Manipadam John Mathew, S Mahesh, Kadamapuzha Jacob Mathew, H Ramesh
Department of GI Surgery and Liver Transplantation, VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, India.
Surg J (N Y). 2018 Mar 20;4(1):e37-e42. doi: 10.1055/s-0038-1639343. eCollection 2018 Jan.
Surgeons and endoscopists welcome routine preoperative biliary drainage prior to pancreaticoduodenectomy despite evidence that it increases complications. Its effect on postoperative pancreatic fistula is variably reported in literature. Simultaneous biliary and pancreatic drainage is rarely performed for very selected indications and its effects on postoperative pancreatic fistula are largely unknown. Our aim was to analyze the same while eliminating confounding factors. Retrospective single center cohort study of patients who underwent pancreaticoduodenectomy over the past 10 years for carcinoma obstructing the lower common bile duct. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, and no stenting prior to pancreaticoduodenectomy were the three study cohort groups and their records were scrutinized for the incidence of postoperative pancreatic fistula. Sixty-two patients underwent biliary stenting alone, 5 patients underwent both biliary and pancreatic stenting, and 237 patients were not stented in the adenocarcinoma group without chronic pancreatitis. The pancreatic fistula rate was similar in the patients who underwent biliary stenting alone when compared with the group which was not stented. (24/62 versus 67/237, odds ratio [OR] =0.619, confidence interval (CI) =0.345-1.112, = 0.121). However, the patients who underwent both biliary and pancreatic stenting had a significant increase in postoperative pancreatic fistula compared with the not stented ( = 0.003). By univariate and multivariate analysis using Firth logistic regression, pancreatic texture (OR = 1.205, CI = 0.103-2.476, = 0.032) and the presence of a biliary and pancreatic stent (OR = 2.695, CI = 0.273-7.617, = 0.027) were the significant factors affecting pancreatic fistula. Preoperative biliary drainage alone has no significant influence on postoperative pancreatic fistula except when combined with pancreatic stenting. We need more such studies from other centers to confirm that the rare event of preoperative biliary and pancreatic stenting has indeed this harmful effect on healing of postoperative pancreatic anastomosis.
尽管有证据表明术前常规胆道引流会增加并发症，但外科医生和内镜医师仍倾向于在胰十二指肠切除术前行该操作。其对术后胰瘘的影响在文献中的报道不一。同时进行胆道和胰腺引流仅在极少数特定情况下实施，其对术后胰瘘的影响很大程度上尚不明确。我们的目的是在消除混杂因素的情况下对此进行分析。
对过去10年因低位胆总管癌接受胰十二指肠切除术的患者进行回顾性单中心队列研究。在胰十二指肠切除术前行单纯胆道支架置入、胆道和胰腺支架置入以及未行支架置入的患者作为三个研究队列组，仔细审查他们术后胰瘘的发生率。
在无慢性胰腺炎的腺癌组中，62例患者仅接受了胆道支架置入，5例患者同时接受了胆道和胰腺支架置入，237例患者未行支架置入。与未行支架置入的组相比，仅接受胆道支架置入的患者胰瘘发生率相似。（24/62对67/237，比值比[OR]=0.619，置信区间(CI)=0.345 - 1.112，P = 0.121）。然而，与未行支架置入的患者相比，同时接受胆道和胰腺支架置入的患者术后胰瘘显著增加（P = 0.003）。通过使用Firth逻辑回归进行单因素和多因素分析，胰腺质地（OR = 1.205，CI = 0.103 - 2.476，P = 0.032）以及胆道和胰腺支架的存在（OR = 2.695，CI = 0.273 - 7.617，P = 0.027）是影响胰瘘的重要因素。
单独的术前胆道引流对术后胰瘘没有显著影响，除非与胰腺支架置入联合使用。我们需要其他中心进行更多此类研究来证实术前胆道和胰腺支架置入这一罕见情况确实对术后胰腺吻合口愈合有这种有害影响。
