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In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy.

ABSTRACT: BACKGROUND:It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We compared PJ and PG after pancreaticoduodenectomy (PD). METHODS:A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the secondary outcomes were overall morbidity and mortality. We used the Student t, Mann-Whitney U and ?(2) tests for intention to treat analysis. The effect of randomization, American Society of Anesthesiologists score, soft pancreatic texture and use of pancreatic stent on overall complications and fistula rates was calculated using logistic regression. RESULTS:Our trial included 98 patients. The rate of pancreatic fistula formation was 18% in the PJ and 25% in the PG groups (p = 0.40). Postoperative complications occurred in 48% of patients in the PJ and 58% in the PG groups (p = 0.31). There were no significant predictors of overall complications in the multivariate analysis. Only soft pancreatic gland predicted the occurrence of pancreatic fistula (odds ratio 5.89, p = 0.003). CONCLUSION:There was no difference in the rates of pancreatic leak/fistula, overall complications or mortality between patients undergoing PG and and those undergoing PJ after PD.

SUBMITTER: Grendar J

PROVIDER: S-EPMC4447507 | biostudies-literature | 2015 Jun

REPOSITORIES: biostudies-literature

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In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy.

Grendar Jan J Ouellet Jean-François JF Sutherland Francis R FR Bathe Oliver F OF Ball Chad G CG Dixon Elijah E

Canadian journal of surgery. Journal canadien de chirurgie 20150601 3

<h4>Background</h4>It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We compared PJ and PG after pancreaticoduodenectomy (PD).<h4>Methods</h4>A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the ...[more]

PMID: 25799130

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Project description:ImportanceThe operative scenarios with the highest postoperative pancreatic fistula (POPF) risk represent situations in which fistula prevention and mitigation strategies have the strongest potential to affect surgical outcomes after pancreaticoduodenectomy. Evidence from studies providing risk stratification is lacking.ObjectiveTo investigate whether pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG), both with externalized transanastomotic stent, is the best reconstruction method for patients at high risk of POPF after pancreaticoduodenectomy.Design, setting, and participantsA single-center, phase 3, randomized clinical trial was conducted at the Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy, from July 12, 2017, through March 15, 2019, among adults undergoing elective pancreaticoduodenectomy and considered at high risk for pancreatic fistula after intraoperative assessment of the fistula risk score, some of whom were randomized to undergo PG or PJ. All analyses were performed on an intention-to-treat basis.InterventionsIntervention consisted of PJ or PG, both with externalized transanastomotic stent and octreotide omission.Main outcomes and measuresThe primary end point was POPF. The secondary end points were Clavien-Dindo grade 3 or higher morbidity, postpancreatectomy hemorrhage, delayed gastric emptying, and average complication burden.ResultsA total of 604 patients were screened for eligibility; 82 were at high risk for POPF (fistula risk score, 7-10), and 72 were randomized undergo PG (n = 36; 20 men and 16 women; median age, 65 years [interquartile range, 23-82]) or PJ (n = 36; 26 men and 10 women; median age, 63 years [interquartile range, 35-79]). There was no significant difference in the incidence of POPF between patients who underwent PG and patients who underwent PJ (18 [50.0%] vs 14 [38.9%]; P = .48), but for patients who developed a POPF, the mean (SD) average complication burden was lower for those who underwent PJ than for those who underwent PG (0.25 [0.13] vs 0.39 [0.17]; P = .04). The rates of postpancreatectomy hemorrhage (14 [38.9%] in the PG group vs 9 [25.0%] in the PJ group; P = .31) and delayed gastric emptying (16 [44.4%] in the PG group vs 18 [50.0%] in the PJ group; P = .81) were similar, but patients who underwent PG presented with a significantly higher incidence of Clavien-Dindo grade 3 or higher morbidity than those who underwent PJ (17 [47.2%] vs 8 [22.2%]; P = .047).Conclusions and relevanceAmong patients at the highest risk for POPF, those who underwent PG or PJ experienced similar rates of POPF. However, PG was associated with an increased incidence of Clavien-Dindo grade 3 or higher morbidity and with an increased average complication burden for the patients who developed a POPF. For patients at high risk for pancreatic fistula, PJ with the use of externalized stent and octreotide omission should be considered the most appropriate technical strategy.Trial registrationClinicalTrials.gov Identifier: NCT03212196.

Dataset Information

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy.

Publications

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy.

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