The purpose of this study was to compare POPF rates in patients undergoing TDP to those undergoing EDP and determine the impact that traumatic injury has on pancreatic leak rates following DP. In addition, we performed a stratified descriptive analysis of each population separately (trauma and elective) to further establish the risk factors for POPF in each separate patient population. After controlling for various other risk factors, we determined that traumatic etiology is an independent risk factor for the development of clinically significant POPFs following DP compared with elective resections. Importantly, we found no evidence that this difference in leak rates was attributable to differences in pancreatic parenchymal texture, pancreatic remnant closure method, preoperative nutritional status, BMI, or higher numbers of simultaneous additional procedures performed. When analyzing risk factors in TDPs and EDPs separately, we found that TDP patients who developed POPFs had less sutured closure of their pancreatic duct, higher incidence of infectious complications, and longer hospital LOS. In EDP patients, we found male sex, younger age, and a higher incidence of infectious complications were associated with an increased rate of POPF development. In addition, EDP patients, who developed clinically significant fistulas trended toward higher EBL, were more likely to receive platelets and FFP, had an increased incidence of overall complications, and a longer hospital LOS compared with those without POPF. Lastly, when analyzing only patients with intraoperative drains placed, trauma remained a significant risk factor for the development of any postoperative pancreatic leak, including clinically significant grade B and C POPFs.
Previous studies have identified several different risk factors for the development of pancreatic fistulae following DP, including higher BMI, male sex, younger age, DM, extended lymphadenectomy, soft parenchymal texture, concomitant splenectomy, larger pancreatic remnant, and increased operating time.13–18 There is still debate about which pancreatic closure method is superior for reducing POPFs. Makni et al.19 demonstrated sutured closure was associated with fewer fistulae. Similarly, Kleef et al. showed stapled closure was an independent risk factor for development of POPF compared with sutured closure.17 However, several studies have found stapled closure to decrease POPF,4,18,20,21 while others have found equivocal results.13–16,22–24 Only two randomized trials are included in these studies, one finding stapled closure superior20 and one finding no difference between methods.23 In our study population, significantly more patients undergoing elective resection had sutured closure compared with those resected for trauma; however, closure method was not found to predict the development of POPF.
Pancreatic duct size and soft parenchymal texture are known risk factors for POPF following pancreaticoduodenectomy,25 yet studies have mixed findings regarding the effect of these variables following DP.15,16,25 To control for these potential risk factors, we performed an analysis comparing TDP to benign etiology EDP, assuming that gland texture and duct size would be more similar when excluding malignant disease from EDPs. On multivariable analysis, traumatic etiology was still shown to be a risk factor for POPF. These findings strengthen the notion that gland texture and duct size are not prominent risk factors for POPF following DP while further highlighting the significance of trauma as a risk factor for developing a fistula.
It is worthwhile to note that TDPs were performed by 16 different surgeons while the vast majority of EDP were performed by only four surgeons. Studies have shown that variability of surgeon training and experience, even at the same high-volume institution, can affect outcomes following pancreatic resection, including POPF rate.26,27 However, the effect of surgeon training and experience for pancreatic resections in the setting of trauma has not been extensively studied. Nevertheless, available data suggest that outcomes following hepatopancreaticobiliary trauma specifically are not significantly different between general surgeons and fellowship trained trauma surgeons.28 Future studies are needed that more thoroughly evaluate how training and experience affect outcomes in pancreatic trauma requiring resection.
Wound infection rate was significantly higher in TDP at 44.7% compared with EDP with 1.9%. When analyzing each population individually, wound infection was significantly associated with the development of POPF in each population. The high incidence of infectious complications is well documented with both pancreatic injury and elective pancreatic surgery, typically ranging from 12% to 18%.3,29,30 While POPF has been cited as risk factor for surgical site and organ space infections,31 less is understood about the relationship between wound infections and POPFs. In our study, wound infection was found to be associated with POPF on univariate analysis, yet, similar to age and sex, was significantly correlated with traumatic etiology and therefore not retained in the multivariable model. It is reasonable to infer that hollow viscus injuries may predispose patients to infectious complications. However, our data, as well as those of several other studies, do not support the notion that hollow viscus injuries or resultant multi-visceral resections increase the risk for developing a POPF.13–18 Likely, the etiology of high wound infection rates in trauma patients is multifactorial.
