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Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy

View Article: PubMed Central - PubMed

ABSTRACT

Aim: To analyze the risk factors for pancreatic fistula after pancreaticoduodenectomy.

Methods: We conducted a retrospective analysis of 539 successive cases of pancreaticoduodenectomy performed at our hospital from March 2012 to October 2015. Pancreatic fistula was diagnosed in strict accordance with the definition of pancreatic fistula from the International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.

Results: A total of 269 (49.9%) cases of pancreatic fistula occurred after pancreaticoduodenectomy, including 71 (13.17%) cases of grade A pancreatic fistula, 178 (33.02%) cases of grade B, and 20 (3.71%) cases of grade C. Univariate analysis showed no significant correlation between postoperative pancreatic fistula (POPF) and the following factors: age, hypertension, alcohol consumption, smoking, history of upper abdominal surgery, preoperative jaundice management, preoperative bilirubin, preoperative albumin, pancreatic duct drainage, intraoperative blood loss, operative time, intraoperative blood transfusion, Braun anastomosis, and pancreaticoduodenectomy (with or without pylorus preservation). Conversely, a significant correlation was observed between POPF and the following factors: gender (male vs female: 54.23% vs 42.35%, P = 0.008), diabetes (non-diabetic vs diabetic: 51.61% vs 39.19%, P = 0.047), body mass index (BMI) (≤ 25 vs > 25: 46.94% vs 57.82%, P = 0.024), blood glucose level (≤ 6.0 mmol/L vs > 6.0 mmol/L: 54.75% vs 41.14%, P = 0.002), pancreaticojejunal anastomosis technique (pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis vs pancreatic-jejunum single-layer mucosa-to-mucosa anastomosis: 57.54% vs 35.46%, P = 0.000), diameter of the pancreatic duct (≤ 3 mm vs > 3 mm: 57.81% vs 38.36%, P = 0.000), and pancreatic texture (soft vs hard: 56.72% vs 29.93%, P = 0.000). Multivariate logistic regression analysis showed that gender (male), BMI > 25, pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis, pancreatic duct diameter ≤ 3 mm, and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.

Conclusion: Gender (male), BMI > 25, pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis, pancreatic duct diameter ≤ 3 mm, and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.

No MeSH data available.


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Photomicrographs of the pathological examination for pancreatic fibrosis. A: No significant fibrosis; B: Severe fibrosis (hematoxylin-eosin staining; original magnification, × 100).
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Figure 1: Photomicrographs of the pathological examination for pancreatic fibrosis. A: No significant fibrosis; B: Severe fibrosis (hematoxylin-eosin staining; original magnification, × 100).

Mentions: A soft pancreas is a risk factor for pancreatic fistula after pancreaticoduodenectomy[35-37,41,42]. The pancreatic stumps of all cases were submitted for pathological diagnosis of the degree of pancreatic fibrosis. All cases of pancreatic texture were divided into two groups (normal soft pancreas with no significant fibrosis, as shown in Figure 1A, and hard pancreas with fibrosis, as shown in Figure 1B). In this study, 402 patients had a soft pancreas (POPF rate: 56.72%), and 137 patients had a hard pancreas (POPF rate: 29.93%). Univariate analysis showed that the difference in the POPF rates was significant (P = 0.000), suggesting that patients with a soft pancreas were at a higher risk of developing a pancreatic fistula after pancreaticoduodenectomy than patients with a hard pancreas. Additionally, multivariate logistic regression analysis demonstrated that the difference was significant (P = 0.000), which indicated that a soft pancreas was an independent risk factor for pancreatic fistula after pancreaticoduodenectomy. The OR (3.048, 95%CI: 1.953-4.757) showed that the risk of developing a pancreatic fistula after pancreaticoduodenectomy was 3.048-fold higher in patients with a soft pancreas than in patients with a hard pancreas. The higher incidence of pancreatic fistula after pancreaticoduodenectomy in patients with a soft pancreas may be related to insecure suturing and knotting, which can result in unsatisfactory pancreaticojejunal anastomosis and a higher risk of damage to the pancreatic tissue and fine pancreatic ducts during suturing and knotting of a soft pancreas, resulting in pancreatic leakage. The lower incidence of pancreatic fistula after pancreaticoduodenectomy in patients with a hard pancreas may be related to pancreatic exocrine dysfunction due to prolonged pancreatic duct obstruction and pancreatic fibrosis, secure pancreaticojejunal anastomosis, and obstructed minor ducts at the cut-surface of the hard pancreas, and this could help reduce POPF[43] and risk of damage to the pancreatic tissue and fine pancreatic ducts during suturing and knotting. Pancreatic texture is the most significant single predictor of POPF, and clinicians should select a pancreaticojejunal anastomosis technique based on the texture of the pancreas to reduce the incidence of POPF[44].


Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy
Photomicrographs of the pathological examination for pancreatic fibrosis. A: No significant fibrosis; B: Severe fibrosis (hematoxylin-eosin staining; original magnification, × 100).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5016380&req=5

Figure 1: Photomicrographs of the pathological examination for pancreatic fibrosis. A: No significant fibrosis; B: Severe fibrosis (hematoxylin-eosin staining; original magnification, × 100).
Mentions: A soft pancreas is a risk factor for pancreatic fistula after pancreaticoduodenectomy[35-37,41,42]. The pancreatic stumps of all cases were submitted for pathological diagnosis of the degree of pancreatic fibrosis. All cases of pancreatic texture were divided into two groups (normal soft pancreas with no significant fibrosis, as shown in Figure 1A, and hard pancreas with fibrosis, as shown in Figure 1B). In this study, 402 patients had a soft pancreas (POPF rate: 56.72%), and 137 patients had a hard pancreas (POPF rate: 29.93%). Univariate analysis showed that the difference in the POPF rates was significant (P = 0.000), suggesting that patients with a soft pancreas were at a higher risk of developing a pancreatic fistula after pancreaticoduodenectomy than patients with a hard pancreas. Additionally, multivariate logistic regression analysis demonstrated that the difference was significant (P = 0.000), which indicated that a soft pancreas was an independent risk factor for pancreatic fistula after pancreaticoduodenectomy. The OR (3.048, 95%CI: 1.953-4.757) showed that the risk of developing a pancreatic fistula after pancreaticoduodenectomy was 3.048-fold higher in patients with a soft pancreas than in patients with a hard pancreas. The higher incidence of pancreatic fistula after pancreaticoduodenectomy in patients with a soft pancreas may be related to insecure suturing and knotting, which can result in unsatisfactory pancreaticojejunal anastomosis and a higher risk of damage to the pancreatic tissue and fine pancreatic ducts during suturing and knotting of a soft pancreas, resulting in pancreatic leakage. The lower incidence of pancreatic fistula after pancreaticoduodenectomy in patients with a hard pancreas may be related to pancreatic exocrine dysfunction due to prolonged pancreatic duct obstruction and pancreatic fibrosis, secure pancreaticojejunal anastomosis, and obstructed minor ducts at the cut-surface of the hard pancreas, and this could help reduce POPF[43] and risk of damage to the pancreatic tissue and fine pancreatic ducts during suturing and knotting. Pancreatic texture is the most significant single predictor of POPF, and clinicians should select a pancreaticojejunal anastomosis technique based on the texture of the pancreas to reduce the incidence of POPF[44].

View Article: PubMed Central - PubMed

ABSTRACT

Aim: To analyze the risk factors for pancreatic fistula after pancreaticoduodenectomy.

Methods: We conducted a retrospective analysis of 539 successive cases of pancreaticoduodenectomy performed at our hospital from March 2012 to October 2015. Pancreatic fistula was diagnosed in strict accordance with the definition of pancreatic fistula from the International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.

Results: A total of 269 (49.9%) cases of pancreatic fistula occurred after pancreaticoduodenectomy, including 71 (13.17%) cases of grade A pancreatic fistula, 178 (33.02%) cases of grade B, and 20 (3.71%) cases of grade C. Univariate analysis showed no significant correlation between postoperative pancreatic fistula (POPF) and the following factors: age, hypertension, alcohol consumption, smoking, history of upper abdominal surgery, preoperative jaundice management, preoperative bilirubin, preoperative albumin, pancreatic duct drainage, intraoperative blood loss, operative time, intraoperative blood transfusion, Braun anastomosis, and pancreaticoduodenectomy (with or without pylorus preservation). Conversely, a significant correlation was observed between POPF and the following factors: gender (male vs female: 54.23% vs 42.35%, P = 0.008), diabetes (non-diabetic vs diabetic: 51.61% vs 39.19%, P = 0.047), body mass index (BMI) (≤ 25 vs > 25: 46.94% vs 57.82%, P = 0.024), blood glucose level (≤ 6.0 mmol/L vs > 6.0 mmol/L: 54.75% vs 41.14%, P = 0.002), pancreaticojejunal anastomosis technique (pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis vs pancreatic-jejunum single-layer mucosa-to-mucosa anastomosis: 57.54% vs 35.46%, P = 0.000), diameter of the pancreatic duct (≤ 3 mm vs > 3 mm: 57.81% vs 38.36%, P = 0.000), and pancreatic texture (soft vs hard: 56.72% vs 29.93%, P = 0.000). Multivariate logistic regression analysis showed that gender (male), BMI > 25, pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis, pancreatic duct diameter ≤ 3 mm, and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.

Conclusion: Gender (male), BMI > 25, pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis, pancreatic duct diameter ≤ 3 mm, and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.

No MeSH data available.


Related in: MedlinePlus