Role of Stent in Pancreatic Fistula

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Role of Stent in Pancreatic Fistula

• Article-External Drainage of pancreatic duct with
  stent to reduce leakage rate of
  Pancreaticojejunostomy after pancreaticoduodenecto
  my-A Prospective Randomised Trial-From Sept 2007
  issue of Annals of Surgery
• Study at Dept of surgery,Queen Mary Hospital,The
  Uni.of HongKong.

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Role of Stent in Pancreatic Fistula

• Article-External Drainage of pancreatic duct with
  stent to reduce leakage rate of
  Pancreaticojejunostomy after pancreaticoduodenecto
  my-A Prospective Randomised Trial-From Sept 2007
  issue of Annals of Surgery
• Study at Dept of surgery,Queen Mary Hospital,The
  Uni.of HongKong.

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Introduction

• Pancreaticoduodenectomy-Rx of Choice of Ca
  pancreatic head and periampullary region
• Mortality rate following surgery has declined to
  lt5percent
• 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

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• 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

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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.

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• 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

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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

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• Postop outcome-Fistula rate significantly lower
  in stented group(6.7Vs20 P-0.032)
• Clinical Leakage-2 of 4 pts in stented group VS 9
  of 12 pts in nonstented group.Significantly lower
  rate(3.3vs15,P0.027)
• 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.

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• Results of univariate analysis for factors
  related to pancreatic fistula-2
  factors,pancreatic duct diameter(p-.032),pancreati
  c 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-lt3mm-significant risk
  factors

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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

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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 29.3to
  6.3.This trial showed similar reduction of
  fistula rate.

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• 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.

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• This study also identified significantly higher
  fistula rate in pts with small PD lt3mm.
• 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

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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.

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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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• Thank You