Comparison of three reconstruction techniques performed after pancreaticoduodenectomy: Using external, internal, or no stent

Table 1 The preoperative characteristics of patients in the three groups who underwent pancreaticoduodenectomy, n (%)

Characteristics	EDS group (n = 129)	IDS group (n = 71)	NDS group (n = 44)	P value
Age, years	68 (45-86)	64 (17-85)	66 (16-89)	0.091
Sex, male/female	65/64 (50.4/ 49.6)	43/28 (60.6/39.4)	24/20 (54.5/45.5)	0.384
ASA score				0.652
I-II	62 (48.1)	38 (53.6)	22 (50)
III-IV	67 (51.9)	33 (46.4)	22 (50)
Body mass index, kg/m2	24.6 (16-41)	25.2 (14-43.3)	24.5 (18-36.3)	0.760
Comorbidities
Cardiovascular	68 (52.7)	32 (45.1)	22 (50)	0.124
Hypertension	59 (45.7)	31 (43.7)	16 (36.4)	0.556
Smoker	28 (21.7)	17 (23.9)	8 (18.2)	0.887
Diabetes	27 (20.9)	23 (32.4)	14 (31.8)	0.109
Pulmonary	24 (18.6)	18 (25.3)	8 (18.2)	0.096
Tumor	19 (14.7)	9 (12.7)	8 (18.2)	0.549
Alcohol use	18 (14)	10 (14.1)	4 (9.1)	0.886
Neoadjuvant chemotherapy	19 (14.7)	7 (9.9)	2 (4.5)	0.165
Clinical
Jaundice	84 (65.1)	42 (59.2)	24 (54.5)	0.412
Weight loss	72 (55.8)
Abdominal pain	62 (48.1)	25 (35.2)	18 (40.9)	0.204
Cholangitis	24 (18.6)	13 (18.3)	8 (18.2)	0.997
Preoperative pancreatitis	10 (7.8)	6 (8.5)	12 (27.3)	0.001
Duodenal obstruction	9 (7)	4 (5.6)	0 (0)	0.203
Upper gastrointestinal bleeding	8 (6.2)	3 (4.2)	2 (4.5)	0.811
Diagnostic examinations/findings
CT scan	126 (97.7)	69 (97.2)	43 (97.7)	0.973
MRI	91 (70.5)	53 (74.6)	30 (68.2)	0.728
Endoscopic ultrasound	73 (56.6)	49 (69)	27 (61.4)	0.226
ERCP	64 (49.6)	38 (53.5)	23 (52.3)	0.886
PTHC	19 (14.7)	8 (11.3)	3 (6.8)	0.368
Tumor size, cm	2.2 (0.1-6)	2.1 (0.2-7.1)	2 (0.2-5.5)	0.653
Bile duct size, cm	1.2 (0.3-2.5)	1.2 (0.2-2.4)	1 (0.2-3.1)	0.303
Preoperative biliary stent				0.127
No stent	78 (60.5)	37 (52.1)	23 (52.3)
Stent	51 (39.5)	34 (47.9)	21 (47.7)
Laboratory findings
Hemoglobin, g/dL	13.1 (9.1-17.2)	12.6 (10-16)	13 (11.2-16)	0.401
Platelet count, × 103	238 (59-431)	236 (130-487)	227 (80-390)	0.103
INR	1 (0.7-1.34)	1.02 (0.89-1.26)	1 (0.87-1.47)	0.664
Creatinine, mg/dL	0.78 (0.38-1.62)	0.76 (0.52-2.48)	0.77 (0.53-2.15)	0.379
Glycemia, mg/dL	105 (56-304)	92 (77-107)	120 (76-267)	0.401
Bilirubin, mg/dL	2.7 (0.2-26)	1.2 (0.2-2.4)	4.2 (0.2-28.9)	0.475
GOT, IU/L	60 (14-571)	63 (17-372)	79 (12-1140)	0.658
GPT, IU/L	226 (10-2246)	281 (9-1877)	228 (8-1407)	0.877
GGT, IU/L	76 (13-584)	117 (13-933)	89 (9-1682)	0.554
Alkaline phosphatase, U/L	274 (39-2262)	191 (42-1378)	359 (31-1441)	0.799
CA19-9, U/mL	75.4 (3-13950)	28.1 (21-950)	16.5 (10-1052)	0.004
CEA, ng/mL	2.7 (0.1-831)	0.53 (0-33.7)	2.8 (0.7-48)	0.313
Cytology	23 (17.8)	10 (14.1)	5 (11.4)	0.545

