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Randomized Controlled Single-Center Trial Comparing Pancreatogastrostomy Versus Pancreaticojejunostomy After Partial Pancreatoduodenectomy

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Journal of Gastrointestinal Surgery

Abstract

Background

The aim of this single-center randomized trial was to compare the perioperative outcome of pancreatoduodenectomy with pancreatogastrostomy (PG) vs pancreaticojejunostomy (PJ).

Methods

Randomization was done intraoperatively. PG was performed via anterior and posterior gastrotomy with pursestring and inverting seromuscular suture; control intervention was PJ with duct–mucosa anastomosis. The primary endpoint was postoperative pancreatic fistula (POPF).

Results

From 2006 to 2011, n = 268 patients were screened and n = 116 were randomized to n = 59 PG and n = 57 PJ. There was no statistically significant difference regarding the primary endpoint (PG vs PJ, 10 % vs 12 %, p = 0.775). The subgroup of high-risk patients with a soft pancreas had a non-significantly lower pancreatic fistula rate with PG (PG vs PJ, 14 vs 24 %, p = 0.352). Analysis of secondary endpoints demonstrated a shorter operation time (404 vs 443 min, p = 0.005) and reduced hospital stay for PG (15 vs 17 days, p = 0.155). Delayed gastric emptying (DGE; PG vs PJ, 27 vs 17 %, p = 0.246) and intraluminal bleeding (PG vs PJ, 7 vs 2 %, p = 0.364) were more frequent with PG. Mortality was low in both groups (<2 %).

Conclusions

Our randomized controlled trial shows no difference between PG and PJ as reconstruction techniques after partial pancreatoduodenectomy. POPF rate, DGE, and bleeding were not statistically different. Operation time was significantly shorter in the PG group.

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References

  1. Kausch W. Das carcinom der papilla duodeni und seine radikale entfernung. Beitr Z Clin Chir 1912;78:439–486.

    Google Scholar 

  2. Shrikhande SV, Qureshi SS, Rajneesh N, Shukla PJ. Pancreatic anastomoses after pancreaticoduodenectomy: Do we need further studies? World J Surg 2005;29:1642–1649.

    Article  PubMed  Google Scholar 

  3. Fernandez-Cruz L, Cosa R, Blanco L, Lopez-Boado MA, Astudillo E. Pancreatogastrostomy with gastric partition after pylorus-preserving pancreatoduodenectomy versus conventional pancreaticojejunostomy: A prospective randomized study. Ann Surg 2008;248:930–938.

    Article  PubMed  Google Scholar 

  4. Veillette G, Dominguez I, Ferrone C, Thayer SP, McGrath D, Warshaw AL, Fernandez-del Castillo C. Implications and management of pancreatic fistulas following pancreaticoduodenectomy: The massachusetts general hospital experience. Arch Surg 2008;143:476–481.

    Article  PubMed  Google Scholar 

  5. Fuks D, Piessen G, Huet E, Tavernier M, Zerbib P, Michot F, Scotte M, Triboulet JP, Mariette C, Chiche L, Salame E, Segol P, Pruvot FR, Mauvais F, Roman H, Verhaeghe P, Regimbeau JM. Life-threatening postoperative pancreatic fistula (grade c) after pancreaticoduodenectomy: Incidence, prognosis, and risk factors. Am J Surg 2009;197:702–709.

    Article  PubMed  Google Scholar 

  6. Kang CM, Kim DH, Choi GH, Kim KS, Choi JS, Lee WJ. Detrimental effect of postoperative complications on oncologic efficacy of r0 pancreatectomy in ductal adenocarcinoma of the pancreas. J Gastrointest Surg 2009;13:907–914.

    Article  PubMed  Google Scholar 

  7. Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM, Jr. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007;245:443–451.

    Article  PubMed  Google Scholar 

  8. Kent TS, Sachs TE, Callery MP, Vollmer CM, Jr. Readmission after major pancreatic resection: A necessary evil? J Am Coll Surg 2011;213:515–523.

    Article  PubMed  Google Scholar 

  9. Shukla PJ, Barreto SG, Fingerhut A, Bassi C, Buchler MW, Dervenis C, Gouma D, Izbicki JR, Neoptolemos J, Padbury R, Sarr MG, Traverso W, Yeo CJ, Wente MN. Toward improving uniformity and standardization in the reporting of pancreatic anastomoses: A new classification system by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2010;147:144–153.

    Article  PubMed  Google Scholar 

  10. Wente MN, Shrikhande SV, Muller MW, Diener MK, Seiler CM, Friess H, Buchler MW. Pancreaticojejunostomy versus pancreaticogastrostomy: Systematic review and meta-analysis. Am J Surg 2007;193:171–183.

