Objectives: The use of an external pancreatic duct stent to prevent fistula formation of pancreatic anastomosis remains a matter of debate. This study is a meta-analysis of the available evidence. Methods: Articles published until the end of March 2011 comparing external stenting and non-stenting in pancreatic anastomosis were included. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model. Results: Six articles were identified for inclusion: 3 randomized controlled trials and 3 observational clinical studies. The meta-analysis revealed that the use of an external pancreatic duct stent was associated with a statistically significant reduction in overall postoperative morbidity (OR 0.56; 95% CI 0.39–0.81; p = 0.002), pancreatic fistula (OR 0.34; 95% CI 0.23–0.15; p < 0.001), severity of pancreatic fistula (OR 0.70; 95% CI 0.32–1.57; p = 0.04), delayed gastric emptying (OR 0.44; 95% CI 0.25–0.80; p = 0.007), and length of hospital stay (WMD –3.95; 95% CI –6.38 to –1.52; p = 0.001). Conclusions: The current literature suggests that the use of an external pancreatic duct stent reduced the leakage rate of pancreatic anastomosis after pancreatic resection.

1.
Kleespies A, Albertsmeier M, Obeidat F, et al: The challenge of pancreatic anastomosis. Langenbecks Arch Surg 2008;393:459–471.
2.
Okamoto A, Tsuruta K: Fistulation method: simple and safe pancreaticojejunostomy after pancreatoduodenectomy. Surgery 2000;127:433–438.
3.
Ohwada S, Tanahashi Y, Ogawa T, et al: In situ vs. ex situ pancreatic duct stents of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy with billroth I-type reconstruction. Arch Surg 2002;137:1289–1293.
4.
Batignani G, Fratini G, Zuckermann M, et al: Comparison of Wirsung-jejunal duct-to-mucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int 2005;4:450–455.
5.
Hosotani R, Doi R, Imamura M: Duct-to-mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatoduodenectomy. World J Surg 2002;26:99–104.
6.
Maggiori L, Sauvanet A, Nagarajan G, et al: Binding versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a case-matched study. J Gastrointest Surg 2010;14:1395–1400.
7.
Bassi C, Falconi M, Molinari E, et al: Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg 2005;242:767–771.
8.
Sutton CD, Garcea G, White SA, et al: Isolated Roux-loop pancreaticojejunostomy: a series of 61 patients with zero postoperative pancreaticoenteric leaks. J Gastrointest Surg 2004;8:701–705.
9.
Maeda A, Ebata T, Kanemoto H, et al: Omental flap in pancreaticoduodenectomy for protection of splanchnic vessels. World J Surg 2005;29:1122–1126.
10.
Kawai M, Tani M, Terasawa H, et al: Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients. Ann Surg 2006;244:1–7.
11.
Hiraoka T, Kanemitsu K, Tsuji T, et al: A method for safe pancreaticojejunostomy. Am J Surg 1995;165:270–272.
12.
Matsumoto Y, Fujii H, Miura K, et al: Successful pancreatojejunal anastomosis for pancreatoduodenectomy. Surg Gynecol Obstet 1992;175:555–562.
13.
Hamanaka Y, Suzuki T: Total pancreatic duct drainage for leakproof pancreatojejunostomy. Surgery 1994;115:22–26.
14.
Howard JM: Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection. J Am Coll Surg 1997;184:454–457.
15.
Roder JD, Stein HJ, Böttcher KA, et al: Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy: a prospective study. Ann Surg 1999;229:41–48.
16.
Yoshimi F, Ono H, Asato Y, et al: Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy in patients undergoing pancreatoduodenectomy to promote earlier discharge from hospital. Surg Today 1996;26:665–667.
17.
Poon RT, Fan ST, Lo CM, et al: External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial. Ann Surg 2007;246:425–433.
18.
Kuroki T, Tajima Y, Kitasato A, et al: Stenting versus non-stenting in pancreaticojejunostomy: a prospective study limited to a normal pancreas without fibrosis sorted by using dynamic MRI. Pancreas 2011;40:25–29.
19.
Jadad AR, Moore RA, Carroll D, et al: Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17:1–12.
20.
McKay A, Mackenzie S, Sutherland FR, et al: Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy. Br J Surg 2006;93:929–936.
21.
Shibuya T, Uchiyama K, Imai S, et al: Improvement of pancreaticojejunostomy in pancreatoduodenectomy. Int Surg 1995;80:57–60.
22.
Kimura W: Pancreaticojejunal anastomosis, using a stent tube, in pancreaticoduodenectomy. J Hepatobiliary Pancreat Surg 2009;16:305–309.
23.
Prenzel KL, Hölscher AH, Grabolle I, et al: Impact of duct-to-mucosa pancreaticojejunostomy with external drainage of the pancreatic duct after pancreaticoduodenectomy. J Surg Res 2010, Epub ahead of print.
24.
Kamoda Y, Fujino Y, Matsumoto I, et al: Usefulness of performing a pancreaticojejunostomy with an internal stent after a pancreatoduodenectomy. Surg Today 2008;38:524–528.
25.
Tani M, Kawai M, Hirono S, et al: A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy. Am J Surg 2010;199:759–764.
26.
Imaizumi T, Hatori T, Tobita K, et al: Pancreaticojejunostomy using duct-to-mucosa anastomosis without a stenting tube. J Hepatobiliary Pancreat Surg 2006;13:194–201.
27.
Pessaux P, Sauvanet A, Mariette C, et al: External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg 2011;253:879–885.
28.
Sriussadaporn S, Pak-Art R, Sriussadaporn S, et al: Pancreaticoduodenectomy with external drainage of the pancreatic remnant. Asian J Surg 2008;31:167–173.
29.
Satoi S, Toyokawa H, Yanagimoto H, et al: Is a nonstented duct-to-mucosa anastomosis using the modified Kakita method a safe procedure? Pancreas 2010;39:165–170.
30.
Bassi C, Dervenis C, Butturini G, et al: Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8–13.
31.
Biehl T, Traverso LW: Is stenting necessary for a successful pancreatic anastomosis? Am J Surg 1992;163:530–532.
32.
Winter JM, Cameron JL, Campbell KA, et al: Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2006;10:1280–1290.
33.
Suzuki S, Kaji S, Koike N, et al: Pancreaticojejunostomy of duct to mucosa anastomosis can be performed more safely without than with a stenting tube. Am J Surg 2009;198:51–54.
34.
Smyrniotis V, Arkadopoulos N, Kyriazi MA, et al: Does internal stenting of the pancreaticojejunostomy improve outcomes after pancreatoduodenectomy? A prospective study. Langenbecks Arch Surg 2010;395:195–200.
35.
Park JS, Hwang HK, Kim JK, et al: Clinical validation and risk factors for delayed gastric emptying based on the International Study Group of Pancreatic Surgery (ISGPS) Classification. Surgery 2009;146:882–887.
36.
Malleo G, Crippa S, Butturini G, et al: Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB (Oxford) 2010;12:610–618.
37.
Poon RT, Fan ST: Decreasing the pancreatic leak rate after pancreaticoduodenectomy. Adv Surg 2008;42:33–48.
38.
MacLehose RR, Reeves BC, Harvey IM, et al: A systematic review of comparisons of effect sizes derived from randomised and non-randomised studies. Health Technol Assess 2000;4:1–154.
39.
Abulkhir A, Limongelli P, Healey AJ, et al: Preoperative portal vein embolization for major liver resection: a meta-analysis. Ann Surg 2008;247:49–57.
40.
Egger M, Davey Smith G, Schneider M, et al: Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629–634.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.