Characterization and Optimal Management of High-Risk Pancreatic Anastomoses During Pancreatoduodenectomy

Brett L. Ecker, Matthew T. McMillan, Horacio J. Asbun, Chad G. Ball, Claudio Bassi, Joal D. Beane, Stephen W. Behrman, Adam C. Berger, Euan J. Dickson, Mark Bloomston, Mark P. Callery, John D. Christein, Elijah Dixon, Jeffrey A. Drebin, Carlos Fernandez del Castillo, William E. Fisher, Zhi Ven Fong, Ericka Haverick, Robert H. Hollis, Michael G. HouseSteven J. Hughes, Nigel B. Jamieson, Ammar A. Javed, Tara S. Kent, Stacy J. Kowalsky, John W. Kunstman, Giuseppe Malleo, Katherine E. Poruk, Ronald R. Salem, Carl R. Schmidt, Kevin Soares, John A. Stauffer, Vicente Valero, Lavanniya K.P. Velu, Amarra A. Watkins, Christopher L. Wolfgang, Amer H. Zureikat, Charles M. Vollmer

Research output: Contribution to journalArticle

17 Citations (Scopus)

Abstract

OBJECTIVE:: The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy. BACKGROUND:: 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. METHODS:: 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. RESULTS:: 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). CONCLUSIONS:: 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.

Original languageEnglish (US)
JournalAnnals of Surgery
DOIs
StateAccepted/In press - Jun 7 2017

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Pancreaticoduodenectomy
Risk Management
Pancreatic Fistula
Fistula
Octreotide
Stents
Propensity Score
Odds Ratio
Pancreaticojejunostomy
Confidence Intervals
Drainage
Regression Analysis

ASJC Scopus subject areas

  • Surgery

Cite this

Ecker, B. L., McMillan, M. T., Asbun, H. J., Ball, C. G., Bassi, C., Beane, J. D., ... Vollmer, C. M. (Accepted/In press). Characterization and Optimal Management of High-Risk Pancreatic Anastomoses During Pancreatoduodenectomy. Annals of Surgery. https://doi.org/10.1097/SLA.0000000000002327

Characterization and Optimal Management of High-Risk Pancreatic Anastomoses During Pancreatoduodenectomy. / Ecker, Brett L.; McMillan, Matthew T.; Asbun, Horacio J.; Ball, Chad G.; Bassi, Claudio; Beane, Joal D.; Behrman, Stephen W.; Berger, Adam C.; Dickson, Euan J.; Bloomston, Mark; Callery, Mark P.; Christein, John D.; Dixon, Elijah; Drebin, Jeffrey A.; Castillo, Carlos Fernandez del; Fisher, William E.; Fong, Zhi Ven; Haverick, Ericka; Hollis, Robert H.; House, Michael G.; Hughes, Steven J.; Jamieson, Nigel B.; Javed, Ammar A.; Kent, Tara S.; Kowalsky, Stacy J.; Kunstman, John W.; Malleo, Giuseppe; Poruk, Katherine E.; Salem, Ronald R.; Schmidt, Carl R.; Soares, Kevin; Stauffer, John A.; Valero, Vicente; Velu, Lavanniya K.P.; Watkins, Amarra A.; Wolfgang, Christopher L.; Zureikat, Amer H.; Vollmer, Charles M.

In: Annals of Surgery, 07.06.2017.

