Reoperation for pancreatic fistula: a systematic review of completion pancreatectomy vs. pancreas-preserving-procedures and outcomes

Alessio Marchetti; Gaetano Corvino; Giampaolo Perri; Giovani Marchegiani; Raffaele De Luca

doi:10.1016/j.hpb.2024.11.006

Reoperation for pancreatic fistula: a systematic review of completion pancreatectomy vs. pancreas-preserving-procedures and outcomes

HPB (Oxford). 2024 Nov 27:S1365-182X(24)02420-1. doi: 10.1016/j.hpb.2024.11.006. Online ahead of print.

Authors

Alessio Marchetti¹, Gaetano Corvino², Giampaolo Perri³, Giovani Marchegiani⁴, Raffaele De Luca⁵

Affiliations

¹ Department of Pancreatic Surgery, Verona University Hospital, Piazzale Ludovico Antonio Scuro 10, 37134, Verona, VR, Italy; Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA.
² Department of Pancreatic Surgery, Verona University Hospital, Piazzale Ludovico Antonio Scuro 10, 37134, Verona, VR, Italy.
³ Hepato Pancreato Biliary (HPB) and Liver Transplant Surgery, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Via Giustiniani 2, 35128, Padova, Italy.
⁴ Hepato Pancreato Biliary (HPB) and Liver Transplant Surgery, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Via Giustiniani 2, 35128, Padova, Italy. Electronic address: [email protected].
⁵ Department of Surgical Oncology, I.R.C.C.S Istituto Tumori "Giovanni Paolo II", Viale Orazio Flacco 65, 70124, Bari, Italy.

PMID: 39658409
DOI: 10.1016/j.hpb.2024.11.006

Abstract

Background: Consensus on the nomenclature and indications for reoperation for post-operative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is lacking. This study explores the available literature to classify the different types of reoperations and report outcomes.

Methods: A systematic literature search was performed, including articles from 2010 to 2024 reporting reoperations for POPF after PD. The primary outcome was 30- or 90-day-mortality. Secondary outcomes included reoperation date, additional relaparotomy, ICU-admission, hospital stay, rate of pancreatic-exocrine-insufficiency, diabetes and long-term survivors.

Results: Twenty-five studies were reviewed with 766 patients reoperated for POPF after PD, 283 (37 %) undergoing completion pancreatectomy (CP) and 483 (63 %) pancreas-preserving-procedures (PPPs). Among PPPs, drainage (30 %), wirsungostomy (14 %), pancreatic anastomosis repair (6 %), "sinking" of pancreatic stump (6 %) and re-do pancreatic anastomosis (4 %) were identified. The main indications for reoperation were post-pancreatectomy hemorrhage, necrotizing acute pancreatitis, sepsis and peritonitis. PPPs were preferred with severe hemodynamic instability. Mortality rates after CP and PPPs ranged from 20 to 56 % and 0-67 %, respectively. Early reoperation was associated with reduced ICU-recovery after "sinking" (p = 0.049).

Conclusion: Reoperation for POPF after PD is rarely needed. When it is, early timing seems critical for better outcomes, and PPPs seems to be the best bail out option in patients with severe hemodynamic instability.