Risk Factors Analysis Of Pancreatic Fistula Related Clinicopathological Characters After Pancreaticoduodenectomy

Background:Pancreatic fistula is a frequent life threatening complication after pancreaticoduodenectomy (PD). There are numerous modifiable and non-modifiable risk factors of postoperative pancreatic fistula (POPF). Pancreaticojejunostomy (PJ) technique is one of the most important modifiable risk factor. There are various methods of PJ techniques to avoid occurrence of POPF and the superiority of one PJ technique over the other has not yet been established. Here, we describe a single-layer end-to-side PJ and compare various perioperative parameters in terms of formation of POPF.Methods:From September2008to March2012, a total of151patients that underwent PD by a single surgeon in a high surgical volume hospital were included. PJ anastomosis was performed using binding with internal stenting (BIS) method (n=43), single-layer end-to-side with internal stenting (SLIS) method (n=40) and single-layer end-to-side with external stenting (SLES) method (n=68). Retrospective analysis of prospectively collected data included gender, age, body mass index (BMI), diabetes, smoking, heart diseases, hypertension (HTN), pre-operative biliary stenting; operative time, blood transfusion, anastomosis type; main pancreatic duct diameter (PDD), pancreatic texture, pathology, fibrosis score and fattiness score. Statistical analyses of these data were aimed at investigating their relationship with different anastomosis types and with the occurrence of POPF.Results:POPF rate of34.9%(n=15) in BIS group,30%(n=12) in SLIS group and48.5%(n=33) in SLES group was observed; statistical analysis yielded no significance at p=0.05. Total POPF rate was39.7%(Grade A:26.5%; Grade B:8.6%and Grade C:4.6%). Clinically significant POPF (CS-POPF) in BIS, SLIS and SLES were14%(n=6),15%(n=6), and10.3%(n=7) respectively with no statistical significance. Length of hospital stay (LOS) was significantly lower in SLES group (Averege LOS: SLES=14.9(±6.4)<SLIS=16.3(±8.5)<BIS=17.9(±8.2)) at p=0.021. Beside POPF, among other complications, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), intra-abdominal abscess, and respiratory complications yielded no statistical significance.Risk factor analysis resulted PDD<3mm (p=0.000), higher BMI (p=0.017), low fibrosis score (p=0.000), no PV/SMV resection (p=0.003), less operative time(p=0.021) and benign pathology(0.019) to be significant risk factors. While Multivariate analysis showed only PDD<3mm (p=0.002, OR=4.96), low fibrosis score (p=0.006, OR=0.54) and higher BMI (p=0.029, OR=1.23) to be significant risk factors.Histopathological fibrosis score correlated strongly with intraoperative assessment of pancreatic texture (correlation coefficient=+0.311at p=0.008) and PDD (correlation coefficient=+0.381at p=0.000).Conclusion:Our latest PJ technique (SLES) is simple, easy, has no Grade C POPF, no mortality and decreased length of hospital stay (LOS). The pre-existing pancreatic parenchyma is to blame for the development of pancreatic fistula as patient’s BMI, fibrosis score and PDD are very important predictive factors. And the intraoperative assessment of hard pancreatic texture and larger PDD (>3mm) correlates strongly with increased histopathological fibrosis grading.