This is a paper dealing with the two different reconstruction options after a PD: a PJ vs a PG anastomosis. We used retrospectively data from institutional database and implement the prognostic fistula risk score described by Callery et al in order to differentiate between patients that are high risk vs low risk for anastomotic fistula. This is a first study comparing POPF according to PE using CRS-PF score. Even though many meta-analyses compared POPF rates between PJ and PG prior, those studies didn’t use objective criteria for risk of POPF and the results were not conclusive. In this study, we tried to differentiate approach by stratifying patients according to the risk of developing a POPF.
Theoretically, PG could induce favorable outcome after PD with regards to POPF. Exocrine pancreatic secretions are easily activated in the presence of intestinal enterokinase and bile, but not in the acidic gastric environment and postoperative gastric decompression can result in removal of gastric and pancreatic secretions.
In meta-analysis, PG seemed to be superior to PJ with regards to lesser incidence of POPF and other complications such as biliary fistula and intra-abdominal fluid collection after PD [5-8]. Therefore, authors concluded surgeons should consider reconstructing the pancreatic remnant following PD with PG [6]. However, largest study [9] about POPF after PG and PJ could not demonstrate that one surgical procedure is better than the other. PJ may have little or no difference from PG in overall POPF rate (PJ 24.3%; PG 21.4%). In this study [9], author pointed out few studies clearly distinguished clinically significant pancreatic fistula which required a change in the patient's management.
Recently, investigators [10,11] recommended needs for randomized control trial recruiting specifically patients with “high risk pancreas” to be randomized to PG or PJ. In addition, author [11] focused on limitation of previous studies and standardization of surgical techniques, definition of POPF, complication and perioperative management. Previous meta-analysis didn’t showed objective criteria such as CRS-PF recording POPF yet.
Considering well known higher risk such as soft and non-dilated pancreatic duct, objective risk model for POPF was established by Callery and colleagues [1]. They proved the CRS-PF based on four easily identifiable intraoperative parameters such as pancreatic duct diameter, pancreas texture, pathology, and EBL.
The CRS-PF is a clinically useful tool for POPF risk stratification after PD and allows for targeted intra- and postoperative measures to address patients at increased risk. Multi-institutional experience also confirmed the CRS-PF as a valid tool for predicting the development of CR-POPF after PD (1). The CRS-PF might organize the information on pancreatic fistula, although not always recorded according to standardized methodology before [3]. Herein we applied the CRS-PF for assessment of POPF according to the risk grades between PJ and PG.
Despite POPF can be observed in Low, Intermediate risk, clinically relevant form is mainly occurred in High risk glands (13/24, 54.1%). So, we have to focus on ‘High Risk’ gland and reveal which method of PE is feasible on high risks.
This study has several limitations requiring mention. First, the current work is not a randomized controlled study and, therefore, is subject to certain limitations secondary to the retrospective nature of the data collection. Secondly, this study includes two surgeons’ procedure and the technique evolved over the study periods. In fact, senior surgeon favored PG with higher fistula rate and junior mainly performed PJ during later periods, with lower rate of POPF. However, we did not find any difference in the POPF rate at any CRS-PF within the study time period (data was not shown). Third, pancreas texture and duct size were a subjective assessment and could have variance between surgeons and they would ideally be measured in an objective and scientific fashion. However, these measurements may be easier to standardize than measurements of estimating the blood loss after PD which can have wide surgeon specific or institution specific variation. The last, we used only a sample of 159 patients operated by two surgeons over the course of 12 years. As this study spans, some aspects of the perioperative care in pancreatic surgery have evolved making little difficult the comparison of patients operated in 2019 vs those operated in 2008. Nevertheless we made effort to keep perioperative protocol used constant throughout the study period.
In this series, small ducts (<2mm) were equivalently distributed on both PE. However, PG patients might be sometimes placed in the higher risk groups based on blood loss (p=0.09). The “high risk” PG and PJ patients were around one third in each procedure but POPF in High risk was larger in PG (31.0%) than PJ (22.2%) without any significance. It might be up to various factors such as surgeon’s skill, experience and preference of operative technique. Within the factors of the risk score, however, soft pancreas and non-dilated small main duct appear to be the greatest factor to predict POPF. When comparing surgeons, institutions or techniques, one should take in consideration that blood loss is a controllable factor and by including it in the CRS-PF, a surgeon or technique that has an increased blood loss during surgery would benefit from having patients with a higher blood loss attributed to a higher risk.
In conclusion, as previously shown, CRS-PF is a very good predictor for pancreatic fistula. POPF rate was similar on both procedures and overall rate was 15.1% in this study. Even in higher risk of glands, any procedure wasn’t superior to another regarding POPF. Randomized controlled study of this subject is inevitable in future.