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Management of Severe Pancreatic Fistula After Pancreatoduodenectomy.

Abstract：

Importance:Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking. Objective:To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy. Design, Setting, and Participants:A multicenter, retrospective, propensity-matched cohort study was conducted in 9 centers of the Dutch Pancreatic Cancer Group from January 1, 2005, to September 30, 2013. From a cohort of 2196 consecutive patients who underwent pancreatoduodenectomy, 309 patients with severe pancreatic fistula were included. Propensity score matching (based on sex, age, comorbidity, disease severity, and previous reinterventions) was used to minimize selection bias. Data analysis was performed from January to July 2016. Exposures:First intervention for pancreatic fistula: catheter drainage or relaparotomy. Main Outcomes and Measures:Primary end point was in-hospital mortality; secondary end points included new-onset organ failure. Results:Of the 309 patients included in the analysis, 209 (67.6%) were men, and mean (SD) age was 64.6 (10.1) years. Overall in-hospital mortality was 17.8% (55 patients): 227 patients (73.5%) underwent primary catheter drainage and 82 patients (26.5%) underwent primary relaparotomy. Primary catheter drainage was successful (ie, survival without relaparotomy) in 175 patients (77.1%). With propensity score matching, 64 patients undergoing primary relaparotomy were matched to 64 patients undergoing primary catheter drainage. Mortality was lower after catheter drainage (14.1% vs 35.9%; P = .007; risk ratio, 0.39; 95% CI, 0.20-0.76). The rate of new-onset single-organ failure (4.7% vs 20.3%; P = .007; risk ratio, 0.15; 95% CI, 0.03-0.60) and new-onset multiple-organ failure (15.6% vs 39.1%; P = .008; risk ratio, 0.40; 95% CI, 0.20-0.77) were also lower after primary catheter drainage. Conclusions and Relevance:In this propensity-matched cohort, catheter drainage as first intervention for severe pancreatic fistula after pancreatoduodenectomy was associated with a better clinical outcome, including lower mortality, compared with primary relaparotomy.

journal_name

JAMA Surg

journal_title

JAMA surgery

authors

Smits FJ,van Santvoort HC,Besselink MG,Batenburg MCT,Slooff RAE,Boerma D,Busch OR,Coene PPLO,van Dam RM,van Dijk DPJ,van Eijck CHJ,Festen S,van der Harst E,de Hingh IHJT,de Jong KP,Tol JAMG,Borel Rinkes IHM,Molenaar IQ

doi

10.1001/jamasurg.2016.5708

subject

Has Abstract

pub_date

2017-06-01 00:00:00

pages

540-548

issue

eissn

2168-6254

issn

2168-6262

pii

2603370

journal_volume

152

pub_type

杂志文章,多中心研究

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Management of Severe Pancreatic Fistula After Pancreatoduodenectomy.