First-line catheter drainage tied to better outcomes in severe postop pancreatic fistula

Last Updated: 2017-03-02

By Marilynn Larkin

NEW YORK (Reuters Health) - Compared with relaparotomy, initial use of catheter drainage for severe pancreatic fistula was associated with better clinical outcomes and less mortality after pancreatoduodenectomy, researchers say.

Dr. Marco Del Chiaro of the Karolinska Institute in Stockholm, Sweden, explained, “Severe pancreatic fistula is associated with a longer hospital stay and also with secondary, potentially life-threatening complications. That generally happens when the pancreas is healthy (soft texture with small duct) - typical of patients affected by benign pancreatic diseases . . . or by the less aggressive kind of tumors. That makes the situation complicated because, potentially, the patients affected by more curable diseases are also the ones with more risks from surgery.”

“Today there is not a universally accepted management strategy for patients affected by severe pancreatic fistula,” he told Reuters Health by email. “Some centers have a less aggressive attitude, handling this complication with percutaneous drains. (Others) proceed to reoperation and the completion of pancreatectomy quicker. No studies have evaluated in depth which treatment is best, and when.”

Dr. Inne Borel Rinkes, head of the Department of Surgical Oncology, Endocrine and GI Surgery at University Medical Center Utrecht, the Netherlands, and colleagues undertook that comparison by reviewing data on patients who underwent pancreatoduodenectomy in nine centers between 2005 and 2013.

Of the 309 patients with severe pancreatic fistula included in the analysis, two thirds were men and the mean age was 65.

As reported in JAMA Surgery, online February 22, 73.5% of patients underwent primary catheter drainage and 26.5% underwent primary relaparotomy. Overall in-hospital mortality was 17.8%. Primary catheter drainage was successful for 77% of patients, who did not need a subsequent relaparotomy.

Analyses comparing 64 patients who underwent catheter drainage and 64, matched by propensity score, who underwent relaparotomy showed that mortality was lower after catheter drainage (14.1% versus 35.9%; P=0.007; risk ratio, 0.39), as were rates of new-onset single-organ failure (4.7% versus 20.3%; P=0.007; RR, 0.15) and new-onset multiorgan failure (15.6% versus 39.1%; P=0.008; RR, 0.40).

Data on 50 patients followed up at three months showed new-onset diabetes in 12% of those who had catheter drainage versus 44% of those who underwent relaparotomy (P<0.001; RR, 0.27). No significant differences were seen in other clinically relevant outcomes.

The authors acknowledged several limitations, including the retrospective nature of the study, which may have caused selection bias and confounding, and the limits of propensity score matching in creating the comparator subgroups.

Summing up, Dr. Rinkes told Reuters Health, “Primary catheter drainage was associated with a better clinical outcome, including two-fold lower mortality, less organ failure, fewer additional re-operations, and less new-onset diabetes.”

“Whenever minimally invasive drainage is possible, this should be regarded as the first choice primary strategy in patients with grade B/C pancreatic fistula following pancreaticoduodenectomy,” he said by email.

He added, “There have been no other studies comparing these two strategies in this patient population. It should be noted that this outcome requires expertise of both interventional radiology and surgery teams, adding strength to the need for centralization of this type of surgery.”

Dr. Del Chiaro, coauthor of a related editorial, called the study “very interesting,” but noted “the biggest limitation is the retrospective design and also the differences between the two groups.”

The “step-up” approach for the management of pancreatic fistula, advocated by Dr. Del Chiaro and his coauthors, “is based on a well defined approach suggested for acute pancreatitis,” he said. “Invasiveness should probably be progressive. In other words, we should start to handle patients first with the more conservative treatment (i.e., percutaneous drainage) and go to more aggressive treatment - i.e., reoperation - when the (conservative approach) fails.”

“However, treatment should be personalized,” he stressed. “While this paper gives us a new hypothesis to work with, the best timing and type of surgery for postoperative pancreatic fistula still needs to be investigated in large prospective studies.”

SOURCE: http://bit.ly/2liJUVC

JAMA Surg 2017.