title: External tube pancreatostomy reduces the risk of mortality associated with completion pancreatectomy for symptomatic fistulas complicating pancreaticoduodenectomy.
abstract: OBJECTIVE
  This study aimed to compare the outcome of a pancreas-preserving technique consisting in a two-step procedure (external tube pancreatostomy (ETP) after resection of dehisced anastomosis followed by late anastomosis completion) with that of completion pancreatectomy (CP) for grade C fistulas complicating pancreaticoduodenectomies (PDs).
  
  
  BACKGROUND
  CP is the most commonly performed operation to treat a dehisced pancreato-jejunal anastomosis associated with deteriorating clinical status or hemorrhage. However, mortality of CP is high and long-term consequences are severe.
  
  
  METHODS
  All consecutive patients who underwent PD between 1990 and 2010 were identified. Clinicopathological data, operative details, and outcomes were analyzed.
  
  
  RESULTS
  Out of 370 patients, 112 (30.2 %) developed a pancreatic fistula, which was severe (grade C) in 47 cases. Forty-two patients were treated surgically by CP (n = 23; median time following PD, 10 days), ETP (n = 9; median time following PD, 8 days) or other various procedures (n = 10). Indications for re-operation and operative time of CP and ETP (207.5' versus 170', respectively) were similar, while postoperative mortality was significantly higher after CP (43.5 % versus 0 %, p = 0.030). Moreover, the need for a second emergency re-operation was threefold higher after CP than after ETP (39.1 % versus 11.1 %). After a median of 88 days, seven patients completed the pancreato-jejunal anastomosis without major complications or mortality. After a median follow-up of 14 months, none of the ETP patients developed diabetes.
  
  
  CONCLUSIONS
  External tube pancreatostomy significantly reduces the mortality associated with emergency CP. Thus, it should always be considered when deciding the treatment option in emergency surgery for severe pancreatic fistulas.
authors.affiliation: Division of Hepato-Biliary-Pancreatic and Digestive Surgery, Ospedale Mauriziano Umberto I, Torino, Italy. dribero@mauriziano.it
authors.forename: Dario
authors.initials: D
authors.lastname: Ribero
authors.forename: Marco
authors.initials: M
authors.lastname: Amisano
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Zimmitti
authors.forename: Francesco
authors.initials: F
authors.lastname: Giraldi
authors.forename: Alessandro
authors.initials: A
authors.lastname: Ferrero
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Capussotti
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010030:Ostomy / Q000295:instrumentation; D010179:Pancreas / Q000601:surgery*; D010180:Pancreatectomy / Q000009:adverse effects* / Q000401:mortality*; D010185:Pancreatic Fistula / Q000209:etiology* / Q000401:mortality*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors