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Total pancreatectomy as alternative to pancreatico-jejunal anastomosis in patients with high fistula risk score: the choice of the fearful or of the wise?

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Abstract

Purpose

Patients with fistula risk score (FRS) ≥7 are at the highest risk of develo** clinically relevant post-operative pancreatic fistula (CR-POPF). There is no agreement on the management of this subpopulation. The primary outcome of the study was the definition of the role of intraoperative completion pancreatectomy (ICP) in patients at high risk for CR-POPF, as an alternative to high-risk pancreaticoduodenectomy (PD).

Methods

This is an observational study set in a single tertiary referral center. Patients scheduled for PD in our center between 2010 and 2019 with FRS ≥7 were included in the study. Data were prospectively collected.

Results

A total of 738 patients were scheduled for between 2010 and 2019, and 62 had FRS ≥7. Thirty-five patients were managed with PD and pancreatico-jejunal anastomosis (group A), and 27 with ICP (group B). Overall complication rate was significantly higher in group A than group B (95 versus 59%; p=0.005) and there was a not significantly higher rate of major complications (Clavien-Dindo ≥3) (43 versus 26%; p=0.192). In group A, 49% of patients had a CR-POPF. Median post-operative length of stay was 15 days in group A and 12 in group B (p=0.043). Readmission was observed only in group A (26%). In multivariate analysis, PD was an independent predictive factor of major post-operative morbidity (RR 9.27; CI 1.74–49.31). No patients in either group suffered major adverse events related to endocrine and exocrine insufficiency.

Conclusion

In high-FRS patients, ICP has good short-term outcomes relative to PD without major long-term events related to endocrine and exocrine insufficiency. ICP could be considered as a feasible alternative in selected cases.

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Data availability

The authors confirm that the data supporting the findings of this study are available within the article; raw data are available upon request to the corresponding author.

References

  1. Ho CK, Kleeff J, Friess H, Büchler MW (2005) Complications of pancreatic surgery. HPB (Oxford) 7(2):99–108

    Article  Google Scholar 

  2. Macedo FIB, Jayanthi P, Mowzoon M, Yakoub D, Dudeja V, Merchant N (2017) The impact of surgeon volume on outcomes after pancreaticoduodenectomy: a meta-analysis. J Gastrointest Surg 21(10):1723–1731

    Article  Google Scholar 

  3. McMillan MT, Soi S, Asbun HJ, Ball CG, Bassi C, Beane JD, Behrman SW, Berger AC, Bloomston M, Callery MP, Christein JD, Dixon E, Drebin JA, Castillo CF, Fisher WE, Fong ZV, House MG, Hughes SJ, Kent TS, Kunstman JW, Malleo G, Miller BC, Salem RR, Soares K, Valero V, Wolfgang CL, Vollmer CM Jr (2016) Risk-adjusted outcomes of clinically relevant pancreatic fistula following pancreatoduodenectomy: a model for performance evaluation. Ann Surg 264(2):344–352

    Article  Google Scholar 

  4. Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr (2013) A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 216(1):1–14

    Article  Google Scholar 

  5. Miller BC, Christein JD, Behrman SW, Drebin JA, Pratt WB, Callery MP, Miller BC, Christein JD, Behrman SW, Drebin JA, Pratt WB, Callery MP, Vollmer CM Jr et al (2018) A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy. J Gastrointest Surg 18(1):172–180

    Article  Google Scholar 

  6. Nahm CB, Connor SJ, Samra JS, Mittal A (2018) Postoperative pancreatic fistula: a review of traditional and emerging concepts. Clin Exp Gastroenterol 11:105–118

    Article  CAS  Google Scholar 

  7. Kawaida H, Kono H, Hosomura N, Amemiya H, Itakura J, Fujii H, Ichikawa D (2019) Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol 25(28):3722–3737

