title: Management of Severe Pancreatic Fistula After Pancreatoduodenectomy.
abstract: Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking.
  
  
  
  To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy.
  
  
  
  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.
  
  
  
  First intervention for pancreatic fistula: catheter drainage or relaparotomy.
  
  
  
  Primary end point was in-hospital mortality; secondary end points included new-onset organ failure.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: F Jasmijn
authors.initials: FJ
authors.lastname: Smits
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands3Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.
authors.forename: Hjalmar C
authors.initials: HC
authors.lastname: van Santvoort
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands.
authors.forename: Marc G
authors.initials: MG
authors.lastname: Besselink
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Marilot C T
authors.initials: MCT
authors.lastname: Batenburg
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Robbert A E
authors.initials: RAE
authors.lastname: Slooff
authors.affiliation: Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.
authors.forename: Djamila
authors.initials: D
authors.lastname: Boerma
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands.
authors.forename: Olivier R
authors.initials: OR
authors.lastname: Busch
authors.affiliation: Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands.
authors.forename: Peter P L O
authors.initials: PPLO
authors.lastname: Coene
authors.affiliation: Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
authors.forename: Ronald M
authors.initials: RM
authors.lastname: van Dam
authors.affiliation: Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
authors.forename: David P J
authors.initials: DPJ
authors.lastname: van Dijk
authors.affiliation: Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.
authors.forename: Casper H J
authors.initials: CHJ
authors.lastname: van Eijck
authors.affiliation: Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.
authors.forename: Sebastiaan
authors.initials: S
authors.lastname: Festen
authors.affiliation: Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands.
authors.forename: Erwin
authors.initials: E
authors.lastname: van der Harst
authors.affiliation: Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
authors.forename: Ignace H J T
authors.initials: IHJT
authors.lastname: de Hingh
authors.affiliation: Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
authors.forename: Koert P
authors.initials: KP
authors.lastname: de Jong
authors.affiliation: Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands.
authors.forename: Johanna A M G
authors.initials: JAMG
authors.lastname: Tol
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Inne H M
authors.initials: IHM
authors.lastname: Borel Rinkes
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: I Quintus
authors.initials: IQ
authors.lastname: Molenaar
mesh_terms: D000368:Aged; D004322:Drainage / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010185:Pancreatic Fistula / Q000401:mortality / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery*; D057216:Propensity Score; D012086:Reoperation / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors