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Characterization and Optimal Management of High-risk Pancreatic Anastomoses During Pancreatoduodenectomy.
Ecker, Brett L; McMillan, Matthew T; Asbun, Horacio J; Ball, Chad G; Bassi, Claudio; Beane, Joal D; Behrman, Stephen W; Berger, Adam C; Dickson, Euan J; Bloomston, Mark; Callery, Mark P; Christein, John D; Dixon, Elijah; Drebin, Jeffrey A; Castillo, Carlos Fernandez-Del; Fisher, William E; Fong, Zhi Ven; Haverick, Ericka; Hollis, Robert H; House, Michael G; Hughes, Steven J; Jamieson, Nigel B; Javed, Ammar A; Kent, Tara S; Kowalsky, Stacy J; Kunstman, John W; Malleo, Giuseppe; Poruk, Katherine E; Salem, Ronald R; Schmidt, Carl R; Soares, Kevin; Stauffer, John A; Valero, Vicente; Velu, Lavanniya K P; Watkins, Amarra A; Wolfgang, Christopher L; Zureikat, Amer H; Vollmer, Charles M.
Afiliación
  • Ecker BL; Departments of Surgery from University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
  • McMillan MT; Departments of Surgery from University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
  • Asbun HJ; Mayo Clinic, Jacksonville, FL.
  • Ball CG; University of Calgary, Calgary, Alberta, Canada.
  • Bassi C; University of Verona, Verona, Italy.
  • Beane JD; Indiana University School of Medicine, Indianapolis, IN.
  • Behrman SW; University of Tennessee Health Science Center, Memphis, TN.
  • Berger AC; Jefferson Medical College, Philadelphia, PA.
  • Dickson EJ; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK.
  • Bloomston M; The Ohio State University Wexner Medical Center, Columbus, OH.
  • Callery MP; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
  • Christein JD; University of Alabama School of Medicine, Birmingham, AL.
  • Dixon E; University of Calgary, Calgary, Alberta, Canada.
  • Drebin JA; Departments of Surgery from University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
  • Castillo CF; Massachusetts General Hospital, Harvard Medical School, Boston, MA.
  • Fisher WE; Baylor College of Medicine, Houston, TX.
  • Fong ZV; Massachusetts General Hospital, Harvard Medical School, Boston, MA.
  • Haverick E; The Ohio State University Wexner Medical Center, Columbus, OH.
  • Hollis RH; University of Alabama School of Medicine, Birmingham, AL.
  • House MG; Indiana University School of Medicine, Indianapolis, IN.
  • Hughes SJ; University of Florida College of Medicine, Gainesville, FL.
  • Jamieson NB; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK.
  • Javed AA; Johns Hopkins School of Medicine, Baltimore, MD.
  • Kent TS; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
  • Kowalsky SJ; University of Pittsburgh Medical Center, Pittsburgh, PA.
  • Kunstman JW; Yale School of Medicine, New Haven, CT.
  • Malleo G; University of Verona, Verona, Italy.
  • Poruk KE; Johns Hopkins School of Medicine, Baltimore, MD.
  • Salem RR; Yale School of Medicine, New Haven, CT.
  • Schmidt CR; The Ohio State University Wexner Medical Center, Columbus, OH.
  • Soares K; Johns Hopkins School of Medicine, Baltimore, MD.
  • Stauffer JA; Mayo Clinic, Jacksonville, FL.
  • Valero V; Johns Hopkins School of Medicine, Baltimore, MD.
  • Velu LKP; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK.
  • Watkins AA; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
  • Wolfgang CL; Johns Hopkins School of Medicine, Baltimore, MD.
  • Zureikat AH; University of Pittsburgh Medical Center, Pittsburgh, PA.
  • Vollmer CM; Departments of Surgery from University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Ann Surg ; 267(4): 608-616, 2018 04.
Article en En | MEDLINE | ID: mdl-28594741
OBJECTIVE: The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy. BACKGROUND: The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circumstances of the anastomosis. The Fistula Risk Score (FRS) identifies a distinct high-risk cohort (FRS 7 to 10) that demonstrates substantially worse clinical outcomes. The value of various fistula mitigation strategies in these particular high-stakes cases has not been previously explored. METHODS: This multinational study included 5323 PDs performed by 62 surgeons at 17 institutions. Mitigation strategies, including both technique related (ie, pancreatogastrostomy reconstruction; dunking; tissue patches) and the use of adjuvant strategies (ie, intraperitoneal drains; anastomotic stents; prophylactic octreotide; tissue sealants), were evaluated using multivariable regression analysis and propensity score matching. RESULTS: A total of 522 (9.8%) PDs met high-risk FRS criteria, with an observed CR-POPF rate of 29.1%. Pancreatogastrostomy, prophylactic octreotide, and omission of externalized stents were each associated with an increased rate of CR-POPF (all P < 0.001). In a multivariable model accounting for patient, surgeon, and institutional characteristics, the use of external stents [odds ratio (OR) 0.45, 95% confidence interval (95% CI) 0.25-0.81] and the omission of prophylactic octreotide (OR 0.49, 95% CI 0.30-0.78) were independently associated with decreased CR-POPF occurrence. In the propensity score matched cohort, an "optimal" mitigation strategy (ie, externalized stent and no prophylactic octreotide) was associated with a reduced rate of CR-POPF (13.2% vs 33.5%, P < 0.001). CONCLUSIONS: The scenarios identified by the high-risk FRS zone represent challenging anastomoses associated with markedly elevated rates of fistula. Externalized stents and omission of prophylactic octreotide, in the setting of intraperitoneal drainage and pancreaticojejunostomy reconstruction, provides optimal outcomes.
Asunto(s)

Texto completo: 1 Bases de datos: MEDLINE Asunto principal: Fístula Pancreática / Pancreaticoduodenectomía Tipo de estudio: Etiology_studies / Observational_studies / Prognostic_studies / Risk_factors_studies Límite: Humans Idioma: En Revista: Ann Surg Año: 2018 Tipo del documento: Article

Texto completo: 1 Bases de datos: MEDLINE Asunto principal: Fístula Pancreática / Pancreaticoduodenectomía Tipo de estudio: Etiology_studies / Observational_studies / Prognostic_studies / Risk_factors_studies Límite: Humans Idioma: En Revista: Ann Surg Año: 2018 Tipo del documento: Article