Advertisement

World Journal of Surgery

, Volume 42, Issue 11, pp 3726–3735 | Cite as

Afferent Loop Decompression Technique is Associated with a Reduction in Pancreatic Fistula Following Pancreaticoduodenectomy

  • Jie Yin
  • Zipeng Lu
  • Pengfei Wu
  • Junli Wu
  • Wentao Gao
  • Jishu Wei
  • Feng Guo
  • Jianmin Chen
  • Kuirong Jiang
  • Yi Miao
Original Scientific Report

Abstract

Objectives

Postoperative pancreatic fistula (POPF) is a major complication and main cause of mortality after pancreaticoduodenectomy (PD). Afferent loop decompression technique (ALDT) has theoretical feasibility to reduce the rate of POPF. The aim of this study is to determine whether ALDT is a protective factor for POPF.

Methods

A total of 492 consecutive patients who underwent PD between January 2012 and December 2014 were identified from a prospective database. All data were extracted and events were judged based on medical records. Propensity score matching was conducted to balance several variables. Univariate and multivariate analyses were performed, respectively, to investigate the independent risk factors for pancreatic fistula. ALDT required a nasogastric tube with multiple side holes to be placed deep into the afferent jejunal limb. The rationale for this technique was to prevent pancreatic fistula by decreasing intraluminal pressure in the afferent jejunal loop by placement of the nasogastric tube and the application of continuous low-pressure suction after surgery.

Results

The total rate of POPF for the entire cohort was 30.7%, and ISGPS grade-A/B/C POPF rates were 18.1, 10.6 and 2.0%, respectively. In-hospital mortality was 1.6%. Among the 331 patients who received ALDT, 89 developed pancreatic leakage (26.9 vs. 38.5% for non-ALDT; P = 0.009) and eight developed biliary leakage (2.4 vs. 6.2% for non-ALDT; P = 0.035). Apart from ALDT, decreased preoperative ALT, soft pancreas, long operative time and tumour presence in the lower common bile duct (as opposed to the pancreas) were identified as other independent risk factors for POPF following multivariate logistic regression analysis.

Conclusions

ALDT may reduce the incidence of POPF after PD.

Notes

Acknowledgements

This study was funded by the National Natural Science Foundation of China (Grant No. 81272382&81672449), the Innovation Capability Development Project of Jiangsu Province (No. BM2015004 to YM), and by the Jiangsu Province Funding Programme for Six Major Talent Summit, China (Grant No.2014-WSW-006). The authors gratefully appreciate Dr. Christopher Halloran for review of the manuscript. The approval number is 2018-SR-070.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

