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Vater’s ampullary carcinoma increases the risk of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis

BMC Gastroenterology volume 22, Article number: 51 (2022) Cite this article

Abstract

Background

Postoperative pancreatic fistula (POPF) is a frequent complication after pancreaticoduodenectomy (PD). This study aimed to investigate the impact of Vater’s ampullary carcinoma (VAC) on clinically relevant POPF (CR-POPF) in patients undergoing PD.

Methods

Clinical data were gathered retrospectively from January 2018 to December 2020 for all patients undergoing PD. The univariate and multivariate analysis were used to identify independent risk factors of CR-POPF. A propensity score-matched (PSM) analysis at a ratio of 1:1 was performed to minimize bias from baseline characteristics between VAC and non-VAC groups. Main postoperative complications were compared between the two groups after PSM.

Results

In 263 patients, 94 (35.7%) patients were diagnosed as VAC. CR-POPF occurred in 99 (37.6%) patients and VAC was identified as an independent risk factor of CR-POPF in multivariate logistic regression analysis (OR = 0.548, 95% CI = 0.327–0.920, P = 0.023). After PSM, there were similar baseline characteristics between the VAC and non-VAC group. Moreover, VAC group had a higher rate of CR-POPF (P = 0.025) and intra-abdominal infection (P = 0.015) compared to the non-VAC group.

Conclusions

In patients undergoing PD, VAC increases the risk of CR-POPF and several other postoperative complications.

Peer Review reports

Background

Pancreaticoduodenectomy (PD) is a complex operation performed in various benign and malignant disease localized in the pancreatic head or periampullary region with high morbidity and mortality [1,2,3]. Clinically relevant postoperative pancreatic fistula (CR-POPF), which is the most frequent complication, sometimes triggers life-threatening complications, such as post-pancreatectomy hemorrhage (PPH), sepsis, and death. As reported previously, many factors affect the occurrence of CR-POPF, such as age, sex, body mass index (BMI), pancreatic texture, diameter of main pancreatic duct (MPD) [4,5,6]. Complication rate, especially of pancreatic fistula (PF) have differed greatly among pancreatic ductal adenocarcinoma (PDAC), distal cholangiocarcinoma (DCC), and Vater’s ampullary carcinoma (VAC) [7]. Several studies identified that underlying pathology type was significantly associated with the occurrence of CR-POPF as PDAC and chronic pancreatitis are always correlated with firm pancreatic texture and dilated MPD [8, 9]. However, few studies established that patients with VAC have a higher risk of postoperative complications especially CR-POPF.

In this study, we explore the risk factors of CR-POPF, analyze the incidence of postoperative complications after PD for patients with VAC and compare them with patients who underwent the same procedure for non-VAC.

Methods

Patients

Data were collected retrospectively for patients who had undergone PD between January 2018 and December 2020 in our center. The study was approved by the Health Research Ethics Board of Drum Tower Hospital of Nanjing University Medical School (2021–271-01). The inclusion criteria were as follows: (a)met the indication for PD; (b) no evidence of locoregional unresectable or other active cancers, and (c) > 18 years of age. The exclusion criteria were as follows: (a) undergone simultaneous hepatic or colon resection; (b) clinical data were incomplete, and (c) history of neoadjuvant chemotherapy. Patients’ demographics, preoperative laboratory tests, pathological result, and postoperative complications were all obtained.

Surgical procedures and perioperative management

All PDs were successfully performed using a standard surgical technique. A modified Child’s method was performed in the reconstruction of the digestive tract. Pancreaticojejunostomy (PJ) was performed with a manual duct-to-mucosal, end-to-side, and double-layer interrupted anastomosis method. According to the diameter of MPD, an internal unabsorbed Wirsung duct stent was placed. Hepaticojejunostomy and gastrojejunostomy were performed on the same jejunal loop. At the end of operation, two closed-suction peritoneal drainage tubes were routinely placed at the superior, inferior sides of PJ.

A standard perioperative management was performed in all patients. Preoperative biliary drainage (PBD) was conducted in the following situations: hyperbilirubinemia with a total bilirubin (TB) level ≥ 15 mg/dl (> 258 μmol/L), preoperative cholangitis occurred, poor nutritional status before operation when needed nutritional support [10]. Prophylactic antibiotics were intravenously administered for 3 days (the operation day and postoperative day 1 and 2).

