Skip to main content

Advertisement

SpringerLink
Log in

Duodeno-jejunal or gastro-enteric leakage after pancreatic resection: a case–control study

  • Original Article
  • Published:
Updates in Surgery Aims and scope Submit manuscript

    We’re sorry, something doesn't seem to be working properly.

    Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Abstract

Duodeno-jejunal (DJ) and gastro-jejunal (GJ) anastomosis leakage represents a rare but life-threatening complication after pancreaticoduodenectomy or total pancreatectomy. The aim of this study was to assess its incidence, clinical presentation, and outcomes, and to identify perioperative risk factors for DJ/GJ leak. Prospectively collected perioperative data were reviewed, and a case–control study was performed. Patients who presented with a DJ/GJ leak (cases) were matched in a 1:5 ratio with patients who did not develop it. Match criteria included age, diagnosis, type of surgery, and anastomosis. Perioperative factors and outcomes were compared between groups. From January 2008 to present, 13 cases were observed and compared to 60 controls. Concerning pre-operative variables, cases showed lower pre-operative serum hemoglobin (p = 0.021) and increased pre-operative radiotherapy (p = 0.037). Cases experienced more severe post-operative complications than Controls, according to the CD classification (p < 0.001), with a higher mortality rate (23% vs. 2%; p < 0.016). They also experienced a more demanding intra-operative course including an increased estimated blood loss (median 600 vs. 400 mL; p = 0.002), a higher rate of blood transfusion (n4 31% vs. n5 8%; p = 0.047) with also a longer operative time (median 360 vs. 318 min; p = 0.038). Moreover, the occurrence of a DJ/GJ leak was significantly associated with other post-operative complications: clinically relevant pancreatic fistula (p = 0.006), bile leak (p = 0.021), and bleeding (p = 0.001). In addition, another post-operative finding significantly related to the DJ/GJ occurrence was sepsis (p < 0.001) The DJ/GJ fistula required a surgical treatment in the majority of cases (92.3%), while, in only one patient, a conservative management was accomplished. Length of hospital stay and mortality at 90 days were higher in the DJ/GJ leak group (p = 0.001). DJ/GJ leakage is a severe complication following pancreatic resection. A higher index of suspicion for DJ/GJ fistula should be maintained in case of concomitant relevant pancreatic fistula and post-operative hemorrhage.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Crist DW, Sitzmann JV, Cameron JL (1987) Improved hospital morbidity, mortality and survival after the whipple procedure. Ann Surg 206:358–365 (PMID: 3632096)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Kleeff J, Friess H, Büchler MW (2005) Complications of pancreatic surgery. HPB (Oxford) 7(2):99–108 (PMID: 18333171)

    Article  PubMed Central  Google Scholar 

  3. De Castro SM, Busch OR, van Gulik TM, Obertop H, Gouma DJ (2005) Incidence and management of pancreatic leakage after pancreatoduodenectomy. Br J Surg 92:1117–1123 (PMID: 15931656)

    Article  PubMed  Google Scholar 

  4. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J et al (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13 (PMID: 16003309)

    Article  PubMed  Google Scholar 

  5. Lin JW, Cameron JL, Yeo CJ et al (2004) Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 8(8):951–959 (PMID: 15585382)

    Article  PubMed  Google Scholar 

  6. De Castro SM, Kuhlmann KF, Busch OR, van Delden OM, Lam_eris JS, van Gulik TM et al (2005) Incidence and management of biliary leakage after hepaticojejunostomy. J Gastrointest Surg 9:1163–1171 (PMID: 16269388)

    Article  PubMed  Google Scholar 

  7. Burkhart RA, Relles D, Pineda DM, Gabale S, Sauter PK, Rosato EL et al (2013) Defining treatment and outcomes of hepaticojejunostomy failure following pancreaticoduodenectomy. J Gastrointest Surg 17:451–460 (PMID: 23292459)

    Article  PubMed  Google Scholar 

  8. Malgras B, Duron S, Gaujoux S, Dokmak S, Aussilhou B, Rebours V, Palazzo M, Belghiti J, Sauvanet A (2015) Early biliary complications following pancreaticoduodenectomy: prevalence and risk factors. HPB (Oxford) 18(4):367–374. https://doi.org/10.1016/j.hpb.2015.10.012 (PMID: 27037207)

    Article  Google Scholar 

  9. Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW et al (2004) Pylorus preserving pancreaticoduodenectomy versus standard whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 240:738–745 (PMID: 15492552)

    Article  PubMed  PubMed Central  Google Scholar 

  10. Winter JM, Cameron JL, Yeo CJ, Lillemoe KD, Campbell KA, Schulick RD (2008) Duodenojejunostomy leaks after pancreaticoduodenectomy. J Gastrointest Surg. 12(2):263–269 (PMID: 17968631)

    Article  PubMed  Google Scholar 

  11. Eshuis WJ, Tol JA, Nio CY, Busch OR, van Gulik TM, Gouma DJ (2014) Leakage of the gastroenteric anastomosis after pancreatoduodenectomy. Surgery 156(1):75–82 (PMID: 24929760)

    Article  PubMed  Google Scholar 

  12. Hennessy S, Bilker WB, Berlin JA, Strom BL (1999) Factors influencing the optimal control-to-case ratio in matched case-control studies. Am J Epidemiol 149(2):195–197 (PMID: 9921965)

    Article  CAS  PubMed  Google Scholar 

  13. Clavien PA, Sanabria JR, Strasberg SM (1992) Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 111(5):518–526 (PMID: 1598671)

