Transampullary pancreatic duct stenting decreases pancreatic fistula rate following left pancreatectomy.
OBJECTIVE
Significant improvements in mortality following pancreatic surgery have been noted by high-volume centers in recent years. Despite this, morbidity from pancreatic resection remains high, with postoperative pancreatic fistula remaining a common problem following distal pancreatectomy (DP). Rates of pancreatic fistula following distal pancreatectomy have ranged from 0 to 61% in a recent meta-analysis of surgical techniques and impact upon pancreatic fistula rates. We postulated that intraoperative placement of a transampullary pancreatic duct stent (TAPDS) at the time of distal pancreatectomy, would decrease ampullary complex-mediated elevation in pancreatic duct pressures, improve healing of the ligated pancreatic duct and result in a decrease in pancreatic fistula following distal pancreatectomy.


METHODS
Sixteen consecutive patients underwent distal pancreatectomy plus TAPDS and were compared to 43 control patients who underwent distal pancreatectomy by the same surgeon, with identical management of the pancreatic remnant. Distal pancreatectomy was performed as the primary operation or as part of an en-bloc resection for a primary malignancy other than pancreatic adenocarcinoma. In patients who underwent transampullary pancreatic duct stenting (TAPDS), the pancreatic duct was identified after transection of the pancreatic parenchyma. A soft, pediatric feeding tube was inserted directly into the pancreatic duct and carefully fed into the duodenum (confirmed by palpation). The stent was placed distally, one centimeter from the cut-edge of the pancreatic duct, which was then ligated as described earlier. Closure of the pancreatic parenchyma was identical to those patients who did not undergo TAPDS placement. Common perioperative outcomes were assessed, including pancreatic fistula.


RESULTS
No statistically significant differences where found between the rates of intraabdominal abscess, intraabdominal hemorrhage or need for reoperation. Pancreatic fistula rates and average length of stay were significantly decreased in patients undergoing distal pancreatectomy with TAPDS (p<0.05 and p<0.0001 respectively).


CONCLUSIONS
Statistically significant reductions in pancreatic fistula and average length of stay were noted in patients who underwent stenting of the pancreatic duct with TAPDS.
Department of Surgery, The Methodist Hospital, Weill Medical College of Cornel University, Houston, Texas 77030, USA. cpfischer@tmh.tmc.edu
Craig P
CP
Fischer
Barbara
B
Bass
Bridget
B
Fahy
Thomas
T
Aloia
D000230:Adenocarcinoma / Q000601:surgery; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D007902:Length of Stay; D008026:Ligation; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000009:adverse effects* / Q000379:methods*; D010183:Pancreatic Ducts / Q000601:surgery; D010185:Pancreatic Fistula / Q000517:prevention & control*; D010190:Pancreatic Neoplasms / Q000601:surgery; D015607:Stents