Drain amylase concentration, bacterial smear, and culture were conducted on postoperative day (POD) 1,3,5,7 to detect pancreatic fistula and intra-abdominal infection. The peritoneal drainage tubes removed on POD 7 after the abdominal enhanced computed tomography (CT) conducted on POD 7 showed no evidences of CR-POPF or fluid collection were found.

Clinical data collection and definition of complication

Clinical data, including demographics (age, sex, hypertension, diabetic mellitus, BMI, preoperative jaundice, PBD), preoperative laboratory data (alanine aminotransferase, aspartate aminotransferase, alkaline phosphate, γ-glutamyl transferase, total bilirubin, direct bilirubin, albumin, white blood cell, hemoglobin, platelet), intraoperative variables (surgical method, vessel resection, operating time, volume of blood loss and transfusion, pancreatic texture and diameter of the main pancreatic duct), the fistula risk score (FRS) [11] and pathological diagnosis. Clavien–Dindo classification was applied for postoperative complications, with major complications defined as grade ≥ III [12]. CR-POPF (Grade B/ C), biliary leakage (BL), chylous fistula, delayed gastric emptying (DGE), and post-pancreatectomy hemorrhage (PPH) were diagnosed according to the International Study Group of Pancreatic Surgery (ISGPS) [13,14,15,16]. Wound infection, intra-abdominal infection, bacteremia, pneumonia, urinary tract infection were all included.

Statistical analysis

Clinical data was analyzed using SPSS 23.0 software for Windows (SPSS Inc.). Categorical variables were compared with 2 test or Fisher’s exact test, with absolute number and percentage expressed. Continuous variables were analyzed by independent t-test, with mean and standard deviation (SD) expressed when the data showed normal distribution. Mann–Whitney U test was applied and showed as median (interquartile range, IQR) when they were not normally distributed. Univariate and multivariate logistic regression analysis of CR-POPF were completed using all patients enrolled. All variables with P < 0.1 in univariate analysis entered the multivariate logistic regression model with a stepwise forward approach to find out the independent risk factors for CR-POPF. Odds ratio (OR) and 95% confidence intervals (95%CI) were obtained. P < 0.05 was considered as statistics significantly.

A 1:1 nearest-neighbor propensity score-matching (PSM) analysis was performed to compare VAC group and none-VAC group adjusting preoperative jaundice, preoperative biliary drainage, alanine aminotransferase, aspartate aminotransferase, alkaline phosphate, γ-glutamyl transferase, total bilirubin, direct bilirubin, albumin, hemoglobin, platelet, surgical method, vessel resection, pancreatic texture, pancreatic duct diameter, intraoperative of blood loss and fistula risk score. Caliper matching on propensity score was estimated, and pairs were matched to within a range of 0.2 standard deviation of the logistic model of the propensity score.

Results

Patient characteristics

In our study, 263 patients were included during the 2-year study period. They were classified into two groups as VAC group and non-VAC group according to the pathological result of the specimen. The clinicopathological variables of all patients were shown in Table 1. There were 94 (35.7%) patients diagnosed with VAC, 61 (23.2%) with pancreatic ductal carcinoma, 24 (9.1%) with distal cholangiocarcinoma, 45 with pancreatic cystic neoplasms (25 IPMN, 10 SCN, 4MCN and 6 SPN), 9 with pNET, 4 with chronic pancreatitis and 26 other types. Furthermore, there were 163 (62%) males and the mean age of the entire cohort was 61.5 ± 12.1 years. Before surgery, levels of total bilirubin (TB) and direct bilirubin (DB) were 16.0 (9.2–58.6) μmol/L and 6.5 (2.3–45.2) μmol/L, respectively. A total of 103 (39.2%) were diagnosed with preoperative jaundice and 77 (29.3%) performed PBD. 99 (37.6%) patients developed CR-POPF, 106 (40.3%) patients underwent intra-abdominal infection, and 57 (21.7%) patients developed major complications (Calvin-Dindo grade ≥  III).

Table 1 Clinical characteristic of all patients
Full size table

Risk factors for CR-POPF

In univariate analysis, age (OR = 1.031, 95% CI = 1.003–1.060, P = 0.030), pathology (VAC vs. non-VAC) (OR = 2.423, 95% CI = 1.223–4.800, P = 0.011), and surgical method (PD vs. PPPD) (OR = 0.496, 95% CI = 0.253–0.973, P = 0.041) were significantly associated with CR-POPF. In multivariate analysis, only pathology (VAC vs. non-VAC) (OR = 1.824, 95% CI = 1.087–3.060 P = 0.023) was the independent risk factor of CR-POPF (Table 2).

