Role of Stent in Pancreatic Fistula

1. Role of Stent in Pancreatic Fistula Article-External Drainage of pancreatic duct with stent to reduce leakage rate of Pancreaticojejunostomy after pancreaticoduodenectomy-A Prospective Randomised Trial-From Sept 2007 issue of Annals of Surgery Study at Dept of surgery,Queen Mary Hospital,The Uni.of HongKong.

2. Role of Stent in Pancreatic Fistula Article-External Drainage of pancreatic duct with stent to reduce leakage rate of Pancreaticojejunostomy after pancreaticoduodenectomy-A Prospective Randomised Trial-From Sept 2007 issue of Annals of Surgery Study at Dept of surgery,Queen Mary Hospital,The Uni.of HongKong.

3. Introduction Pancreaticoduodenectomy-Rx of Choice of Ca pancreatic head and periampullary region Mortality rate following surgery has declined to <5percent Pancreatic fistula rate-5-40percent depending on definition of leakage Pancreaticojejunal anastomosis is classic method of reconstruction after pancreaticoduodenectomy Some retrospective studies have reported low fistula rate by catheter insertion into the pancreatic duct

4. A recent prospective but nonrandomized study showed external drainage of pancreatic duct decreased fistula rate from 29.3 to 6.8 percent and median hospital stay from 29 to 13 days. Thus far no prospective randomized trial on the use of external drainage stent for pancreatic anastomosis has been reported. This is a prospective randomized trial to test the hypothesis that external drainage stent could decrease rate of pancreatic fistula

5. Methods Betn June 2000-Oct2006-127 pts had elective pancreaticoduodenectomy for benign or malignant pathologies of pancreas at dept of Surgery,The uni. Of HongKong,Queen Mary Hospital,HongKong 120 pts in the trial Randomization by opening consecutive sealed envelopes containing random nos that assigned patients in stented and non stented group. Standardized PJ anastomosis-end to side duct to mucosa 2 layer PJ anastomosis using interrupted fine prolene sutures.

6. In Stented group 3-8 Fr polyvinyl catheter with multiple side holes inserted in PD. Catheter migration prevented by an anchoring stitch. 2drains-anterior and posterior to anastomosis Serum and drain fluid amylase levels measured on day1,3,5,7 and 9 postop.If no e/o leakage drains were removed on postop day10

7. Results Total of 120 pts who successfully underwent pancreaticoduodenectomy were recruited in the trial. Complete data collection and no protocol violation. Baseline demographics of the two groups-no significant difference Operative data and pathologic diagnoses-both groups comparable Carcinoma of pancreas was most common pathologic diagnosis

8. Postop outcome-Fistula rate significantly lower in stented group(6.7%Vs20% P-0.032) Clinical Leakage-2 of 4 pts in stented group VS 9 of 12 pts in nonstented group.Significantly lower rate(3.3%vs15%,P=0.027) Mean total volume of pancreatic juice-(646-1726ml) Overall hospital stay-(Mean17 Vs23 days,P-0.039),Significantly longer duration of TPN in nonstented group.

9. Results of univariate analysis for factors related to pancreatic fistula-2 factors,pancreatic duct diameter(p-.032),pancreatic duct stent. Higher fistula incidence in male pts and pts with soft consistency. Multivariate analysis using these 4 factors �no duct stent and PD diameter-<=3mm-significant risk factors

10. Conclusion This prospective randomized trial showed that use of external stent to drain pancreatic duct significantly reduced pancreatic fistula rate of duct to mucosa PJ anastomosis

11. Discussion Merits-Prospective randomized trial This trial showed that external pancreatic stent significantly redused leakage rate of PJ anastomosis thus providing level 1 evidence supporting stenting. Rodger et al reported a prospective but non randomised study of 85 pts of external drainage that decreased fistula rate from 29.3%to 6.3%.This trial showed similar reduction of fistula rate.

12. This study did not use prophylactic octreotide VS the study by Rodger Et al. Clinical relevant observation of the reduction of clinical leakage from 15% to 3.3% Definition of fistula in this study was similar to international study group No imaging was used for diagnosis of fistula.

13. This study also identified significantly higher fistula rate in pts with small PD <=3mm. Subgroup analysis of fistula rate according to PD diameter �fistula rate was lower with use of stent VS no stent but not statistically significant. This study also identified pancreatic texture not a significant risk factor for fistula in both univariate or multivariate analysis

14. Demerits Drains left for 10 days in this study. Total length of stay even in stented group in excess of 17days Potential complication of local peritonitis as reported in study by Ohwada et al.No such complications related to insertion or removal of stent in this study.

15. Points for Discussion 1.Octreotide VS no octreotide 2Pancreaticogastrostomy Vs Pancreaticojejunostomy 3.Obliteration of PD by ligation ,fibrin glue or synthetic polymers Vs no obliteration 4.Internal Vs External Stent 5.Pylorus preserving Vs conventional

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