Several studies have examined risk factors for the development of a pancreatic leak following surgery for trauma. Bradley et al.32 found that injury to the main pancreatic duct was predictive of pancreatic fistula, and Kao et al.33 found that AAST Organ Specific Injury score for the pancreas was associated with pancreas specific postoperative complications. Similar to EDPs, the debate over stapled versus sutured pancreatic remnant closure for TDPs is unsettled. While fewer studies are available, the existing evidence shows no significant difference in POPF rate between techniques.2,6,22,24 Yet, there is a trend favoring stapler use for TDPs, given that they are relatively easy to use, quick, and provide secure closure with equal or improved POPF rates compared with sutured closure.5,34 Our data reflect this trend in the trauma population, favoring stapled closure over sutured closure. Interestingly, however, our data did show that fewer TDPs with sutured closure developed POPFs, while there was no significant difference in fistula development in those with stapled closure.
There were several patients who underwent damage-control surgery (DCS), undergoing definitive distal pancreatic resection after initial operative intervention to control hemorrhage and clinically stabilize the patient. Hwang et al.35 demonstrated that a base deficit ≤−5.8 mM/L, as a surrogate for hypovolemia or hemorrhagic shock, in patients with pancreatic trauma was an independent predictor of morbidity. Therefore, minimizing hemodynamic instability at the time of resection may potentially decrease the rate of POPF development. Additionally, studies have shown that delayed resection does not increase the fistula rate following TDP.2,36 Our study corroborated these findings, demonstrating no significant difference in mean days delayed for surgery between patients who developed fistulas and those who did not (0.71 days vs. 0.86 days, respectively, p = 0.7867). Furthermore, undergoing DCS was not found to be a risk factor for developing a grade B or C fistula for patients undergoing TDP. In fact, when all trauma patients undergoing DCS (n = 10, 26.3%) were excluded, comparing only those with TDP performed at initial operation to EDP, traumatic etiology remained an independent risk factor for developing POPF (OR, 4.63; 95% CI, 2.05–10.45). Taken together, these data suggest that DCS remains an important technique when treating patients with pancreatic injury.
The POPF rates vary throughout the literature; however, these discrepancies have been mitigated by standardizing the definition of a POPF using ISGPF standards.12 For EDP, after acceptance of ISGPF guidelines, fistula rates range from 5% to 40%.37 POPF rates in the trauma literature trend higher, ranging from 14% to 60% following TDP.2,4,6 However, few studies have compared fistula rates in EDPs to TDPs to account for the impact that traumatic etiology has on POPF rates. In a study from 2002, Fahy et al.4 compared 15 traumatic with 36 elective DPs and found a significantly higher fistula rate among the trauma population, 60% versus 11%. To our knowledge, our study represents the largest known cohort comparing fistula rates following DPs for trauma to those performed electively. As pancreatic trauma is rare and TDPs are performed infrequently, it seems reasonable to adopt techniques and compare outcomes to EDPs to improve outcomes. However, understanding how traumatic injury affects outcomes is important and may have significant implications for postoperative care.
An ongoing debate among pancreatic surgeons is whether or not to leave a postoperative drain. Several studies involving electively resected patients suggest that prophylactic drainage after DP is unnecessary and, in fact, may increase complications.38,39 In our study, we performed a subgroup analysis of all EDPs who received prophylactic drain placement and all TDPs that also received drains and compared all grades of POPF, including “grade A” biochemical leaks, between the two groups. On multivariable analysis, we found that TDPs had over an eightfold increased risk of developing any fistula postoperatively compared with EDPs, and over a sixfold increase risk of developing a biochemical leak. Grade A fistulas may be clinically silent but still represent a pancreatic ductal disruption, which can only be detected if drains are present and may potentially lead to more clinically relevant complications if drains are not in place to evacuate the high amylase fluid. Our results from examination of only grade A fistulas in patients that all had intraoperative drains placed suggests that traumatic etiology is an independent risk factor for stump closure disruption following DP, which may provide a potential explanation for the higher prevalence of POPFs noted in TDPs in this study. Furthermore, while routine drain placement following EDP may arguably be unnecessary, the same conclusions should not be applied to patients undergoing TDP.
