The Application Of External Pancreatic Duct Stents In Pancreaticoduodenectomy

Objective:There is no specific evidence regarding the benefits of external and internal pancreatic duct stents after pancreaticoduodenectomy since pancreatic fistula(grade A)have been redefined with no clinical treatment effect.We aimed to re-evaluate the prognostic value of external and internal stents by retrospective study and meta-analysis with regard to the incidence of clinically relevant postoperative pancreatic fistula.Methods:1.A total of 382 patients underwent pancreaticoduodenectomy with duct to mucosa pancreaticojejunostomy were enrolled from January 2015 to October 2019,retrospectively.The receiver operating characteristic curve was performed for subgroup analysis in patients with different risk levels of pancreatic fistula.2.Pub Med,Web of Science,EMBASE and the Cochrane Database were specifically searched for pertinent and original articles published before May 2019.The project has been registered in PROSPERO(Registration number: CRD42019137579).Results:1.There were no significant differences in term of pancreatic fistula or other postoperative complications.Then,according to the receiver operating characteristic curve threshold of 3.5,172 patients with fistula risk score ≥ 4 and 210 patients with fistula risk score < 4 were separated.The number of valid cases was not enough to support the subsequent research in patients with fistula risk score < 4.In patients with fistula risk score ≥ 4,the use of external pancreatic duct stent exerted significant preventive actions than internal stent,especially pancreatic fistula(Grade C)(P = 0.039),to ameliorate the incidence of clinically relevant postoperative pancreatic fistula(P = 0.019).The incidence of lymphatic leakage was significantly higher in the external stent group compared with internal stent group(P = 0.040).2.Four randomized controlled trials and six nonrandomized controlled trials with a total of 2101 patients were enrolled in this meta-analysis.The use of an external stent resulted in better performance than the use of an internal stent in terms of pancreatic fistula(grade C)(OR 0.58,P = 0.03)but did not reduce the rate of pancreatic fistula(grade B)(OR 0.99,P = 0.94)in all studies.The meta-analysis of randomized controlled trials found that the use of an external stent approached a level of significance for an increased rate of clinically relevant postoperative pancreatic fistula compared to the use of an internal stent(OR 1.40,P = 0.10)but had no significant effect on pancreatic fistula(grade B)(OR 1.34,P = 0.26)or pancreatic fistula(grade C)(OR 1.68,P = 0.62).Conclusion:1.The use of external stent could reduce the incidence of clinically relevant postoperative pancreatic fistula in patients with fistula risk score ≥ 4,but the incidence of lymphatic leakage would be increased.2.Compared with internal stents,the use of external stent might be associated with a lower rate of pancreatic fistula(grade C).More randomized clinical trials are warranted to further explore safety and efficacy of pancreatic duct external stents.