Table 2 Risk factors of CR-POPF: Univariate and multivariate logistic regression analysis
Full size table

Propensity score-matched analysis

As shown in Table 3, patients diagnosed VAC had higher level of platelet and FRS, lower level of hemoglobin and albumin and smaller main pancreatic duct dimeter. At the same time, patients in the VAC group had higher level of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphate (AKP), γ-glutamyl transferase(γ-GGT), total bilirubin (TB), and direct bilirubin (DB), indicated these patients may have worse liver function. Furthermore, the rate of preoperative jaundice, biliary drainage and pancreatic texture showed statistical difference.

Table 3 Baseline characteristics in the unmatched and matched group according to the pathological diagnosis
Full size table

In order to adjust the differences of baseline variables in each group, a 1:1 nearest-neighbor propensity score matching (PSM) analysis was conducted. After PSM, a balanced cohort included the VAC group as observational group (59 patients) and the non-VAC group as the control group (59 patients). All baseline characteristics were comparable after PSM.

Postoperative complications

After PSM, CR-POPF occurred in 28 (47.5) patients in the VAC group and 16 (27.1%) patients in the non-VAC group (P = 0.025; Table 4). Both before and after PSM, the intra-abdominal infection occurred more frequently in the VAC group significantly. While major postoperative complication rates had a higher tendency in patients diagnosed with VAC before PSM, the differences were not statistically significant both before and after PSM. Furthermore, the rates of biliary leakage, chylous fistula, delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), wound infections, bacteremia, pneumonia, and urinary tract infection were comparable between the two groups.

Table 4 Postoperative mortality and morbidity according to the pathological diagnosis
Full size table

Discussion

In our study, the rate of CR-POPF, major postoperative complication were 37.6% and 21.7%, respectively, and consistent with previous studies [17,18,19,20,21,22]. We also identified that pathology diagnose (VAC vs. non-VAC) was the independent risk factor for CR-POPF. Furthermore, in order to reduce the bias of baseline variables between two groups, we performed an additional analysis by propensity score-matching (PSM). The occurrence of CR-POPF and intra-abdominal infection between the two groups showed statistically difference both before and after PSM.

The most hazardous postoperative complication of PD is CR-POPF, which is the greatest contributor to postoperative morbidity and mortality after PD as reported previously [23,24,25]. Numerous independent risk factors of CR-POPF now are identified. These include “patient-related factors” such as age, BMI, and hemoglobin, “pancreatic factors” such as pancreatic texture and diameter of MPD, “surgical factors” such as intraoperative blood lose and vessel resection [10, 26, 27]. In previous studies, pancreatic ductal adenocarcinoma was a protective factor of the development of CR-POPF [11, 28]. However, the impact of Vater’s ampullary carcinoma on postoperative complications, especially CR-POPF has yet to be adequately researched.

In the univariate analysis of our study, VAC patients were more likely to have an increased rate of preoperative jaundice and preoperative biliary drainage. Moreover, the preoperative serum level of transaminase and bilirubin, signs of liver function, were statistically higher in the VAC group. Patients with VAC had significantly higher CR-POPF rate compared with patients with other diseases (46.8% vs. 32.5%, P = 0.022). On one hand, jaundice or high level of preoperative serum bilirubin may lead to high levels of serum proinflammatory cytokines and endotoxin, which have been proved in several animal models [29, 30]. On the other hand, intestinal mucosal barrier function was interfered by obstructive jaundice, which accelerates bacterial translocation [31, 32]. At the same time, impaired hepatocellular function, leads to insufficient protein synthesis, and lower hemoglobin level delayed healing of wound especially the pancreatojejunostomy that threaten patients’ recovery [33,34,35]. Part of patients’ primary complaint is gastrointestinal bleed and melena because part of the lesions of ampullary cancer showed ulcerative type. That may explain why patients in the VAC-group had significantly lower hemoglobin level than the patients in non-VAC group in our study. At the same time, the ulcerative type of VAC and anemia may result in translocation and invasion of intestinal bacteria, which lead to the development of CR-POPF and increase the susceptibility to infections [9, 33].

Numerous studies, including prospective studies and random controlled trails, have been performed for the negative impact of PBD on surgical outcomes. Most studies among them demonstrated that biliary drainage increased the rate of postoperative complications including CR-POPF [36,37,38,39]. A high-quality RCT article identified that PBD increase the risk of postoperative complication for cancer of the pancreatic head [40].

