A PROSPECTIVE RANDOMIZED TRIAL OF PANCREATICOGASTROSTOMY VERSUS PANCREATICOJEJUNOSTOMY AFTER PANCREATICODUODENECTOMY

Objective The authors hypothesized that pancreaticogastrostomy is safe r than pancreaticojejunostomy after pancreaticoduodenectomy and less l ikely to be associated with a postoperative pancreatic fistula. Summar y Background Data Pancreatic fistula is a leading cause of morbidity a nd mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastro stomy is less likely than pancreaticojejunostomy to be associated with postoperative complications. Methods Between May 1993 and January 199 5, the findings for 145 patients were analyzed in this prospective tri al at The Johns Hopkins Hospital. After giving their appropriate preop erative informed consent, patients were randomly assigned to pancreati cogastrostomy or pancreaticojejunostomy after completion of the pancre aticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with dosed suction drain age. Pancreatic fistula was defined as drainage of greater than 50 mt of amylase-rich fluid on or after postoperative day 10. Results The pa ncreaticogastrostomy (n = 73) and pancreaticojejunostomy (n = 72) grou ps were comparable with regard to multiple parameters, including demog raphics, medical history, preoperative laboratory values, and intraope rative factors, such as operative time, brood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreatic oduodenectomy was 11.7% (17/145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojeju nostomy (11.1%) groups. Pancreatic fistula was associated with a signi ficant prolongation of postoperative hospital stay (36 +/- 5 vs. 15 +/ - 1 days) (p < 0.001). Factors significantly increasing the risk of pa ncreatic fistula by univariate logistic regression analysis included a mpullary or duodenal disease, soft pancreatic texture, longer operativ e time, greater intraoperative red blood cell transfusions, and lower surgical Volume (p < 0.05). A multivariate logistic regression analysi s revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the r esected specimen. Conclusions Pancreatic fistula is a common complicat ion after pancreaticoduodenectomy, with an incidence most strongly ass ociated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than panc reaticojejunostomy or is associated with a lower incidence of pancreat ic fistula.