    Article  PubMed  Google Scholar 

  11. Yeo CJ, Cameron JL, Maher MM, Sauter PK, Zahurak ML, Talamini MA, Lillemoe KD, Pitt HA. A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Ann Surg 1995;222:580–588; discussion 588–592.

    PubMed  CAS  Google Scholar 

  12. Bassi C, Falconi M, Molinari E, Salvia R, Butturini G, Sartori N, Mantovani W, Pederzoli P. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: Results of a comparative study. Ann Surg 2005;242:767–771, discussion 771–763.

    Article  PubMed  Google Scholar 

  13. Duffas JP, Suc B, Msika S, Fourtanier G, Muscari F, Hay JM, Fingerhut A, Millat B, Radovanowic A, Fagniez PL. A controlled randomized multicenter trial of pancreatogastrostomy or pancreaticojejunostomy after pancreatoduodenectomy. Am J Surg 2005;189:720–729.

    Article  PubMed  Google Scholar 

  14. Warren KW, Cattell RB. Basic techniques in pancreatic surgery. Surg Clin North Am 1956;36:707–724.

    PubMed  CAS  Google Scholar 

  15. Wellner U, Makowiec F, Fischer E, Hopt UT, Keck T. Reduced postoperative pancreatic fistula rate after pancreatogastrostomy versus pancreaticojejunostomy. J Gastrointest Surg 2009;13:745–751.

    Article  PubMed  CAS  Google Scholar 

  16. Niedergethmann M, Dusch N, Widyaningsih R, Weiss C, Kienle P, Post S. Risk-adapted anastomosis for partial pancreaticoduodenectomy reduces the risk of pancreatic fistula: A pilot study. World J Surg 2010;34:1579–1586.

    Article  PubMed  Google Scholar 

  17. O’Neil S, Pickleman J, Aranha GV. Pancreaticogastrostomy following pancreaticoduodenectomy: Review of 102 consecutive cases. World J Surg 2001;25:567–571.

    Article  PubMed  Google Scholar 

  18. Wellner UF, Kayser G, Lapshyn H, Sick O, Makowiec F, Hoppner J, Hopt UT, Keck T. A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively. HPB (Oxford) 2010;12:696–702.

    Article  Google Scholar 

  19. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005;138:8–13.

    Article  PubMed  Google Scholar 

  20. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Buchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761–768.

    Article  PubMed  Google Scholar 

  21. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW. Postpancreatectomy hemorrhage (PPH)—an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142:20–25.

    Article  PubMed  Google Scholar 

  22. Oussoultzoglou E, Bachellier P, Bigourdan JM, Weber JC, Nakano H, Jaeck D. Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy. Arch Surg 2004;139:327–335.

    Article  PubMed  Google Scholar 

  23. Dupont WD, Plummer WD, Jr. Power and sample size calculations. A review and computer program. Control Clin Trials 1990;11:116–128.

    Article  PubMed  CAS  Google Scholar 

  24. Schulz KF, Grimes DA. Allocation concealment in randomised trials: Defending against deciphering. Lancet 2002;359:614–618.

    Article  PubMed  Google Scholar 

  25. Schulz KF, Grimes DA. Unequal group sizes in randomised trials: Guarding against guessing. Lancet 2002;359:966–970.

    Article  PubMed  Google Scholar 

  26. DeMets DL, Lan KK. Interim analysis: The alpha spending function approach. Stat Med 1994;13:1341–1352; discussion 1353–1346.

    Article  PubMed  CAS  Google Scholar 

  27. Wellner U, Adam U, Makowiec F, Hopt UT, Keck T. Unizentrische prospektiv randomisierte studie zum vergleich von pankreatogastrostomie ( pg ) und pankreatikojejunostomie ( pj ) nach pankreatoduodenektomie – interimanalyse –. Kongress der Deutschen Gesellschaft für Chirurgie 2009.

  28. Pratt WB, Callery MP, Vollmer CM, Jr. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg 2008;32:419–428.

    Article  PubMed  Google Scholar 

  29. Adam U, Makowiec F, Riediger H, Schareck WD, Benz S, Hopt UT. Risk factors for complications after pancreatic head resection. Am J Surg 2004;187:201–208.

    Article  PubMed  Google Scholar 

  30. Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 2004;8:951–959.

    Article  PubMed  Google Scholar 

  31. Motoi F, Egawa S, Rikiyama T, Katayose Y, Unno M. Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. The British Journal of Surgery 2012;99:524–531.