    CAS  PubMed  Google Scholar 

  14. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic Surgery (ISGPS) (2017) The 2016 update of the international study group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years After. Surgery 161(3):584–591. https://doi.org/10.1016/j.surg.2016.11.014 (Epub 2016 Dec 28. PMID: 28040257)

    Article  PubMed  Google Scholar 

  15. Rajarathinam G, Kannan DG, Vimalraj V, Amudhan A, Rajendran S, Jyotibasu D, Balachandar TG, Jeswanth S, Ravichandran P, Surendran R (2008) Post pancreaticoduodenectomy haemorrhage: outcome prediction based on new ISGPS clinical severity grading. HPB (Oxford) 10(5):363–370 (PMID: 18982153)

    Article  CAS  Google Scholar 

  16. Child CG (1944) Pancreaticojejunostomy and other problems associated with the surgical management of carcinoma involving the head of the pancreas: report of five additional cases of radical pancreaticoduodenectomy. Ann Surg 119:845–855 (PMID: 17858411)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Partelli S, Tamburrino D, Crippa S, Facci E, Zardini C, Falconi M (2014) Evaluation of a predictive model for pancreatic fistula based on amylase value in drains after pancreatic resection. Am J Surg 208(4):634–639 (Epub 2014 Jun 12 PMID: 25001423)

    Article  PubMed  Google Scholar 

  18. Lassen K, Marielle M, Coolsen E, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Kenneth C, Fearon H, Lobo DN, Demartines N, Braga M, Ljungqvist O, Cornelis H, Dejong C (2013) Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS_) society recommendations. World J Surg 37:240–258 (PMID: 22956014)

    Article  PubMed  Google Scholar 

  19. Partelli S, Pecorelli N, Muffatti F, Belfiori G, Crippa S, Piazzai F, Castoldi R, Marmorale C, Balzano G, Falconi M. Early postoperative prediction of clinically relevant pancreatic fistula after pancreaticoduodenectomy: usefulness of C - reactive protein. HPB (Oxford). 2017 https://doi.org/10.1016/j.hpb.2017.03.001. PMID: 28392159

  20. Partelli S, Crippa S, Castagnani R, Ruffo G, Marmorale C, Franconi AM et al (2016) Evaluation of an enhanced recovery protocol after pancreaticoduodenectomy in elderly patients. HPB 18:153–158 (PMID: 26902134)

    Article  CAS  PubMed  Google Scholar 

  21. Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V (2008) Fast-track recovery programme after pancreatico- duodenectomy reduces delayed gastric emptying. Br J Surg 95(11):1387–1393. https://doi.org/10.1002/bjs.6324

    Article  CAS  PubMed  Google Scholar 

  22. Iancu C, Mocan LC, Todea-Iancu D, Mocan T, Acalovschi I, Ionescu D, Zaharie FV, Osian G, Puia CI, Muntean V (2008) Host-related predictive factors for anastomotic leakage following large bowel resections for colorectal cancer. J Gastrointestin Liver Dis 17(3):299–303

    PubMed  Google Scholar 

  23. Park JS, Huh JW, Park YA, Cho YB, Yun SH, Kim HC, Lee WY (2016) Risk factors of anastomotic leakage and long-term survival after colorectal surgery. Medicine, 95(8). (PMID: 26937928)

  24. Deguchi Yasunori, Fukagawa Takeo, Morita Shinji, Ohashi Masaki, Saka Makoto, Katai Hitoshi (2012) Identification of risk factors for esophagojejunal anastomotic leakage after gastric surgery. World J Surg 36:1617–1622 (PMID: 22415758)

    Article  PubMed  Google Scholar 

  25. Alves A, Panis Y, Trancart D, Regimbeau J-M, Pocard M, Valleur P (2002) Factors associated with clinically significant anastomotic leakage after large bowel resection: multivariate analysis of 707 Patients. World J. Surg. 26(4). (PMID: 11910487)

  26. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED (2005) Early goal-directed therapy after major surgery reduces complications and duration of hospital stay A randomised, controlled trial. Crit Care 9(6):R687–R693 (Epub 2005 Nov 8. PMID: 16356219)

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Author notes

  1. Michele Mazza and Stefano Crippa contributed equally to the present study.

Authors and Affiliations

  1. San Raffaele Hospital, Pancreatic Surgery, Pancreas Translational and Clinical Research Center, 20132, Milan, Italy

    Michele Mazza, Stefano Crippa, Niccolò Pecorelli, Domenico Tamburino, Stefano Partelli, Renato Castoldi, Gianpaolo Balzano & Massimo Falconi

  2. Division of Pancreatic Surgery, University School of Medicine, Vita e Salute San Raffaele University, 20132, Milan, Italy

    Massimo Falconi

Authors
  1. Michele Mazza
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stefano Crippa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Niccolò Pecorelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Domenico Tamburino
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stefano Partelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Renato Castoldi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Gianpaolo Balzano
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Massimo Falconi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Massimo Falconi.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Research involving human participants and/or animals

Ethical approval from the Ethical Committee of institution is not required as it is a retrospective investigation. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki declaration of 1975, as revised in 2008.

Informed consent

Informed consent was obtained from all patients for being included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 15 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mazza, M., Crippa, S., Pecorelli, N. et al. Duodeno-jejunal or gastro-enteric leakage after pancreatic resection: a case–control study. Updates Surg 71, 295–303 (2019). https://doi.org/10.1007/s13304-019-00637-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13304-019-00637-0

Keywords

Search

Navigation