    Article  Google Scholar 

  8. Shrikhande SV, Sivasanker M, Vollmer CM Jr, Friess H, Besselink MG, Fingerhut A, Yeo CJ, Fernandez-delCastillo C, Dervenis C, Halloran C, Gouma DJ, Radenkovic D, Asbun HJ, Neoptolemos JP, Izbicki JR, Lillemoe KD, Conlon KC, Fernandez-Cruz L, Montorsi M, Bockhorn M, Adham M, Charnley R, Carter R, Hackert T, Hartwig W, Miao Y, Sarr M, Bassi C, Büchler MW (2017) International Study Group of Pancreatic Surgery (ISGPS). Pancreatic anastomosis after pancreatoduodenectomy: a position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 161(5):1221–1234

    Article  Google Scholar 

  9. Balzano G, Maffi P, Nano R, Mercalli A, Melzi R, Aleotti F, Zerbi A, De Cobelli F, Gavazzi F, Magistretti P, Scavini M, Peccatori J, Secchi A, Ciceri F, Del Maschio A, Falconi M, Piemonti L (2016) Autologous islet transplantation in patients requiring pancreatectomy: a broader spectrum of indications beyond chronic pancreatitis. Am J Transplant 16(6):1812–1826

    Article  CAS  Google Scholar 

  10. Balzano G, Maffi P, Nano R, Zerbi A, Venturini M, Melzi R, Mercalli A, Magistretti P, Scavini M, Castoldi R, Carvello M, Braga M, Del Maschio A, Secchi A, Staudacher C, Piemonti L (2013) Extending indications for islet autotransplantation in pancreatic surgery. Ann Surg 258(2):210–218

    Article  Google Scholar 

  11. Balzano G, Piemonti L (2014) Autologous islet transplantation in patients requiring pancreatectomy for neoplasm. Curr Diab Rep 14(8):512

    Article  Google Scholar 

  12. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    Article  Google Scholar 

  13. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilai M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, , Fernandez-del Castillo C, Fingerhut A, Friess H, Gouma DJ, , Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR Jr, Wolfgang CL, Yeo CJ, Salvia R, Buchler M (2017) International Study Group of Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 161(3):584-591.

    Article  Google Scholar 

  14. Merkow RP, Bilimoria KY, Tomlinson JS, Paruch JL, Fleming JB, Talamonti MS, Ko CY, Bentrem DJ (2014) Postoperative complications reduce adjuvant chemotherapy use in resectable pancreatic cancer. Ann Surg 260(2):372–377

    Article  Google Scholar 

  15. Van Der Gaag NA, Harmsen K, Eshuis WJ, Busch ORC, Van Gulik TM, Gouma DJ (2014) Pancreatoduodenectomy associated complications influence cancer recurrence and time interval to death. Eur J Surg Oncol 40(5):551–558

    Article  Google Scholar 

  16. Williamsson C, Ansari D, Andersson R, Tingstedt B (2017) Postoperative pancreatic fistula-impact on outcome, hospital cost and effects of centralization. HPB (Oxford) 19(5):436–442

    Article  Google Scholar 

  17. Andrianello S, Marchegiani G, Malleo G, Masini G, Balduzzi A, Paiella S, Esposito A, Landoni L, Casetti L, Tuveri M, Salvia R, Bassi C (2020) Pancreaticojejunostomy with externalized stent vs pancreaticogastrostomy with externalized stent for patients with high-risk pancreatic anastomosis a single-center, phase 3, randomized clinical trial. JAMA Surg 155(4):313–321

    Article  Google Scholar 

  18. Trudeau MT, Casciani F, Ecker BL, Maggino L, Seykora TF, Puri P, McMillan M, Miller B, Pratt WB. Asbun HJ, Ball CG. Bassi C, Behrman SW. Berger AC. Bloomston MP, Callery MP, Fernandez del Castillo C, Christein JD, Dillhoff ME. Dickson EJ. Dixon E, Fisher WE. House MG, Hughes SJ, Kent TS, Malleo G, Salem RR., Wolfgang CL. Zureikat AH, Vollmer CM (2020) The fistula risk score catalog: toward precision medicine for pancreatic fistula after pancreatoduodenectomy. Ann Surg epub ahead of print, The Fistula Risk Score Catalog.