References

  1. 1.
    Whipple AO, Parsons WB, Mullins CR (1935) Treatment of carcinoma of the ampulla of vater. Ann Surg 102(4):763–779CrossRefGoogle Scholar
  2. 2.
    Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J (1993) One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 217(5):430–438CrossRefGoogle Scholar
  3. 3.
    Yoshioka R, Yasunaga H, Hasegawa K, Horiguchi H, Fushimi K, Aoki T, Sakamoto Y, Sugawara Y, Kokudo N (2014) Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy. Br J Surg 101(5):523–529CrossRefGoogle Scholar
  4. 4.
    Lai EC, Lau SH, Lau WY (2009) Measures to prevent pancreatic fistula after pancreatoduodenectomy: a comprehensive review. Arch Surg 144(11):1074–1080CrossRefGoogle Scholar
  5. 5.
    Gaujoux S, Cortes A, Couvelard A, Noullet S, Clavel L, Rebours V, Levy P, Sauvanet A, Ruszniewski P, Belghiti J (2010) Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. Surgery 148(1):15–23CrossRefGoogle Scholar
  6. 6.
    Mathur A, Pitt HA, Marine M, Saxena R, Schmidt CM, Howard TJ, Nakeeb A, Zyromski NJ, Lillemoe KD (2007) Fatty pancreas: a factor in postoperative pancreatic fistula. Ann Surg 246(6):1058–1064CrossRefGoogle Scholar
  7. 7.
    Kollmar O, Moussavian MR, Bolli M, Richter S, Schilling MK (2007) Pancreatojejunal leakage after pancreas head resection: anatomic and surgeon-related factors. J Gastrointest Surg 11(12):1699–1703CrossRefGoogle Scholar
  8. 8.
    Bassi C, Falconi M, Molinari E, Mantovani W, Butturini G, Gumbs AA, Salvia R, Pederzoli P (2003) Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial. Surgery 134(5):766–771CrossRefGoogle Scholar
  9. 9.
    Winter JM, Cameron JL, Campbell KA, Chang DC, Riall TS, Schulick RD, Choti MA, Coleman J, Hodgin MB, Sauter PK, Sonnenday CJ, Wolfgang CL, Marohn MR, Yeo CJ (2006) Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 10(9):1280–1290CrossRefGoogle Scholar
  10. 10.
    Xiong JJ, Tan CL, Szatmary P, Huang W, Ke NW, Hu WM, Nunes QM, Sutton R, Liu XB (2014) Meta-analysis of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Br J Surg 101(10):1196–1208CrossRefGoogle Scholar
  11. 11.
    Xiong JJ, Altaf K, Mukherjee R, Huang W, Hu WM, Li A, Ke NW, Liu XB (2012) Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy. Br J Surg 99(8):1050–1061CrossRefGoogle Scholar
  12. 12.
    Hartwig W, Vollmer CM, Fingerhut A, Yeo CJ, Neoptolemos JP, Adham M, Andren-Sandberg A, Asbun HJ, Bassi C, Bockhorn M, Charnley R, Conlon KC, Dervenis C, Fernandez-Cruz L, Friess H, Gouma DJ, Imrie CW, Lillemoe KD, Milicevic MN, Montorsi M, Shrikhande SV, Vashist YK, Izbicki JR, Buchler MW (2014) Extended pancreatectomy in pancreatic ductal adenocarcinoma: definition and consensus of the International Study Group for Pancreatic Surgery (ISGPS). Surgery 156(1):1–14CrossRefGoogle Scholar
  13. 13.
    Wei J, Liu X, Wu J, Xu W, Zhou J, Lu Z, Chen J, Guo F, Gao W, Li Q, Jiang K, Dai C, Miao Y (2015) Modified one-layer duct-to-mucosa pancreaticojejunostomy reduces pancreatic fistula after pancreaticoduodenectomy. Int Surg.  https://doi.org/10.9738/INTSURG-D-15-00094.1 CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13CrossRefGoogle Scholar
  15. 15.
    Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142(1):20–25CrossRefGoogle Scholar
  16. 16.
    Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Buchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142(5):761–768CrossRefGoogle Scholar
  17. 17.
    Li SQ, Liang LJ, Peng BG, Lu MD, Lai JM, Li DM (2007) Bile leakage after hepatectomy for hepatolithiasis: risk factors and management. Surgery 141(3):340–345CrossRefGoogle Scholar
  18. 18.
    Besselink MG, van Rijssen LB, Bassi C, Dervenis C, Montorsi M, Adham M, Asbun HJ, Bockhorn M, Strobel O, Buchler MW, Busch OR, Charnley RM, Conlon KC, Fernandez-Cruz L, Fingerhut A, Friess H, Izbicki JR, Lillemoe KD, Neoptolemos JP, Sarr MG, Shrikhande SV, Sitarz R, Vollmer CM, Yeo CJ, Hartwig W, Wolfgang CL, Gouma DJ, International Study Group on Pancreatic Surgery (2017) Definition and classification of chyle leak after pancreatic operation: a consensus statement by the International Study Group on Pancreatic Surgery. Surgery 161(2):365–372CrossRefGoogle Scholar
  19. 19.
    Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, Hodgin MB, Sauter PK, Hruban RH, Riall TS, Schulick RD, Choti MA, Lillemoe KD, Yeo CJ (2006) 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg 10(9):1199–1211CrossRefGoogle Scholar
  20. 20.