EDS: External duct stent; IDS: Internal duct stent; NDS: Non-ductal stent; ASA: American Society of Anesthesiologists; CA: Carbohydrate antigen; CEA: Carcinoembryonic antigen; CT: Computed tomography; ERCP: Endoscopic retrograde cholangiopancreatography; GGT: Gamma-glutamyl transferase; GOT: Glutamic oxaloacetic transaminase; GPT: Glutamic pyruvic transaminase; INR: International normalized ratio; MRI: Magnetic resonance imaging; PTHC: Percutaneous transparietohepatic cholangiography.

Table 2 Perioperative variables and histological features among the three groups, n (%)

Variable/feature	EDS group (n = 129)	IDS group (n = 71)	NDS group (n = 44)	P value
Duration of surgery, minutes	370 (190-590)	430 (300-748)	415 (240-710)	0.001
Patient transfused	14 (10.6)	19 (26.8)	6 (13.6)	0.036
Surgical findings/techniques
Caliber of Wirsung duct, mm	3.5 (1-13)	3 (2-10)	5 (1-17)	0.001
Consistency of the pancreas				< 0.001
Hard	60 (46.5)	20 (28.2)	31 (70.5)
Soft	38 (29.5)	16 (22.5)	5 (11.4)
Normal	31 (24)	35 (49.3)	8 (18.1)
Pylorus preservation	55 (42.6)	41 (57.7)	26 (59.1)	0.051
Vascular resection	12 (9.3)	6 (8.5)	5 (11.4)	0.872
Type of reconstruction				0.119
One intestinal loop	99 (76.7)	64 (90.1)	37 (86)
Two intestinal loops	30 (23.3)	7 (9.9)	6 (14)
Histological features
Type of tumor				0.558
Adenocarcinoma	89 (68.9)	50 (70.4)	29 (65.9)
Cholangiocarcinoma	10 (7.7)	4 (5.6)	3 (6.8)
Neuroendocrine	6 (4.6)	4 (5.6)	4 (9.1)
Other	24 (18.6)	13 (18.3)	8 (18.2)
Degree of differentiation				0.991
Good	32 (24.8)	17 (23.9)	11 (25)
Moderate	45 (34.9)	30 (42.3)	20 (45.5)
Poor	19 (14.7)	12 (16.9)	7 (15.9)
Not valuable	33 (25.6)	12 (16.9)	6 (13.6)
Tumor invasion				0.339
In situ	2 (1.5)	1 (1.4)	2 (4.5)
< 2 cm	20 (15.5)	14 (19.7)	10 (22.7)
> 2 cm, limited to pancreas	36 (27.9)	28 (39.4)	10 (22.7)
Peripancreatic invasion	44 (34.1)	20 (18.2)	17 (38.6)
Invasion at CA or SMA	6 (4.6)	1 (1.4)	0 (0)
Lymph node invasion	71 (55)	38 (53.5)	25 (56.8)	0.938
Number of resected nodes	15 (11-38)	15 (10-53)	13 (8-78)	0.602
Number of positive nodes	1 (0-11)	1 (0-14)	1.5 (0-8)	0.707
Macrovascular invasion	18 (13.9)	12 (16.9)	8 (18.2)	0.961
Microvascular invasion	48 (37.2)	27 (38)	16 (36.4)	0.961
Neural invasion	61 (47.3)	35 (49.3)	16 (36.4)	0.228
R0 resection	84 (65.1)	48 (67.6)	24 (54.5)	0.361
Tumor staging
IA	7 (6.7)	8 (13.1)	4 (10.3)
IB	8 (7.6)	11 (18)	0 (0)
IIA	11 (10.5)	5 (8.2)	7 (17.9)
IIB	41 (39)	15 (24.6)	17 (43.6)
III	15 (14.3)	11 (18)	3 (7.7)
IV	4 (3.8)	2 (3.3)	2 (5.1)

EDS: External duct stent; IDS: Internal duct stent; NDS: Non-ductal stent; CA: Celiac artery; SMA: Superior mesenteric artery.

