External tube pancreatostomy reduces the risk of mortality associated with completion pancreatectomy for symptomatic fistulas complicating pancreaticoduodenectomy.

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 DATA: 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.