The position of the pancreatic duct in pancreatic section affects the occurrence of postoperative pancreatic fistula_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

LI Angzhi , CHEN Lang , XIONG Junjie , ZHANG Yi , WANG Li , HOU Shengzhong ,  TIAN Bole

Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

TIAN Bole, Email: tianbole@scu.edu.cn

Keywords：

Position of the pancreatic duct in the pancreatic section; pancreaticojejunostomy; postoperative pancreatic fistula; risk factor

DOI：

10.7507/1007-9424.202112036

Video：

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Objective To investigate the effect of the position of pancreatic duct in pancreatic section on postoperative pancreatic fistula. Methods The clinical data of patients undergoing pancreaticoduodenectomy admitted to the pancreatic surgery department of our hospital from September 2018 to August 2020 were retrospectively collected. The consistency between intraoperative pancreatic section data and preoperative CT cross-sectional images of pancreatic duct was compared, and the occurrence of postoperative pancreatic fistula was analyzed by univariate analysis and multivariate logistic regression model analysis, to determine whether the position of pancreatic duct on pancreatic section during pancreaticojejunostomy had an impact on the occurrence of postoperative pancreatic fistula. Results A total of 373 patients were included in this study. In 44 cases, the ratio of the thickness of the short distance from the center of the pancreatic duct to the edge of the pancreas at the pancreatic section was 0.41±0.09, and the imaging measurement value was 0.40±0.10. The interclass correlation coefficient detection value of the two measurement methods was 0.916 (>0.75), P<0.001, this had high consistency. Patients had a high BMI [OR=1.276, 95%CI (1.154, 1.411), P<0.000 1] and soft pancreatic texture [OR=2.771, 95%CI (1.558, 4.927), P=0.001] were independent risk factors for postoperative pancreatic fistula, while the risk of postoperative pancreatic fistula decreased with the increased proportion of pancreatic duct thickness from center to edge [OR=0.875, 95%CI (0.840, 0.911), P<0.000 1]. Conclusions Patients with high BMI and soft pancreas are independent risk factors for postoperative pancreatic fistula, and the risk of postoperative pancreatic fistula is reduced when the center of pancreatic duct is far from the edge of pancreas. The ratio of short distance from the center of pancreatic duct to the edge of pancreas to the total thickness of pancreas measured by preoperative imaging can be used to evaluate the risk of postoperative pancreatic fistula.

Citation： LI Angzhi, CHEN Lang, XIONG Junjie, ZHANG Yi, WANG Li, HOU Shengzhong, TIAN Bole. The position of the pancreatic duct in pancreatic section affects the occurrence of postoperative pancreatic fistula. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2022, 29(3): 294-301. doi: 10.7507/1007-9424.202112036 Copy

