The Effect of Pancreaticojejunostomy Technique on Fistula Formation Following Pancreaticoduodenectomy in the Soft Pancreas

IntroductionA soft pancreas has been associated with an increased risk of post-operative pancreatic fistula formation. Few studies have evaluated the effect of anastomotic technique (duct to mucosa vs invagination) on fistula formation. This study aims to compare the effect of anastomotic technique on fistula formation among patients with a soft pancreas in a large multiinstitutional database.MethodsThe targeted pancreas module of the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) Database was used. All patients with a soft pancreas who underwent pancreaticoduodenectomy from 2014 to 2015 were identified. Demographic data, comorbid conditions, operative variables, and 30-day outcomes were compared using univariate and multivariable analyses.ResultsA total of 975 patients met inclusion criteria. Eight-hundred fifty four (88%) underwent a duct to mucosa pancreaticojejunostomy technique and 121 (12%) underwent invagination. Patients who underwent invagination had higher 30-day mortality (5.8% vs 1.4%, p<0.01), higher fistula formation (38% vs 25%, p<0.01), and more often had percutaneous drain placement post-operatively (27% vs 14%, p<0.01). Following multivariable analysis, invagination remained associated with pancreatic fistula formation (OR 2.5, CI 1.4-4.3) and post-operative percutaneous drain placement (OR 1.8, CI 1.1-2.9).ConclusionInvagination technique for pancreaticojejunostomy in patients with a soft pancreas is associated with increased rates of pancreatic fistula. Surgeons should consider utilizing a duct to mucosa technique when feasible to decrease morbidity following pancreaticoduodenectomy in this patient population.