PSM was conducted to further analyze the postoperative outcomes in VAC group and non-VAC group, higher CR-POPF, PPH, intra-abdominal infection rates were observed in VAC patients both before and after accounting for other variables. Another mechanism by which VAC increase the risk of CR-POPF may relate to the effect of softer pancreas texture. Periampullary lesions except PDAC and chronic pancreatitis always do not cause fibrotic reactions. As a result, performing pancreatojejunostomy after the resection of VAC is expected to be more challenging induced by the soft pancreatic texture, which increase the risk of anastomotic leakage. Kawai et al. identified that a soft pancreas was a significant risk factor of CR-POPF from 11 Japanese medical centers [41]. Callery et al. [11] conducted a validated pancreatic fistula risk score and four risk factors are identified including excessive blood lose, softer pancreatic gland, smaller pancreatic duct and high-risk pathologies such as duodenal and ampullary tumors. These results were in line with our studies.

As our best knowledge, the present study is the first retrospective cohort focused on the impact of pathology VAC about the postoperative complications especially CR-POPF. Although selection bias cannot be totally eliminated, we performed PSM to adjust the baseline variables and reduce the bias. After PSM, postoperative complications can be compared between the two groups. The result of our studies demonstrated that VAC increases the development of CR-POPF, PPH and intra-abdominal infection. Although it is difficult to evaluate the texture of pancreas before surgery accurately, the possibility of CR-POPF even postoperative complications could be assessed by guessing the pathology through preoperative CT or endoscopic biopsy.

The present study has some limitations. First, it was a retrospective study with a selection and historical background bias. Second, the study was a small study from a single center, to validate the impact of pathology VAC on CR-POPF even postoperative complications, future randomize controlled trails are indispensable.

Conclusions

VAC was an independent risk factor of CR-POPF after PD. At the same time, the VAC patients experience a higher rate of PPH and intra-abdominal infection even after PSM. Therefore, these observations strongly support a cautious evaluation before PD and better perioperative management for patients diagnosed VAC.

Availability of data and materials

All data generated or analyzed during this study are available from the corresponding author on reasonable request.

Abbreviations

PD:

Pancreaticoduodenectomy

CR-POPF:

Clinically relevant postoperative pancreatic fistula

PPH:

Post-pancreatectomy hemorrhage

MPD:

Main pancreatic duct

PF:

Pancreatic fistula

PDAC:

Pancreatic ductal adenocarcinoma

DCC:

Distal cholangiocarcinoma

VAC:

Vater’s ampullary carcinoma

PBD:

Preoperative biliary drainage

TB:

Total bilirubin

POD:

Postoperative day

DGE:

Delayed gastric emptying

ISGPS:

The International Study Group of Pancreatic Surgery

OR:

Odds ratio

CI:

Confidence intervals

PSM:

Propensity score-matching

References

  1. McMillan MT, Allegrini V, Asbun HJ, et al. Incorporation of procedure-specific risk into the ACS-NSQIP surgical risk calculator improves the prediction of morbidity and mortality after pancreatoduodenectomy. Ann Surg. 2017;265(5):978–86.

    Article  Google Scholar 

  2. de Wilde RF, Besselink MG, van der Tweel I, de Hingh IH, van Eijck CH, Dejong CH, et al. Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg. 2012;99:404–10.

    Article  Google Scholar 

  3. Pugalenthi A, Protic M, Gonen M, Kingham TP, Angelica MI, Dematteo RP, et al. Postoperative complications and overall survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. J Surg Oncol. 2016;113:188–93.

    Article  Google Scholar 

  4. Roberts KJ, Sutcliffe RP, Marudanayagam R, Hodson J, Isaac J, Muiesan P, et al. Scoring system to predict pancreatic fistula after pancreaticoduodenectomy: A UK multicenter study. Ann Surg. 2015;261:1191–7.

    Article  Google Scholar 

  5. Partelli S, Tamburrino D, Cherif R, Muffatti F, Moggia E, Gaujoux S, et al. Risk and predictors of postoperative morbidity and mortality after pancreaticoduodenectomy for pancreatic neuroendocrine neoplasms: a comparative study with pancreatic ductal adenocarcinoma. Pancreas. 2019;48:504–9.

    Article  Google Scholar 

  6. Hu BY, Wan T, Zhang WZ, Dong JH. Risk factors for postoperative pancreatic fistula: analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol. 2016;22:7797–805.