Table 3 Postoperative morbimortality among the three groups, n (%)

	EDS group (n = 129)	IDS group (n = 71)	NDS group (n = 44)	P value
C-reactive protein, mg/dL, 3rd day	14.6 (0.1-39)	20.4 (2-57)	10.3 (0.6-33.6)	0.054
Medical complications	39 (30.3)	24 (33.8)	17 (38.6)	0.307
Surgical complications
Wound infection	20 (15.5)	12 (16.9)	4 (9.3)	0.515
Postoperative pancreatic fistula				0.009
Grade A/non-POPF	108 (83.7)	50 (70.5)	36 (81.8)
Grade B	19 (14.7)	11 (15.5)	4 (9.1)
Grade C	2 (1.6)	10 (14.1)	4 (9.1)
Delayed gastric emptying				0.195
Grade A	20 (15.5)	12 (16.9)	10 (22.7)
Grade B	20 (15.5)	19 (26.8)	6 (13.6)
Grade C	7 (5.4)	4 (5.6)	0 (0)
No delayed gastric emptying	82 (63.6)	36 (50.7)	28 (63.6)
Postoperative hemorrhage				0.460
Grade A	6 (4.7)	4 (5.6)	2 (4.5)
Grade B	7 (5.4)	3 (4.2)	4 (9.1)
Grade C	3 (2.3)	5 (7)	4 (9.1)
No postoperative hemorrhage	113 (87.6)	59 (83.1)	34 (77.3)
Reoperations	16 (12.4)	14 (19.7)	9 (20.5)	0.063
Hemoperitoneum	3 (2.3)	4 (5.6)	4 (9.1)
Pancreatic fistula	2 (1.6)	10 (14.1)	4 (9.1)
Jejunostomy	3 (2.3)	0 (0)	0 (0)
Other	8 (6.2)	0 (0)	1 (2.3)
Complications, Clavien-Dindo classification
Grade I-II	74 (57.3)	18 (40.9)	25 (35.2)	0.007
Grade III-IV	26 (20.1)	13 (29.5)	23 (32.5)	0.149
Intensive care unit stay, days	2 (1-15)	2 (1-30)	2 (1-30)	0.157
Hospital stay, days	17 (5-78)	20 (7-97)	18 (5-59)	0.089
Follow-up
Mortality, 90 days	2 (1.6)	4 (5.6)	2 (4.5)	0.046
Morbidity, 90 days	90 (70.3)	42 (59.1)	30 (73.2)	0.436
De novo endocrine insufficiency	16 (12.4)	15 (21.1)	6 (13.6)	0.293
De novo exocrine insufficiency	53 (41.1)	30 (42.3)	19 (43.2)	0.217
Venous thrombosis	4 (3.1)	5 (7)	3 (6.8)	0.142
Pulmonary embolism	4 (3.1)	2 (2.8)	0 (0)	0.204
Adjuvant chemotherapy	62 (48)	34 (47.9)	22 (50)	0.975

EDS: External duct stent; IDS: Internal duct stent; NDS: Non-ductal stent; POPF: Postoperative pancreatic fistula.

Table 4 Results of the logistic binary regression for postoperative pancreatic fistula of grades B/C after pancreaticoduodenectomy

Factor	Odds ratio	P value	95% confidence interval
External duct stent	0.466	0.034	0.231-0.943
Age > 80 years	0.530	0.349	0.140-2.001
ASA III/IV	1.404	0.345	0.695-2.838
Preoperative pancreatitis	1.461	0.529	0.449-4.757
Wirsung duct < 3 mm	3.794	0.001	1.761-8.173
Preoperative biliary drainage	0.924	0.827	0.453-1.883
Soft consistency of pancreas	1.057	0.803	0.683-1.637

ASA: American Society of Anesthesiologists.

Table 5 Results of the logistic binary regression for 90-day mortality after pancreaticoduodenectomy

Factor	Odds ratio	P value	95% confidence interval
External duct stent	0.289	0.018	0.019-0.670
Age > 80 years	1.420	0.760	0.150-13.479
ASA III/IV	0.569	0.404	0.152-2.142
Preoperative pancreatitis	0.532	0.583	0.056-5.052
Wirsung duct < 3 mm	4.223	0.031	1.122-15.252
Preoperative biliary stent	0.615	0.463	0.168-2.253
Soft consistency of pancreas	1.320	0.517	0.565-3.104

ASA: American Society of Anesthesiologists.