1.	Vallance AE, Young AL, Macutkiewicz C, et al. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. HPB (Oxford), 2015, 17(11): 1040-1048.
2.	Xiong JJ, Tan CL, Szatmary P, et al. Meta-analysis of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Br J Surg, 2014, 101(10): 1196-1208.
3.	Bassi C, Butturini G, Molinari E, et al. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg, 2004, 21(1): 54-59.
4.	Luu AM, Krasemann L, Fahlbusch T, et al. Facing the surgeon’s nightmare: Incidence and management of postoperative pancreatic fistulas grade C after pancreaticoduodenectomy based on the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). J Hepatobiliary Pancreat Sci, 2020, 27(4): 171-181.
5.	Pedrazzoli S. Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60 739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore), 2017, 96(19): e6858. doi: 10.1097/MD.0000000000006858.
6.	Fuks D, Piessen G, Huet E, et al. Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors. Am J Surg, 2009, 197(6): 702-709.
7.	中华医学会外科学分会, 中国研究型医院学会胰腺病专业委员会. 胰腺术后外科常见并发症及预防的专家共识(2017). 中华外科杂志, 2017, 5(7): 328-334.
8.	Callery MP, Pratt WB, Kent TS, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg, 2013, 216(1): 1-14.
9.	Kopljar M, Čoklo M, Krstačić A, et al. Validation of a clinical score in predicting pancreatic fistula after pancreaticoduodenectomy. Acta Chir Belg, 2021, 121(1): 30-35.
10.	Olakowski M, Grudzińska E, Mrowiec S. Pancreaticojejunostomy–a review of modern techniques. Langenbecks Arch Surg, 2020, 405(1): 13-22.
11.	Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery, 2017, 161(3): 584-591.
12.	Tempero MA, Malafa MP, Chiorean EG, et al. Pancreatic Adenocarcinoma, Version 1. 2019. J Natl Compr Canc Netw, 2019, 17(3): 202-210.
13.	Malleo G, Pulvirenti A, Marchegiani G, et al. Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg, 2014, 399(7): 801-810.
14.	Roberts KJ, Storey R, Hodson J, et al. Pre-operative prediction of pancreatic fistula: is it possible? Pancreatology, 2013, 13(4): 423-428.
15.	Kusafuka T, Kato H, Iizawa Y, et al. Pancreas-visceral fat CT value ratio and serrated pancreatic contour are strong predictors of postoperative pancreatic fistula after pancreaticojejunostomy. BMC Surg, 2020, 20(1): 129. doi: 10.1186/s12893-020-00785-w.
16.	Deng Y, Zhao B, Yang M, et al. Association between the incidence of pancreatic fistula after pancreaticoduodenectomy and the degree of pancreatic fibrosis. J Gastrointest Surg, 2018, 22(3): 438-443.
17.	Maehira H, Iida H, Mori H, et al. Computed tomography enhancement pattern of the pancreatic parenchyma predicts postoperative pancreatic fistula after pancreaticoduodenectomy. Pancreas, 2019, 48(2): 209-215.
18.	Miyamoto R, Oshiro Y, Nakayama K, et al. Three-dimensional simulation of pancreatic surgery showing the size and location of the main pancreatic duct. Surg Today, 2017, 47(3): 357-364.
19.	Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol, 2016, 51(10): 1147-1154.
20.	Kawaida H, Kono H, Hosomura N, et al. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol, 2019, 25(28): 3722-3737.
21.	Hu BY, Wan T, Zhang WZ, et al. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol, 2016, 22(34): 7797-7805.
22.	Rosso E, Casnedi S, Pessaux P, et al. The role of "fatty pancreas" and of BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy. J Gastrointest Surg, 2009, 13(10): 1845-1851.
23.	Chen H, Wang W, Ying X, et al. Predictive factors for postoperative pancreatitis after pancreaticoduodenectomy: A single-center retrospective analysis of 1 465 patients. Pancreatology, 2020, 20(2): 211-216.
24.	Tranchart H, Gaujoux S, Rebours V, et al. Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy. Ann Surg, 2012, 256(1): 139-145.
25.	Gruppo M, Angriman I, Martella B, et al. Perioperative albumin ratio is associated with post-operative pancreatic fistula. ANZ J Surg, 2018, 88(7-8): E602-E605. doi: 10.1111/ans.14262.
26.	Malleo G, Mazzarella F, Malpaga A, et al. Diabetes mellitus does not impact on clinically relevant pancreatic fistula after partial pancreatic resection for ductal adenocarcinoma. Surgery, 2013, 153(5): 641-650.
27.	Shen Z, Zhang J, Zhao S, et al. Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. Pancreatology, 2020, 20(3): 529-536.
28.	Mungroop TH, van Rijssen LB, van Klaveren D, et al. Alternative fistula risk score for pancreatoduodenectomy (a-FRS): design and international external validation. Ann Surg, 2019, 269(5): 937-943.
29.	Gaujoux S, Cortes A, Couvelard A, et al. Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. Surgery, 2010, 148(1): 15-23.
30.	Eshmuminov D, Schneider MA, Tschuor C, et al. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB (Oxford), 2018, 20(11): 992-1003.
31.	Hong TH, Choi JI, Park MY, et al. Pancreatic hardness: Correlation of surgeon’s palpation, durometer measurement and preoperative magnetic resonance imaging features. World J Gastroenterol, 2017, 23(11): 2044-2051.
32.	D’Onofrio M, Tremolada G, De Robertis R, et al. Prevent pancreatic fistula after pancreatoduodenectomy: possible role of ultrasound elastography. Dig Surg, 2018, 35(2): 164-170.
33.	Lee TK, Kang CM, Park MS, et al. Prediction of postoperative pancreatic fistulas after pancreatectomy: assessment with acoustic radiation force impulse elastography. J Ultrasound Med, 2014, 33(5): 781-786.
34.	Kuwahara T, Hirooka Y, Kawashima H, et al. Usefulness of endoscopic ultrasonography-elastography as a predictive tool for the occurrence of pancreatic fistula after pancreatoduodenectomy. J Hepatobiliary Pancreat Sci, 2017, 24(12): 649-656.
35.	Yamamoto Y, Sakamoto Y, Nara S, et al. A preoperative predictive scoring system for postoperative pancreatic fistula after pancreaticoduodenectomy. World J Surg, 2011, 35(12): 2747-2755.
36.	El Nakeeb A, Salah T, Sultan A, et al. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J Surg, 2013, 37(6): 1405-1418.
37.	Ecker BL, McMillan MT, Asbun HJ, et al. Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg, 2018, 267(4): 608-616.