    Article  PubMed  CAS  Google Scholar 

  32. DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, Clavien PA. Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244:931–937; discussion 937–939.

    Article  PubMed  Google Scholar 

  33. Pratt WB, Callery MP, Vollmer CM, Jr. The latent presentation of pancreatic fistulas. Br J Surg 2009;96:641–649.

    Article  PubMed  CAS  Google Scholar 

  34. Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, Tomazic A, Bruns CJ, Busch OR, Farkas S, Belyaev O, Neoptolemos JP, Halloran C, Keck T, Niedergethmann M, Gellert K, Witzigmann H, Kollmar O, Langer P, Steger U, Neudecker J, Berrevoet F, Ganzera S, Heiss MM, Luntz SP, Bruckner T, Kieser M, Buchler MW. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (dispact): A randomised, controlled multicentre trial. Lancet 2011;377:1514–1522.

    Article  PubMed  Google Scholar 

  35. Diener MK, Knaebel HP, Heukaufer C, Antes G, Buchler MW, Seiler CM. A systematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Ann Surg 2007;245:187–200.

    Article  PubMed  Google Scholar 

  36. Pessaux P, Sauvanet A, Mariette C, Paye Fo, Muscari F, Cunha AS, Sastre B, Arnaud J-P. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: Prospective multicenter randomized trial. Annals of surgery 2011;253:879–885.

    Article  PubMed  Google Scholar 

  37. Poon RTP, Fan ST, Lo CM, Ng KK, Yuen WK, Yeung C, Wong J. External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized trial. Annals of surgery 2007;246:425–433; discussion 433–435–425–433; discussion 433–435.

    Article  PubMed  Google Scholar 

  38. **ong JJ, Altaf K, Mukherjee R, Huang W, Hu WM, Li A, Ke NW, Liu XB. Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy. The British Journal of Surgery 2012.

  39. Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, Talamini G, Pederzoli P. Early versus late drain removal after standard pancreatic resections: Results of a prospective randomized trial. Annals of Surgery 2010;252:207–214.

    Article  PubMed  Google Scholar 

  40. Koti RS, Gurusamy KS, Fusai G, Davidson BR. Meta-analysis of randomized controlled trials on the effectiveness of somatostatin analogues for pancreatic surgery: A cochrane review. HPB (Oxford) 2010;12:155–165.

    Article  Google Scholar 

  41. Zeng Q, Zhang Q, Han S, Yu Z, Zheng M, Zhou M, Bai J, ** R. Efficacy of somatostatin and its analogues in prevention of postoperative complications after pancreaticoduodenectomy: A meta-analysis of randomized controlled trials. Pancreas 2008;36:18–25.

    Article  PubMed  CAS  Google Scholar 

  42. Murakami Y, Uemura K, Hayasidani Y, Sudo T, Hashimoto Y, Nakagawa N, Ohge H, Sueda T. A soft pancreatic remnant is associated with increased drain fluid pancreatic amylase and serum crp levels following pancreatoduodenectomy. J Gastrointest Surg 2008;12:51–56.

    Article  PubMed  Google Scholar 

  43. Uchida E, Tajiri T, Nakamura Y, Aimoto T, Naito Z. Relationship between grade of fibrosis in pancreatic stump and postoperative pancreatic exocrine activity after pancreaticoduodenectomy: With special reference to insufficiency of pancreaticointestinal anastomosis. J Nippon Med Sch 2002;69:549–556.

    Article  Google Scholar 

  44. Sato N, Yamaguchi K, Chijiiwa K, Tanaka M. Duct-parenchymal ratio predicts exocrine pancreatic function after pancreatoduodenectomy and distal pancreatectomy. Am J Surg 1998;176:270–273.

    Article  PubMed  CAS  Google Scholar 

  45. Sato N, Yamaguchi K, Chijiiwa K, Tanaka M. Risk analysis of pancreatic fistula after pancreatic head resection. Arch Surg 1998;133:1094–1098.

    Article  PubMed  CAS  Google Scholar 

  46. Liang TB, Bai XL, Zheng SS. Pancreatic fistula after pancreaticoduodenectomy: Diagnosed according to international study group pancreatic fistula (isgpf) definition. Pancreatology 2007;7:325–331.

    Article  PubMed  Google Scholar 

  47. Marcus SG, Cohen H, Ranson JH. Optimal management of the pancreatic remnant after pancreaticoduodenectomy. Ann Surg 1995;221:635–645; discussion 645–638.