  19. Del Chiaro M, Rangelova E, Segersvärd R, Arnelo U (2016) Are there still indications for total pancreatectomy? Updat Surg 68(3):257–263

    Article  Google Scholar 

  20. Pulvirenti A, Pea A, Rezaee N, Gasparini C, Malleo G, Weiss MJ, Cameron JL, Wolfgang CL, He J, Salvia R (2019) Perioperative outcomes and long-term quality of life after total pancreatectomy. Br J Surg 106(13):1819–1828

    Article  CAS  Google Scholar 

  21. Epelboym I, Winner M, Dinorcia J, Lee MK, Lee JA, Schrope B, Chabot JA, Allendorf JD (2014) Quality of life in patients after total pancreatectomy is comparable with quality of life in patients who undergo a partial pancreatic resection. J Surg Res 187(1):189–196

    Article  Google Scholar 

  22. Hartwig W, Gluth A, Hinz U, Bergmann F, Spronk PER, Hackert T, Werner J, Buchler MW (2015) Total pancreatectomy for primary pancreatic neoplasms: renaissance of an unpopular operation. Ann Surg 261(3):537–546

    Article  Google Scholar 

  23. Fernández-Cruz L, Orduña D, Cesar-Borges G, López-Boado MA (2005) Distal pancreatectomy: en-bloc splenectomy vs spleen-preserving pancreatectomy. HPB (Oxford) 7(2):93–98

    Article  Google Scholar 

  24. Varley PR, Geller DA, Tsung A (2017) Factors influencing failure to rescue after pancreaticoduodenectomy: a National Surgical Quality Improvement Project Perspective. J Surg Res 214:131–139

    Article  Google Scholar 

  25. Stoop TF, Ateeb Z, Ghorbani P, Scholten L, Arnelo U, Besselink MG, Del Chiaro M (2020) Impact of endocrine and exocrine insufficiency on quality of life after total pancreatectomy. Ann Surg Oncol 27(2):587–596

    Article  Google Scholar 

  26. Balzano G, Zerbi A, Capretti G, Rocchetti S, Capitanio V, Di Carlo V (2008) Effect of hospital volume on outcome of pancreaticoduodenectomy in Italy. Br J Surg 95(3):357–362

    Article  CAS  Google Scholar 

  27. Balzano G, Capretti G, Callea G, Cantù E, Carle F, Pezzilli R (2016) Overuse of surgery in patients with pancreatic cancer. A nationwide analysis in Italy. HPB (Oxford) 18(5):470–478

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090, Pieve Emanuele, MI, Italy

    Giovanni Capretti & Alessandro Zerbi

  2. Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy

    Giovanni Capretti, Greta Donisi, Francesca Gavazzi, Gennaro Nappo, Andrea Pansa & Alessandro Zerbi

  3. San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina, 60, 20132, Milan, MI, Italy

    Lorenzo Piemonti

Authors
  1. Giovanni Capretti
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  2. Greta Donisi
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  3. Francesca Gavazzi
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  4. Gennaro Nappo
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  5. Andrea Pansa
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  7. Alessandro Zerbi
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Contributions

Giovanni Capretti and Alessandro Zerbi conceived and designed the project. Francesca Gavazzi, Gennaro Nappo, Andrea Pansa, and Greta Donisi collected clinical and pathological data. Giovanni Capretti and Greta Donisi performed statistical analysis. Greta Donisi, Giovanni Capretti, and Alessandro Zerbi drafted the work and substantially revised it. Lorenzo Piemonti revised the work. All authors approved the submitted version of the manuscript.

Corresponding author

Correspondence to Giovanni Capretti.

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Ethics approval and consent to participate

The study was approved by the institutional ethical committee of Humanitas Research Hospital. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

The authors declare no competing interest.

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Capretti, G., Donisi, G., Gavazzi, F. et al. Total pancreatectomy as alternative to pancreatico-jejunal anastomosis in patients with high fistula risk score: the choice of the fearful or of the wise?. Langenbecks Arch Surg 406, 713–719 (2021). https://doi.org/10.1007/s00423-021-02157-1

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