1. Vallance AE, Young AL, Macutkiewicz C, et al. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. HPB (Oxford), 2015, 17(11): 1040-1048.
2. Xiong JJ, Tan CL, Szatmary P, et al. Meta-analysis of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy. Br J Surg, 2014, 101(10): 1196-1208.
3. Bassi C, Butturini G, Molinari E, et al. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg, 2004, 21(1): 54-59.
4. Luu AM, Krasemann L, Fahlbusch T, et al. Facing the surgeon’s nightmare: Incidence and management of postoperative pancreatic fistulas grade C after pancreaticoduodenectomy based on the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). J Hepatobiliary Pancreat Sci, 2020, 27(4): 171-181.
5. Pedrazzoli S. Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60 739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore), 2017, 96(19): e6858. doi: 10.1097/MD.0000000000006858.
6. Fuks D, Piessen G, Huet E, et al. Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors. Am J Surg, 2009, 197(6): 702-709.
7. 中华医学会外科学分会, 中国研究型医院学会胰腺病专业委员会. 胰腺术后外科常见并发症及预防的专家共识(2017). 中华外科杂志, 2017, 5(7): 328-334.
8. Callery MP, Pratt WB, Kent TS, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg, 2013, 216(1): 1-14.
9. Kopljar M, Čoklo M, Krstačić A, et al. Validation of a clinical score in predicting pancreatic fistula after pancreaticoduodenectomy. Acta Chir Belg, 2021, 121(1): 30-35.
10. Olakowski M, Grudzińska E, Mrowiec S. Pancreaticojejunostomy–a review of modern techniques. Langenbecks Arch Surg, 2020, 405(1): 13-22.
11. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery, 2017, 161(3): 584-591.
12. Tempero MA, Malafa MP, Chiorean EG, et al. Pancreatic Adenocarcinoma, Version 1. 2019. J Natl Compr Canc Netw, 2019, 17(3): 202-210.
13. Malleo G, Pulvirenti A, Marchegiani G, et al. Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg, 2014, 399(7): 801-810.
14. Roberts KJ, Storey R, Hodson J, et al. Pre-operative prediction of pancreatic fistula: is it possible? Pancreatology, 2013, 13(4): 423-428.
15. Kusafuka T, Kato H, Iizawa Y, et al. Pancreas-visceral fat CT value ratio and serrated pancreatic contour are strong predictors of postoperative pancreatic fistula after pancreaticojejunostomy. BMC Surg, 2020, 20(1): 129. doi: 10.1186/s12893-020-00785-w.
16. Deng Y, Zhao B, Yang M, et al. Association between the incidence of pancreatic fistula after pancreaticoduodenectomy and the degree of pancreatic fibrosis. J Gastrointest Surg, 2018, 22(3): 438-443.
17. Maehira H, Iida H, Mori H, et al. Computed tomography enhancement pattern of the pancreatic parenchyma predicts postoperative pancreatic fistula after pancreaticoduodenectomy. Pancreas, 2019, 48(2): 209-215.
18. Miyamoto R, Oshiro Y, Nakayama K, et al. Three-dimensional simulation of pancreatic surgery showing the size and location of the main pancreatic duct. Surg Today, 2017, 47(3): 357-364.
19. Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol, 2016, 51(10): 1147-1154.
20. Kawaida H, Kono H, Hosomura N, et al. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol, 2019, 25(28): 3722-3737.
21. Hu BY, Wan T, Zhang WZ, et al. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol, 2016, 22(34): 7797-7805.
