Management of Severe Pancreatic Fistula After Pancreatoduodenectomy

F. Jasmijn Smits; Hjalmar C. van Santvoort; Marc G. Besselink; Marilot C. T. Batenburg; Robbert A. E. Slooff; Djamila Boerma; Olivier R. Busch; Peter P. L. O. Coene; Ronald M. van Dam; David P. J. van Dijk; Casper H. J. van Eijck; Sebastiaan Festen; Erwin van der Harst; Ignace H. J. T. de Hingh; Koert P. de Jong; Johanna A. M. G. Tol; Inne H. M. Borel Rinkes; I. Quintus Molenaar; Dutch Pancreatic Canc Grp

doi:10.1001/jamasurg.2016.5708

Management of Severe Pancreatic Fistula After Pancreatoduodenectomy

F. Jasmijn Smits, Hjalmar C. van Santvoort, Marc G. Besselink, Marilot C. T. Batenburg, Robbert A. E. Slooff, Djamila Boerma, Olivier R. Busch, Peter P. L. O. Coene, Ronald M. van Dam, David P. J. van Dijk, Casper H. J. van Eijck, Sebastiaan Festen, Erwin van der Harst, Ignace H. J. T. de Hingh, Koert P. de Jong, Johanna A. M. G. Tol, Inne H. M. Borel Rinkes, I. Quintus Molenaar^*, Dutch Pancreatic Canc Grp

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

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.

Original language	English
Pages (from-to)	540-548
Number of pages	9
Journal	JAMA Surgery
Volume	152
Issue number	6
DOIs	https://doi.org/10.1001/jamasurg.2016.5708
Publication status	Published - Jun 2017

Keywords

INTERNATIONAL STUDY-GROUP
COMPLETION PANCREATECTOMY
SURGICAL COMPLICATIONS
CONFIDENCE-INTERVALS
GRADE C
SURGERY
DEFINITIONS
GUIDELINES
RISK

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10.1001/jamasurg.2016.5708

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Smits, F. J., van Santvoort, H. C., Besselink, M. G., Batenburg, M. C. T., Slooff, R. A. E., Boerma, D., Busch, O. R., Coene, P. P. L. O., van Dam, R. M., van Dijk, D. P. J., van Eijck, C. H. J., Festen, S., van der Harst, E., de Hingh, I. H. J. T., de Jong, K. P., Tol, J. A. M. G., Rinkes, I. H. M. B., Molenaar, I. Q., & Dutch Pancreatic Canc Grp (2017). Management of Severe Pancreatic Fistula After Pancreatoduodenectomy. JAMA Surgery, 152(6), 540-548. https://doi.org/10.1001/jamasurg.2016.5708

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title = "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.",

keywords = "INTERNATIONAL STUDY-GROUP, COMPLETION PANCREATECTOMY, SURGICAL COMPLICATIONS, CONFIDENCE-INTERVALS, GRADE C, SURGERY, DEFINITIONS, GUIDELINES, RISK",

author = "Smits, {F. Jasmijn} and {van Santvoort}, {Hjalmar C.} and Besselink, {Marc G.} and Batenburg, {Marilot C. T.} and Slooff, {Robbert A. E.} and Djamila Boerma and Busch, {Olivier R.} and Coene, {Peter P. L. O.} and {van Dam}, {Ronald M.} and {van Dijk}, {David P. J.} and {van Eijck}, {Casper H. J.} and Sebastiaan Festen and {van der Harst}, Erwin and {de Hingh}, {Ignace H. J. T.} and {de Jong}, {Koert P.} and Tol, {Johanna A. M. G.} and Rinkes, {Inne H. M. Borel} and Molenaar, {I. Quintus} and {Dutch Pancreatic Canc Grp}",

year = "2017",

month = jun,

doi = "10.1001/jamasurg.2016.5708",

language = "English",

volume = "152",

pages = "540--548",

journal = "JAMA Surgery",

issn = "2168-6254",

publisher = "American Medical Association",

number = "6",

}

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, Rinkes, IHMB, Molenaar, IQ & Dutch Pancreatic Canc Grp 2017, 'Management of Severe Pancreatic Fistula After Pancreatoduodenectomy', JAMA Surgery, vol. 152, no. 6, pp. 540-548. https://doi.org/10.1001/jamasurg.2016.5708

TY - JOUR

T1 - Management of Severe Pancreatic Fistula After Pancreatoduodenectomy

AU - Smits, F. Jasmijn

AU - van Santvoort, Hjalmar C.

AU - Besselink, Marc G.

AU - Batenburg, Marilot C. T.

AU - Slooff, Robbert A. E.

AU - Boerma, Djamila

AU - Busch, Olivier R.

AU - Coene, Peter P. L. O.

AU - van Dam, Ronald M.

AU - van Dijk, David P. J.

AU - van Eijck, Casper H. J.

AU - Festen, Sebastiaan

AU - van der Harst, Erwin

AU - de Hingh, Ignace H. J. T.

AU - de Jong, Koert P.

AU - Tol, Johanna A. M. G.

AU - Rinkes, Inne H. M. Borel

AU - Molenaar, I. Quintus

AU - Dutch Pancreatic Canc Grp

PY - 2017/6

Y1 - 2017/6

N2 - 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.

AB - 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.

KW - INTERNATIONAL STUDY-GROUP

KW - COMPLETION PANCREATECTOMY

KW - SURGICAL COMPLICATIONS

KW - CONFIDENCE-INTERVALS

KW - GRADE C

KW - SURGERY

KW - DEFINITIONS

KW - GUIDELINES

KW - RISK

U2 - 10.1001/jamasurg.2016.5708

DO - 10.1001/jamasurg.2016.5708

M3 - Article

C2 - 28241220

SN - 2168-6254

VL - 152

SP - 540

EP - 548

JO - JAMA Surgery

JF - JAMA Surgery

IS - 6

ER -