    Kimura W, Miyata H, Gotoh M, Hirai I, Kenjo A, Kitagawa Y, Shimada M, Baba H, Tomita N, Nakagoe T, Sugihara K, Mori M (2014) A pancreaticoduodenectomy risk model derived from 8575 cases from a national single-race population (Japanese) using a web-based data entry system: the 30-day and in-hospital mortality rates for pancreaticoduodenectomy. Ann Surg 259(4):773–780CrossRefGoogle Scholar
  21. 21.
    El Nakeeb A, Salah T, Sultan A, El Hemaly M, Askr W, Ezzat H, Hamdy E, Atef E, El Hanafy E, El-Geidie A, Abdel Wahab M, Abdallah T (2013) Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J Surg 37(6):1405–1418.  https://doi.org/10.1007/s00268-013-1998-5 CrossRefPubMedGoogle Scholar
  22. 22.
    El Nakeeb A, Askr W, Mahdy Y, Elgawalby A, El Sorogy M, Abu Zeied M, Abdallah T, Abd Elwahab M (2015) Delayed gastric emptying after pancreaticoduodenectomy. Risk factors, predictors of severity and outcome. A single center experience of 588 cases. J Gastrointest Surg 19(6):1093–1100CrossRefGoogle Scholar
  23. 23.
    Pratt WB, Callery MP, Vollmer CM Jr (2008) Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg 32(3):419–428.  https://doi.org/10.1007/s00268-007-9388-5 CrossRefPubMedGoogle Scholar
  24. 24.
    van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ (2010) Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 362(2):129–137CrossRefGoogle Scholar
  25. 25.
    Pessaux P, Sauvanet A, Mariette C, Paye F, Muscari F, Cunha AS, Sastre B, Arnaud JP (2011) External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg 253(5):879–885CrossRefGoogle Scholar
  26. 26.
    Figueras J, Sabater L, Planellas P, Munoz-Forner E, Lopez-Ben S, Falgueras L, Sala-Palau C, Albiol M, Ortega-Serrano J, Castro-Gutierrez E (2013) Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy on the rate and severity of pancreatic fistula after pancreaticoduodenectomy. Br J Surg 100(12):1597–1605CrossRefGoogle Scholar
  27. 27.
    Chen Y, Ke N, Tan C, Zhang H, Wang X, Mai G, Liu X (2015) Continuous versus interrupted suture techniques of pancreaticojejunostomy after pancreaticoduodenectomy. J Surg Res 193(2):590–597CrossRefGoogle Scholar
  28. 28.
    Tani M, Kawai M, Hirono S, Okada KI, Miyazawa M, Shimizu A, Kitahata Y, Yamaue H (2014) Randomized clinical trial of isolated Roux-en-Y versus conventional reconstruction after pancreaticoduodenectomy. Br J Surg 101(9):1084–1091CrossRefGoogle Scholar
  29. 29.
    Hatzigeorgiadis A, Boulas KA, Barettas N, Papageorgiou I, Blouhos K (2014) Tube pancreatico- duodenostomy for management of a severe penetrating pancreaticoduodenal injury. JOP 15(3):250–253PubMedGoogle Scholar
  30. 30.
    Motoi F, Egawa S, Rikiyama T, Katayose Y, Unno M (2012) Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. Br J Surg 99(4):524–531CrossRefGoogle Scholar
  31. 31.
    Williamsson C, Karlsson N, Sturesson C, Lindell G, Andersson R, Tingstedt B (2015) Impact of a fast-track surgery programme for pancreaticoduodenectomy. Br J Surg 102(9):1133–1141CrossRefGoogle Scholar
  32. 32.
    Kunstman JW, Klemen ND, Fonseca AL, Araya DL, Salem RR (2013) Nasogastric drainage may be unnecessary after pancreaticoduodenectomy: a comparison of routine vs selective decompression. J Am Coll Surg 217(3):481–488CrossRefGoogle Scholar
  33. 33.
    Ausania F, Snowden CP, Prentis JM, Holmes LR, Jaques BC, White SA, French JJ, Manas DM, Charnley RM (2012) Effects of low cardiopulmonary reserve on pancreatic leak following pancreaticoduodenectomy. Br J Surg 99(9):1290–1294CrossRefGoogle Scholar
  34. 34.
    El Nakeeb A, Sultan AM, Salah T, El Hemaly M, Hamdy E, Salem A, Moneer A, Said R, AbuEleneen A, Abu Zeid M, Abdallah T, Abdel Wahab M (2013) Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy. World J Gastroenterol 19(41):7129–7137CrossRefGoogle Scholar
  35. 35.
    Polanco PM, Zenati MS, Hogg ME, Shakir M, Boone BA, Bartlett DL, Zeh HJ, Zureikat AH (2016) An analysis of risk factors for pancreatic fistula after robotic pancreaticoduodenectomy: outcomes from a consecutive series of standardized pancreatic reconstructions. Surg Endosc 30(4):1523–1529CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  • Jie Yin
    • 1
  • Zipeng Lu
    • 1
  • Pengfei Wu
    • 1
  • Junli Wu
    • 1
  • Wentao Gao
    • 1
  • Jishu Wei
    • 1
  • Feng Guo
    • 1
  • Jianmin Chen
    • 1
  • Kuirong Jiang
    • 1
  • Yi Miao
    • 1
  1. 1.Department of General Surgery, Pancreas CenterThe First Affiliated Hospital with Nanjing Medical UniversityNanjingChina

Personalised recommendations