22. Rosso E, Casnedi S, Pessaux P, et al. The role of "fatty pancreas" and of BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy. J Gastrointest Surg, 2009, 13(10): 1845-1851.
23. Chen H, Wang W, Ying X, et al. Predictive factors for postoperative pancreatitis after pancreaticoduodenectomy: A single-center retrospective analysis of 1 465 patients. Pancreatology, 2020, 20(2): 211-216.
24. Tranchart H, Gaujoux S, Rebours V, et al. Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy. Ann Surg, 2012, 256(1): 139-145.
25. Gruppo M, Angriman I, Martella B, et al. Perioperative albumin ratio is associated with post-operative pancreatic fistula. ANZ J Surg, 2018, 88(7-8): E602-E605. doi: 10.1111/ans.14262.
26. Malleo G, Mazzarella F, Malpaga A, et al. Diabetes mellitus does not impact on clinically relevant pancreatic fistula after partial pancreatic resection for ductal adenocarcinoma. Surgery, 2013, 153(5): 641-650.
27. Shen Z, Zhang J, Zhao S, et al. Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. Pancreatology, 2020, 20(3): 529-536.
28. Mungroop TH, van Rijssen LB, van Klaveren D, et al. Alternative fistula risk score for pancreatoduodenectomy (a-FRS): design and international external validation. Ann Surg, 2019, 269(5): 937-943.
29. Gaujoux S, Cortes A, Couvelard A, et al. Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. Surgery, 2010, 148(1): 15-23.
30. Eshmuminov D, Schneider MA, Tschuor C, et al. Systematic review and meta-analysis of postoperative pancreatic fistula rates using the updated 2016 International Study Group Pancreatic Fistula definition in patients undergoing pancreatic resection with soft and hard pancreatic texture. HPB (Oxford), 2018, 20(11): 992-1003.
31. Hong TH, Choi JI, Park MY, et al. Pancreatic hardness: Correlation of surgeon’s palpation, durometer measurement and preoperative magnetic resonance imaging features. World J Gastroenterol, 2017, 23(11): 2044-2051.
32. D’Onofrio M, Tremolada G, De Robertis R, et al. Prevent pancreatic fistula after pancreatoduodenectomy: possible role of ultrasound elastography. Dig Surg, 2018, 35(2): 164-170.
33. Lee TK, Kang CM, Park MS, et al. Prediction of postoperative pancreatic fistulas after pancreatectomy: assessment with acoustic radiation force impulse elastography. J Ultrasound Med, 2014, 33(5): 781-786.
34. Kuwahara T, Hirooka Y, Kawashima H, et al. Usefulness of endoscopic ultrasonography-elastography as a predictive tool for the occurrence of pancreatic fistula after pancreatoduodenectomy. J Hepatobiliary Pancreat Sci, 2017, 24(12): 649-656.
35. Yamamoto Y, Sakamoto Y, Nara S, et al. A preoperative predictive scoring system for postoperative pancreatic fistula after pancreaticoduodenectomy. World J Surg, 2011, 35(12): 2747-2755.
36. El Nakeeb A, Salah T, Sultan A, et al. Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience). World J Surg, 2013, 37(6): 1405-1418.
37. Ecker BL, McMillan MT, Asbun HJ, et al. Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg, 2018, 267(4): 608-616.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

The position of the pancreatic duct in pancreatic section affects the occurrence of postoperative pancreatic fistula

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