Comparison of end-to-end invagination and duct-to-mucosa pancreaticojejunostomies following Whipple's resection : A randomized controlled trial in patients at high risk of postoperative pancreatic fistula

• Introduction: Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatic resection. Various pancreatoenteric reconstruction techniques exist, yet there is no consensus on the optimal strategy to decrease POPF. The aim of this trial was to compare a novel end-to-end invaginated pancreaticojejunostomy (INV) with the duct-to-mucosa anastomosis (DM) in patients at high risk for POPF. Methods: Consecutive patients between September 2011 and 2015 that were evaluated at a multidisciplinary tumor board and planned for a pancreaticoduodenectomy were randomized prospectively to INV or DM, in an unblinded dual-institution superiority trial. All patients had an assessment of their pancreatic gland both pre- and intra-operatively to select for patients at high risk for POPF. The primary end point was clinically relevant POPF as classified by established definitions.  Secondary outcomes were postoperative mortality and morbidity.Results: Hundred and twenty-three patients were included in the final analysis (61 DM, 62 INV). All patients had a soft pancreas with a main pancreatic duct <3mm. There was no difference in clinically significant pancreatic leaks (POPF B-C) between the groups (p=0.72). Significantly fewer cases of POPF C were observed in the INV group compared to the DM group (DM n=13, INV n=2, p=0.002). Six life-threatening complications (Clavien-Dindo IV) occurred in the DM group, compared to one in the INV group (p=0.06). Grade C post-pancreatectomy hemorrhage was significantly higher in the DM group (DM n=7, INV n=0, p=0.006). There were no differences between the groups in median operating times, in-hospital mortality, or blood loss. Conclusion: The end-to-end invagination pancreaticojejunostomy is not significantly superior with regards to clinically significant POPF. It does however appear to be a safe reconstruction technique, possibly associated with a lower incidence of severe POPF and post-pancreatectomy hemorrhage. 

Subject headings

MEDICIN OCH HÄLSOVETENSKAP  -- Klinisk medicin -- Kirurgi (hsv//swe)

MEDICAL AND HEALTH SCIENCES  -- Clinical Medicine -- Surgery (hsv//eng)

Keyword

pancreatic cancer

post-operative pancreatic fistula

pancreaticoduodenectomy

Kirurgi

Surgery

Publication and Content Type

vet (subject category)

ovr (subject category)