University)H-Index: 44
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Abstract Background A stent often is placed across the pancreaticojejunostomy. However, there is no report compared between internal drainage and external drainage. Methods We conducted a prospective randomized trial ( NCT00628186 registered at http://ClinicalTrials.gov ) with 100 patients who underwent pancreaticoduodenectomy and we compared the effects on postoperative course. Results The incidence of pancreatic fistula according to the International Study Group on Pancreatic Fistula criteria ...
62 CitationsSource
We report our technique for pancreaticojejunostomy, using a stent tube, and examine the literature with regard to the use of a stent tube in pancreaticojejunostomy. The total number of stitches in the anastomosis of the pancreatic parenchyma and seromuscle layer of the jejunum should be more than 20, and there should be more than 8 stitches in the anastomosis of the pancreatic duct and parenchyma and all layers of the jejunal wall, even in a normal-sized main pancreatic duct. There is no dead sp...
16 CitationsSource
#1Tsafrir Vanounou (BIDMC: Beth Israel Deaconess Medical Center)H-Index: 6
#2Wande B. Pratt (BIDMC: Beth Israel Deaconess Medical Center)H-Index: 17
Last. Charles M. Vollmer (BIDMC: Beth Israel Deaconess Medical Center)H-Index: 40
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Background The efficacy of prophylactic octreotide after pancreaticoduodenectomy has been rigorously scrutinized, yet few studies have specifically illustrated its impact in patients at high risk for pancreatic fistula. Applying a previously validated clinical classification scheme (International Study Group on Pancreatic Fistula) for postoperative pancreatic fistula severity, we examined whether prophylactic octreotide could effectuate a clinical or fiscal benefit, or both, after pancreatic res...
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#1Jordan M. Winter (Johns Hopkins University)H-Index: 36
#2John L. Cameron (Johns Hopkins University)H-Index: 13
Last. Charles J. Yeo (Johns Hopkins University)H-Index: 127
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Pancreatic duct stenting remains an attractive strategy to reduce the incidence of pancreatic fistulas following pancreaticoduodenectomy (PD) with encouraging results in both retrospective and prospective studies. We performed a prospective randomized trial to test the hypothesis that internal pancreatic duct stenting reduces the development of pancreatic fistulas following PD. Two hundred thirty-eight patients were randomized to either receive a pancreatic stent (S) or no stent (NS), and strati...
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#1P.-A. ClavienH-Index: 97
#2SanabriaH-Index: 1
Last. Steven M. StrasbergH-Index: 32
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Abstract Lack of uniform reporting of negative outcomes makes interpretation of surgical literature difficult. We attempt to define and classify negative outcomes by differentiating complications, sequelae, and failures. Complications and sequelae result from procedures, adding new problems to the underlying disease. However, complications are unexpected events not intrinsic to the procedure, whereas sequelae are inherent to the procedure. Failures are events in which the purpose of the procedur...
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#1Yuancong Jiang (ZJU: Zhejiang University)
#2Qin Chen (LMB: Laboratory of Molecular Biology)
Last. Sheng Yan (ZJU: Zhejiang University)H-Index: 14
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#1Thomas F. Seykora (UPenn: University of Pennsylvania)H-Index: 2
#2Laura Maggino (UPenn: University of Pennsylvania)H-Index: 10
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
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Recent data illustrates improved outcomes when adhering to early drain removal following pancreatoduodenectomy (PD). This study aims to explore the potential benefits of expanding the timeframe for early drain removal. Six hundred forty PDs were originally managed by selective drain placement and early removal. Outcomes were reappraised in the framework of a novel proposal; intraoperative drains were omitted based on a low-risk profile (Fistula Risk Score 0–2), followed by drain removal at PODs ...
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1 CitationsSource
#1Priya M. Puri (UPenn: University of Pennsylvania)H-Index: 3
#2Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
Postoperative pancreatic fistula (POPF) is the most common complication after major pancreatic resections and is the greatest contributor to postoperative morbidity and mortality following pancreatoduodenectomy (PD). The relatively recent establishment of a standardized definition of POPF by the International Study Group of Pancreatic Fistula (ISGPF) allowed for the delineation between innocuous biochemical POPF (grade A) and clinically relevant (CR) POPF (grades B and C). This classification sy...
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#1Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 12
#2Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
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#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2Giuseppe Malleo (University of Verona)H-Index: 29
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
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Abstract Introduction Clinically relevant postoperative pancreatic fistula (CR-POPF) is a morbid complication following pancreatoduodenectomy (PD). It is unclear how pancreatic surgeons perceive risk for this complication, and the implications thereof. Methods A web-based survey was distributed to members of 22 international GI surgical societies. CR-POPF risk factors were categorized as follows: (i) patient factors, (ii) pancreatic gland characteristics, (iii) intraoperative variables, (iv) per...
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#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
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Background Evidence suggests externalized trans-anastomotic stents may be beneficial as a fistula mitigation strategy for pancreatoduodenectomy (PD); however, previous studies have not been rigorously risk-adjusted.
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#1Matthew T. McMillan (Mayo Clinic)H-Index: 17
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Objective:To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.Background:Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of
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#1Jashodeep Datta (UPenn: University of Pennsylvania)H-Index: 15
#2Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
The surgical management of pancreatic diseases is rapidly evolving, encompassing advances in evidence-driven selection of patients amenable for surgical therapy, preoperative risk stratification, refinements in the technical conduct of pancreatic operations, and quantification of postoperative morbidity. These advances have resulted in dramatic reductions in mortality following pancreatic surgery, particularly at high-volume pancreatic centers. Surgical decision making is complex, and requires a...
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