    Article  Google Scholar 

  7. Andrianello S, Paiella S, Allegrini V, Ramera M, Pulvirenti A, Malleo G, et al. Pancreaticoduodenectomy for distal cholangiocarcinoma: surgical results, prognostic factors, and long-term follow-up. Langenbecks Arch Surg. 2015;400:623–8.

    Article  Google Scholar 

  8. Halle-Smith JM, Vinuela E, Brown RM, Hodson J, Zia Z, Bramhall SR, et al. A comparative study of risk factors for pancreatic fistula after pancreatoduodenectomy or distal pancreatectomy. HPB (Oxford). 2017;19:727–34.

    Article  Google Scholar 

  9. Søreide K, Healey AJ, Mole DJ, Parks RW. Pre-, peri- and post-operative factors for the development of pancreatic fistula after pancreatic surgery. HPB (Oxford). 2019;21:1621–31.

    Article  Google Scholar 

  10. Sewnath ME, Birjmohun RS, Rauws EA, Huibregtse K, Obertop H, Gouma DJ. The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy. J Am Coll Surg. 2001;192:726–34.

    Article  CAS  Google Scholar 

  11. Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013;216:1–14.

    Article  Google Scholar 

  12. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.

    Article  Google Scholar 

  13. Besselink MG, van Rijssen LB, Bassi C, Dervenis C, Montorsi M, Adham M, et al. Definition and classification of chyle leak after pancreatic operation: a consensus statement by the International Study Group on Pancreatic Surgery. Surgery. 2017;161:365–72.

    Article  Google Scholar 

  14. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142:761–8.

    Article  Google Scholar 

  15. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161:584–91.

    Article  Google Scholar 

  16. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142:20–5.

    Article  Google Scholar 

  17. Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, et al. Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg. 2010;252:207–14.

    Article  Google Scholar 

  18. Kawai M, Tani M, Terasawa H, Ina S, Hirono S, Nishioka R, 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.

    Article  Google Scholar 

  19. Kimura W, Miyata H, Gotoh M, Hirai I, Kenjo A, Kitagawa Y, et al. A pancreaticoduodenectomy risk model derived from 8575 cases from a national single-race population (Japanese) using a web-based data entry system: the 30-day and in-hospital mortality rates for pancreaticoduodenectomy. Ann Surg. 2014;259:773–80.

    Article  Google Scholar 

  20. Sánchez-Velázquez P, Muller X, Malleo G, Park JS, Hwang HK, Napoli N, et al. Benchmarks in pancreatic surgery: a novel tool for unbiased outcome comparisons. Ann Surg. 2019;270:211–8.

    Article  Google Scholar 

  21. Karim S, Abdulla KS, Abdulkarim QH, Rahim FH. The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study. Int J Surg. 2018;52:383–7.

    Article  Google Scholar 

  22. Cameron JL, He J. Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg. 2015;220:530–6.

    Article  Google Scholar 

  23. McMillan MT, Christein JD, Callery MP, Behrman SW, Drebin JA, Hollis RH, et al. Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy. Surgery. 2016;159:1013–22.

    Article  Google Scholar 

  24. Vollmer CM Jr, Lewis RS, Hall BL, Allendorf JD, Beane JD, Behrman SW, et al. Establishing a quantitative benchmark for morbidity in pancreatoduodenectomy using ACS-NSQIP, the Accordion Severity Grading System, and the Postoperative Morbidity Index. Ann Surg. 2015;261:527–36.

    Article  Google Scholar 

  25. McMillan MT, Vollmer CM Jr. Predictive factors for pancreatic fistula following pancreatectomy. Langenbecks Arch Surg. 2014;399:811–24.

    Article  Google Scholar 

  26. Mungroop TH, Klompmaker S, Wellner UF, Steyerberg EW, Coratti A, D et al. (2021) Updated Alternative Fistula Risk Score (ua-FRS) to include minimally invasive pancreatoduodenectomy: Pan-European validation. Ann Surg 273:334–340.

  27. Peng C, Zhou D, Meng L, Cao Y, Zhang H, Pan Z, et al. The value of combined vein resection in pancreaticoduodenectomy for pancreatic head carcinoma: a meta-analysis. BMC Surg. 2019;19:84.

    Article  Google Scholar 

  28. Chen JS, Liu G, Li TR, Chen JY, Xu QM, Guo YZ, et al. Pancreatic fistula after pancreaticoduodenectomy: Risk factors and preventive strategies. J Cancer Res Ther. 2019;15:857–63.