Research output: Contribution to journalArticle

Ecker, BL, McMillan, MT, Asbun, HJ, Ball, CG, Bassi, C, Beane, JD, Behrman, SW, Berger, AC, Dickson, EJ, Bloomston, M, Callery, MP, Christein, JD, Dixon, E, Drebin, JA, Castillo, CFD, Fisher, WE, Fong, ZV, Haverick, E, Hollis, RH, House, MG, Hughes, SJ, Jamieson, NB, Javed, AA, Kent, TS, Kowalsky, SJ, Kunstman, JW, Malleo, G, Poruk, KE, Salem, RR, Schmidt, CR, Soares, K, Stauffer, JA, Valero, V, Velu, LKP, Watkins, AA, Wolfgang, CL, Zureikat, AH & Vollmer, CM 2017, 'Characterization and Optimal Management of High-Risk Pancreatic Anastomoses During Pancreatoduodenectomy', Annals of Surgery. https://doi.org/10.1097/SLA.0000000000002327
Ecker, Brett L. ; McMillan, Matthew T. ; Asbun, Horacio J. ; Ball, Chad G. ; Bassi, Claudio ; Beane, Joal D. ; Behrman, Stephen W. ; Berger, Adam C. ; Dickson, Euan J. ; Bloomston, Mark ; Callery, Mark P. ; Christein, John D. ; Dixon, Elijah ; Drebin, Jeffrey A. ; Castillo, Carlos Fernandez del ; Fisher, William E. ; Fong, Zhi Ven ; Haverick, Ericka ; Hollis, Robert H. ; House, Michael G. ; Hughes, Steven J. ; Jamieson, Nigel B. ; Javed, Ammar A. ; Kent, Tara S. ; Kowalsky, Stacy J. ; Kunstman, John W. ; Malleo, Giuseppe ; Poruk, Katherine E. ; Salem, Ronald R. ; Schmidt, Carl R. ; Soares, Kevin ; Stauffer, John A. ; Valero, Vicente ; Velu, Lavanniya K.P. ; Watkins, Amarra A. ; Wolfgang, Christopher L. ; Zureikat, Amer H. ; Vollmer, Charles M. / Characterization and Optimal Management of High-Risk Pancreatic Anastomoses During Pancreatoduodenectomy. In: Annals of Surgery. 2017.
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title = "Characterization and Optimal Management of High-Risk Pancreatic Anastomoses During Pancreatoduodenectomy",
abstract = "OBJECTIVE:: The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy. BACKGROUND:: 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. METHODS:: 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. RESULTS:: 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). CONCLUSIONS:: 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.",
author = "Ecker, {Brett L.} and McMillan, {Matthew T.} and Asbun, {Horacio J.} and Ball, {Chad G.} and Claudio Bassi and Beane, {Joal D.} and Behrman, {Stephen W.} and Berger, {Adam C.} and Dickson, {Euan J.} and Mark Bloomston and Callery, {Mark P.} and Christein, {John D.} and Elijah Dixon and Drebin, {Jeffrey A.} and Castillo, {Carlos Fernandez del} and Fisher, {William E.} and Fong, {Zhi Ven} and Ericka Haverick and Hollis, {Robert H.} and House, {Michael G.} and Hughes, {Steven J.} and Jamieson, {Nigel B.} and Javed, {Ammar A.} and Kent, {Tara S.} and Kowalsky, {Stacy J.} and Kunstman, {John W.} and Giuseppe Malleo and Poruk, {Katherine E.} and Salem, {Ronald R.} and Schmidt, {Carl R.} and Kevin Soares and Stauffer, {John A.} and Vicente Valero and Velu, {Lavanniya K.P.} and Watkins, {Amarra A.} and Wolfgang, {Christopher L.} and Zureikat, {Amer H.} and Vollmer, {Charles M.}",
year = "2017",
month = "6",
day = "7",
doi = "10.1097/SLA.0000000000002327",
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TY - JOUR

T1 - Characterization and Optimal Management of High-Risk Pancreatic Anastomoses During Pancreatoduodenectomy

AU - Ecker, Brett L.

AU - McMillan, Matthew T.

AU - Asbun, Horacio J.

AU - Ball, Chad G.

AU - Bassi, Claudio

AU - Beane, Joal D.

AU - Behrman, Stephen W.

AU - Berger, Adam C.

AU - Dickson, Euan J.

AU - Bloomston, Mark

AU - Callery, Mark P.

AU - Christein, John D.

AU - Dixon, Elijah

AU - Drebin, Jeffrey A.

AU - Castillo, Carlos Fernandez del

AU - Fisher, William E.

AU - Fong, Zhi Ven

AU - Haverick, Ericka

AU - Hollis, Robert H.

AU - House, Michael G.

AU - Hughes, Steven J.

AU - Jamieson, Nigel B.

AU - Javed, Ammar A.

AU - Kent, Tara S.

AU - Kowalsky, Stacy J.

AU - Kunstman, John W.

AU - Malleo, Giuseppe

AU - Poruk, Katherine E.

AU - Salem, Ronald R.

AU - Schmidt, Carl R.

AU - Soares, Kevin

AU - Stauffer, John A.

AU - Valero, Vicente

AU - Velu, Lavanniya K.P.

AU - Watkins, Amarra A.

AU - Wolfgang, Christopher L.

AU - Zureikat, Amer H.

AU - Vollmer, Charles M.

PY - 2017/6/7

Y1 - 2017/6/7

N2 - OBJECTIVE:: The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy. BACKGROUND:: 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. METHODS:: 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. RESULTS:: 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). CONCLUSIONS:: 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.

AB - OBJECTIVE:: The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy. BACKGROUND:: 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. METHODS:: 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. RESULTS:: 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). CONCLUSIONS:: 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.

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