Peripancreatic drainage without resection has been used to treat pancreatic injuries in certain clinical scenarios, particularly in low grade injuries (AAST grade I and II). Within our trauma cohort, 8 (21%) patients had grade II injuries, and of those 2 (25%) were initially treated with drainage alone, resulting in persistent pancreatic leaks with progressive lifestyle limiting symptoms alleviated only by definitive resection. Previous studies show similar outcomes in pancreatic injuries treated with resection versus nonoperative management in pediatric and select adult patients.40–42 However, nonoperative management often fails in high grade injuries (AAST grades III and IV) as well as some low-grade injuries, requiring subsequent interventions and prolonged hospital stays.43 Current guidelines recommend nonoperative management of AAST grade I and II injuries and operative intervention for high-grade injuries.44 Our study was not designed to determine the rate of failure of nonoperative management, but confirms that grade II injuries can indeed fail conservative management.
Our study possesses several limitations. The retrospective nature of data collection inherently limits the scope and quantity of available data, particularly with regards to intraoperative variables such as pancreatic texture and duct size. However, postoperative complications were well documented, especially those requiring subsequent diagnostic work-up, intervention, consultation, or extended hospital stay. While our study represents, to our knowledge, the largest known cohort of patients comparing TDP to EDPs, due to the low incidence and high mortality associated with pancreatic trauma, our study is still limited by the sample size of our trauma population. More specifically, this limitation precluded us from including variables with multicollinearity in our final multivariable model, namely: age, male sex, and wound infection. Furthermore, the limited sample size of our trauma population prevented us from performing any further multivariable analysis. Lastly, the unequal age distributions among our patient populations limit the applicability of our study. However, most studies involving TDPs have similar age distributions.1,2 The younger age of TDP patients is expected and a factor for which it is not easy to control.
Pancreatic trauma is rare but associated with high mortality. Operations to treat pancreatic trauma, such as DP, are still associated with high postoperative morbidity, the most common of which is POPF. The purpose of this study was to compare POPF rates following TDP to EDP and to assess how different clinical variables affect fistula rate. On multivariable analysis, we found that pancreatic trauma is a prominent risk factor for clinically significant ISGPF grade B and C POPF following DP. In addition, when analyzing TDPs and EDPs separately, we found that male sex, younger age, and higher rates of infectious complications were all associated with an increased rate of POPFs following EDP, verifying findings from the literature. The TDP patients who developed POPF were less likely to have sutured closure of their pancreatic duct, higher rates of infectious complications, and longer LOS. Lastly, by analyzing a subgroup of patients that were all treated with intraoperative drains, we demonstrated that trauma is an independent risk factor for pancreatic stump disruption following DP. Finally, while we cannot conclude from our analysis that leaving prophylactic drains following TDP clearly improves outcomes, based on the higher rates of pancreatic stump disruption in the trauma population, we feel it imprudent to extrapolate the EDP study data on drain placement to the trauma population. Further studies are needed to determine if intraperitoneal drainage following TDP is associated with a lower rate of grade B and C POPFs.
N.S.R. was the primary author of the article, was primarily involved in gathering data and creating the database used for the study, and presented the work at the 77th annual AAST meeting. K.T.M. and J.S.L. both oversaw the entire project as co-P.I.s, including data acquisition, statistical analysis, and editing of the abstract, poster, and final article. J.S.L. developed the initial concept for the project. T.G. and Z.S. helped with gathering data, project design, statistical analysis, and authoring of the abstract, poster, and article. A.L., C.B.S., C.S.B., and A.J. were involved in data acquisition and authoring/editing the abstract, poster, and article. B.H.E., P.K.M., and B.C.A. contributed to the project design, offered key clinical input and co-authored/edited the abstract and article.
The authors declare no funding or conflicts of interest.
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Keywords:© 2019 Lippincott Williams & Wilkins, Inc.
Distal pancreatectomy; trauma; fistula