    Article  Google Scholar 

  29. Bateman RM, Sharpe MD, Jagger JE, Ellis CG, Solé-Violán J, López-Rodríguez M et al. (2016) 36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15–18 March 2016. Crit Care 20:94.

  30. Ljungdahl M, Osterberg J, Ransjö U, Engstrand L, Haglund U. Inflammatory response in patients with malignant obstructive jaundice. Scand J Gastroenterol. 2007;42:94–102.

    Article  Google Scholar 

  31. van der Gaag NA, Kloek JJ, de Castro SM, Busch OR, van Gulik TM, Gouma DJ. Preoperative biliary drainage in patients with obstructive jaundice: history and current status. J Gastrointest Surg. 2009;13:814–20.

    Article  Google Scholar 

  32. Pavlidis ET, Pavlidis TE. Pathophysiological consequences of obstructive jaundice and perioperative management. Hepatobiliary Pancreat Dis Int. 2018;17:17–21.

    Article  Google Scholar 

  33. Sakamoto K, Ogawa K, Inoue H, Shine M, Matsui T, Nishi Y, et al. Significant association between the preoperative erythrocyte mean corpuscular volume and infectious complications after pancreaticoduodenectomy. Surg Today. 2021;51:258–67.

    Article  CAS  Google Scholar 

  34. Sert OZ, Berkesoglu M, Canbaz H, Olmez A, Tasdelen B, Dirlik MM. The factors of pancreatic fistula development in patients who underwent classical pancreaticoduodenectomy. Ann Ital Chir. 2021;92:35–40.

    PubMed  Google Scholar 

  35. Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of Vater. Ann Surg. 1935;102:763–79.

    Article  CAS  Google Scholar 

  36. Lee PJ, Podugu A, Wu D, Lee AC, Stevens T, Windsor JA. Preoperative biliary drainage in resectable pancreatic cancer: a systematic review and network meta-analysis. HPB (Oxford). 2018;20:477–86.

    Article  Google Scholar 

  37. Scheufele F, Schorn S, Demir IE, Sargut M, Tieftrunk E, Calavrezos L, et al. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature. Surgery. 2017;161:939–50.

    Article  Google Scholar 

  38. van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010;362:129–37.

    Article  Google Scholar 

  39. Shaib Y, Rahal MA, Rammal MO, Mailhac A, Tamim H. Preoperative biliary drainage for malignant biliary obstruction: results from a national database. J Hepatobiliary Pancreat Sci. 2017;24:637–42.

    Article  Google Scholar 

  40. Eshuis WJ, van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, Kuipers EJ, et al. Therapeutic delay and survival after surgery for cancer of the pancreatic head with or without preoperative biliary drainage. Ann Surg. 2010;252:840–9.

    Article  Google Scholar 

  41. Kawai M, Kondo S, Yamaue H, Wada K, Sano K, Motoi F, et al. Predictive risk factors for clinically relevant pancreatic fistula analyzed in 1,239 patients with pancreaticoduodenectomy: multicenter data collection as a project study of pancreatic surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. J Hepatobiliary Pancreat Sci. 2011;18:601–8.

    Article  Google Scholar 

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Acknowledgements

We would like to offer our special thanks to members of the multidisciplinary biliopancreatic cancer team of the Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School for their guidance

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Author notes

  1. Yifei Yang and Xu Fu have contributed equally to this work

Authors and Affiliations

  1. Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China

    Yifei Yang, Xu Fu, Saisai Zhu, Zhenghua Cai, Yudong Qiu & Liang Mao

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Contributions

Study concept and design: LM, YQ; Data acquisition: YY, ZC, SZ; Data analysis and interpretation: YY, XF; Drafting of the manuscript: YY, XF; Critical revision of the manuscript for important intellectual content: LM; Statistical analysis: YY; Final approval of manuscript: all authors. All authors read and approved the final manuscript.

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Correspondence to Liang Mao.

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All methods were carried out in accordance with the Declaration of Helsinki. The study was approved by the Health Research Ethics Board of Drum Tower Hospital of Nanjing University Medical School (2021–271-01), and written informed consent was obtained from all the patients included in the study.

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All authors declare that they have no competing interests.

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Yang, Y., Fu, X., Zhu, S. et al. Vater’s ampullary carcinoma increases the risk of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. BMC Gastroenterol 22, 51 (2022). https://doi.org/10.1186/s12876-022-02128-w

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BMC Gastroenterology

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