Departments of Surgery from University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Mayo Clinic, Jacksonville, FL.
Ann Surg. 2018 Apr;267(4):608-616. doi: 10.1097/SLA.0000000000002327.
The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy.
The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circumstances of the anastomosis. The Fistula Risk Score (FRS) identifies a distinct high-risk cohort (FRS 7 to 10) that demonstrates substantially worse clinical outcomes. The value of various fistula mitigation strategies in these particular high-stakes cases has not been previously explored.
This multinational study included 5323 PDs performed by 62 surgeons at 17 institutions. Mitigation strategies, including both technique related (ie, pancreatogastrostomy reconstruction; dunking; tissue patches) and the use of adjuvant strategies (ie, intraperitoneal drains; anastomotic stents; prophylactic octreotide; tissue sealants), were evaluated using multivariable regression analysis and propensity score matching.
A total of 522 (9.8%) PDs met high-risk FRS criteria, with an observed CR-POPF rate of 29.1%. Pancreatogastrostomy, prophylactic octreotide, and omission of externalized stents were each associated with an increased rate of CR-POPF (all P < 0.001). In a multivariable model accounting for patient, surgeon, and institutional characteristics, the use of external stents [odds ratio (OR) 0.45, 95% confidence interval (95% CI) 0.25-0.81] and the omission of prophylactic octreotide (OR 0.49, 95% CI 0.30-0.78) were independently associated with decreased CR-POPF occurrence. In the propensity score matched cohort, an "optimal" mitigation strategy (ie, externalized stent and no prophylactic octreotide) was associated with a reduced rate of CR-POPF (13.2% vs 33.5%, P < 0.001).
The scenarios identified by the high-risk FRS zone represent challenging anastomoses associated with markedly elevated rates of fistula. Externalized stents and omission of prophylactic octreotide, in the setting of intraperitoneal drainage and pancreaticojejunostomy reconstruction, provides optimal outcomes.
本研究旨在确定胰十二指肠切除术后（PD）最佳的瘘管缓解策略。
预防 PD 术后临床相关胰瘘（CR-POPF）的技术策略的应用效果可能因吻合口的情况而异。瘘管风险评分（FRS）确定了一个明显的高危队列（FRS 7-10），该队列的临床结局明显更差。先前尚未探讨各种瘘管缓解策略在这些高风险病例中的应用价值。
这项多中心研究纳入了 62 名外科医生在 17 个机构进行的 5323 例 PD。采用多变量回归分析和倾向评分匹配评估了各种缓解策略，包括与技术相关的策略（即胰胃吻合重建；浸浴；组织补丁）和辅助策略（即腹腔引流；吻合支架；预防性奥曲肽；组织密封剂）。
共有 522 例（9.8%）PD 符合高危 FRS 标准，观察到的 CR-POPF 发生率为 29.1%。胰胃吻合、预防性奥曲肽和不使用外置支架均与 CR-POPF 发生率增加相关（均 P<0.001）。在一个考虑患者、外科医生和机构特征的多变量模型中，使用外置支架[比值比（OR）0.45，95%置信区间（95%CI）0.25-0.81]和不使用预防性奥曲肽（OR 0.49，95%CI 0.30-0.78）与 CR-POPF 发生率降低独立相关。在倾向评分匹配的队列中，“最佳”缓解策略（即外置支架和不使用预防性奥曲肽）与降低 CR-POPF 发生率相关（13.2% vs 33.5%，P<0.001）。
高危 FRS 区确定的情况代表了与瘘管发生率明显升高相关的具有挑战性的吻合口。在腹腔引流和胰肠吻合重建的情况下，使用外置支架和不使用预防性奥曲肽可获得最佳结果。
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