F Jasmijn Smits1, Hjalmar C van Santvoort2, Marc G Besselink3, Marilot C T Batenburg1, Robbert A E Slooff1, Djamila Boerma4, Olivier R Busch3, Peter P L O Coene5, Ronald M van Dam6, David P J van Dijk6, Casper H J van Eijck7, Sebastiaan Festen8, Erwin van der Harst5, Ignace H J T de Hingh9, Koert P de Jong10, Johanna A M G Tol3, Inne H M Borel Rinkes1, I Quintus Molenaar1. 1. Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands. 2. Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands3Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands. 3. Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, the Netherlands. 4. Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands. 5. Department of Surgery, Maasstad Hospital, Rotterdam, the Netherlands. 6. Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands. 7. Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands. 8. Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands. 9. Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands. 10. Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Abstract
Importance: Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking. Objective: To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy. Design, Setting, and Participants: 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. Exposures: First intervention for pancreatic fistula: catheter drainage or relaparotomy. Main Outcomes and Measures: Primary end point was in-hospital mortality; secondary end points included new-onset organ failure. Results: 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. Conclusions and Relevance: 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.
Importance: Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking. Objective: To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy. Design, Setting, and Participants: 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. Exposures: First intervention for pancreatic fistula: catheter drainage or relaparotomy. Main Outcomes and Measures: Primary end point was in-hospital mortality; secondary end points included new-onset organ failure. Results: 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. Conclusions and Relevance: 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: Erik von Elm; Douglas G Altman; Matthias Egger; Stuart J Pocock; Peter C Gøtzsche; Jan P Vandenbroucke Journal: Int J Surg Date: 2014-07-18 Impact factor: 6.071
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