    Article  PubMed  CAS  Google Scholar 

  48. Dinter DJ, Aramin N, Weiss C, Singer C, Weisser G, Schoenberg SO, Post S, Niedergethmann M. Prediction of anastomotic leakage after pancreatic head resections by dynamic magnetic resonance imaging (DMRI). J Gastrointest Surg 2009;13:735–744.

    Article  PubMed  Google Scholar 

  49. Mathur A, Pitt HA, Marine M, Saxena R, Schmidt CM, Howard TJ, Nakeeb A, Zyromski NJ, Lillemoe KD. Fatty pancreas: A factor in postoperative pancreatic fistula. Ann Surg 2007;246:1058–1064.

    Article  PubMed  Google Scholar 

  50. Takada T, Yasuda H, Uchiyama K, Hasegawa H, Misu Y, Iwagaki T. Pancreatic enzyme activity after a pylorus-preserving pancreaticoduodenectomy reconstructed with pancreaticogastrostomy. Pancreas 1995;11:276–282.

    Article  PubMed  CAS  Google Scholar 

  51. Aranha GV, Aaron JM, Shoup M. Critical analysis of a large series of pancreaticogastrostomy after pancreaticoduodenectomy. Arch Surg 2006;141:574–579; discussion 579–580.

    Article  PubMed  Google Scholar 

  52. Delcore R, Thomas JH, Pierce GE, Hermreck AS. Pancreatogastrostomy: A safe drainage procedure after pancreatoduodenectomy. Surgery 1990;108:641–645; discussion 645–647.

    PubMed  CAS  Google Scholar 

  53. Fernandez-Cruz L, Lopez-Boado M-A, Ferrer J. Repeated pancreatectomy after pancreato-duodenectomy for a intraductal papillary mucinous tumour: Advantage of pancreatico-gastrostomy with a gastric partition. HPB: the official journal of the International Hepato Pancreato Biliary Association 2012;14:132–135.

    Google Scholar 

  54. Gigot JF, Deprez P, Sempoux C, Descamps C, Metairie S, Glineur D, Gianello P. Surgical management of intraductal papillary mucinous tumors of the pancreas: The role of routine frozen section of the surgical margin, intraoperative endoscopic staged biopsies of the wirsung duct, and pancreaticogastric anastomosis. Archives of surgery (Chicago, Ill: 1960) 2001;136:1256–1262.

    Article  CAS  Google Scholar 

  55. Navarro F, Michel J, Bauret P, Ramos J, Blanc P, Fabre JM, Millat B, Desrousseaux B, Domergue J. Management of intraductal papillary mucinous tumours of the pancreas. The European Journal of Surgery = Acta chirurgica 1999;165:43–48.

    PubMed  CAS  Google Scholar 

  56. Tomimaru Y, Ishikawa O, Ohigashi H, Eguchi H, Yamada T, Sasaki Y, Miyashiro I, Ohue M, Yano M, Uehara H, Nakaizumi A, Imaoka S. Advantage of pancreaticogastrostomy in detecting recurrent intraductal papillary mucinous carcinoma in the remnant pancreas: A case of successful re-resection after pancreaticoduodenectomy. Journal of Surgical Oncology 2006;93:511–515.

    Article  PubMed  Google Scholar 

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Acknowledgments

We thank Joachim Wellner, MD for the artwork of this article.

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Authors and Affiliations

  1. Department of General and Visceral Surgery, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany

    Ulrich F. Wellner, Olivia Sick, Ulrich Adam, Ulrich T. Hopt & Tobias Keck

  2. Institute of Medical Biometry and Medical Informatics (IMBI), University of Freiburg, Freiburg, Germany

    Manfred Olschewski

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  1. Ulrich F. Wellner
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  2. Olivia Sick
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  3. Manfred Olschewski
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  4. Ulrich Adam
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Corresponding author

Correspondence to Tobias Keck.

Additional information

Registration

This trial is registered in the German Clinical Trials Register (trial ID DRKS00000419), initial trial registration as UKF000532 on March 15, 2006.

Funding

This trial has been financed from institutional sources. Analysis of this trial was in part supported by financial support of the German Research Foundation (DFG) for the RECOPANC trial (DFG Ho 810/3-1).

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Wellner, U.F., Sick, O., Olschewski, M. et al. Randomized Controlled Single-Center Trial Comparing Pancreatogastrostomy Versus Pancreaticojejunostomy After Partial Pancreatoduodenectomy. J Gastrointest Surg 16, 1686–1695 (2012). https://doi.org/10.1007/s11605-012-1940-4

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  • DOI: https://doi.org/10.1007/s11605-012-1940-4

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