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Comparative Study
. 2017 Jun 1;152(6):540-548.
doi: 10.1001/jamasurg.2016.5708.

Management of Severe Pancreatic Fistula After Pancreatoduodenectomy

F Jasmijn Smits  1 , Hjalmar C van Santvoort  2 , Marc G Besselink  3 , Marilot C T Batenburg  1 , Robbert A E Slooff  1 , Djamila Boerma  4 , Olivier R Busch  3 , Peter P L O Coene  5 , Ronald M van Dam  6 , David P J van Dijk  6 , Casper H J van Eijck  7 , Sebastiaan Festen  8 , Erwin van der Harst  5 , Ignace H J T de Hingh  9 , Koert P de Jong  10 , Johanna A M G Tol  3 , Inne H M Borel Rinkes  1 , I Quintus Molenaar  1 ; Dutch Pancreatic Cancer Group
Affiliations
Comparative Study

Management of Severe Pancreatic Fistula After Pancreatoduodenectomy

F Jasmijn Smits et al. JAMA Surg. .

Abstract

Importance: Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking.

Objective: To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy.

Design, setting, and participants: A multicenter, retrospective, propensity-matched cohort study was conducted in 9 centers of the Dutch Pancreatic Cancer Group from January 1, 2005, to September 30, 2013. From a cohort of 2196 consecutive patients who underwent pancreatoduodenectomy, 309 patients with severe pancreatic fistula were included. Propensity score matching (based on sex, age, comorbidity, disease severity, and previous reinterventions) was used to minimize selection bias. Data analysis was performed from January to July 2016.

Exposures: First intervention for pancreatic fistula: catheter drainage or relaparotomy.

Main outcomes and measures: Primary end point was in-hospital mortality; secondary end points included new-onset organ failure.

Results: Of the 309 patients included in the analysis, 209 (67.6%) were men, and mean (SD) age was 64.6 (10.1) years. Overall in-hospital mortality was 17.8% (55 patients): 227 patients (73.5%) underwent primary catheter drainage and 82 patients (26.5%) underwent primary relaparotomy. Primary catheter drainage was successful (ie, survival without relaparotomy) in 175 patients (77.1%). With propensity score matching, 64 patients undergoing primary relaparotomy were matched to 64 patients undergoing primary catheter drainage. Mortality was lower after catheter drainage (14.1% vs 35.9%; P = .007; risk ratio, 0.39; 95% CI, 0.20-0.76). The rate of new-onset single-organ failure (4.7% vs 20.3%; P = .007; risk ratio, 0.15; 95% CI, 0.03-0.60) and new-onset multiple-organ failure (15.6% vs 39.1%; P = .008; risk ratio, 0.40; 95% CI, 0.20-0.77) were also lower after primary catheter drainage.

Conclusions and relevance: In this propensity-matched cohort, catheter drainage as first intervention for severe pancreatic fistula after pancreatoduodenectomy was associated with a better clinical outcome, including lower mortality, compared with primary relaparotomy.

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Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure 1.
Figure 1.. Study Patient Selection
Selection of patients included in the analyses.
Figure 2.
Figure 2.. First Intervention for Postoperative Pancreatic Fistula Over the Years
Percentage of patients undergoing catheter drainage vs relaparotomy as primary intervention for pancreatic fistula.
See this image and copyright information in PMC

Comment in

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