Pancreatic Fistula
Conditions
Brief summary
This is a multicenter, investigator initiated, prospective, superiority, parallel-group, randomized, double-blinded trial that aims to compare the efficacy and safety of trans-drain occlusion followed by gradual withdrawal of drain versus gradual withdrawal of drain alone for postoperative pancreatic fistula (POPF) that persists for longer than 21 days.
Detailed description
The most common major complication after pancreatic resection is postoperative pancreatic fistula (POPF), which is defined as a drain output of any measurable volume of fluid on and after postoperative day 3 with an amylase content \> 3 times the upper limit of normal serum level. Gradual withdrawal of surgically placed drains in patients who are clinically stable and tolerate a diet is generally adopted to hasten closure of POPF. For high-output fistulas (\> 150-200 mL of amylase-rich fluid per day), patients are initially managed with fasting and enteral or parenteral nutrition. If fistula output decreases substantially with these measures and the patient remains clinically well, drain withdrawal is initiated and oral intake is slowly restarted. If the patient remains well despite high fistula output, drains are slowly withdrawn in an attempt to decrease the output and close the fistula. When the output decrease to less than 10 mL per day, the drains are removed. However, the current standard practice of gradual drain withdrawal is time consuming. Although clinically stable can be discharged with the drain, the drainage tube often remains in place for a prolonged period, with patient discomfort and increased medical cost. In a pilot study by the investigators, 32.5% (37/114) of POPF patients required drainage for longer than 21 days. Besides, there is also considerable risk of recurrent fluid collection along the drain tube tract after drain removal. The investigators' experience has shown that trans-drain occlusion of the drain tract achieves fistula closure, enabling immediate removal of the drain. In a pilot study, 20 patients underwent trans-catheter occlusion for POPFs that persisted for more than 3 weeks after placement of drainage tubes. No subjective symptoms or abnormalities in blood tests were noted in 17 patients after the procedure. Three patients had abdominal pain without signs of infection, and the pain spontaneously subsided after conservative treatment. POPF healed immediately after occlusion in all of the 20 patients without recurrence during follow-up. This multicenter, investigator initiated, prospective, superiority, parallel-group, randomized, double-blinded trial aims to compare the efficacy and safety of trans-drain occlusion followed by gradual withdrawal of drain versus gradual withdrawal of drain alone for POPF that persists for longer than 21 days.
Interventions
PROCEDUREFistulography and trans-drain occlusion
1. Fistulography: an 18G needle is inserted into the tube and diluted contrast medium is slowly injected into the tube. 2. Trans-drain occlusion: a 0.035-inch guidewire is inserted via the puncture needle. The drain tube is removed, cut at 4 cm proximal to the skin fixation site, and preserved for reinsertion. After inserting a 40cm 5Fr KMP catheter over the guidewire, the guidewire is removed. Afte rinsing the KMP catheter with 3ml 5% glucose water, withdraw the catheter and simultaneously inject glue (33%, 1:2, 0.5ml of NBCA + 1ml Lipiodol) into the catheter until the proximal 5cm of the catheter remains inside the tract. The guidewire is re-inserted through the catheter, and then the original drain tube is re-inserted over the guidewire. The guidewire is removed and the drain is fixed.
PROCEDUREFistulography
Fistulography: an 18G needle is inserted into the tube and diluted contrast medium is slowly injected into the tube.
Sponsors
National Taiwan University Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Intervention model description
Enrolled patients will be randomly assigned in a 2:1 ratio to receive trans-drain occlusion followed by gradual drain withdrawal or gradual drain withdrawal.
Eligibility
Sex/Gender
ALL
Age
20 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients who undergo pancreatectomy (including pancreatoduodenectomy with or without pylorus preservation, distal pancreatectomy, and central pancreatectomy) and develop POPF that persists for 3 weeks after its occurrence. * With POPF that persists for 3 weeks after occurrence
Exclusion criteria
* Younger than 20 years of age * Active infection not adequately controlled \[body temperature ≧38.5℃ and/or eukocytosis (WBC count \>15,000 /uL)/leukopenia (WBC count \<4,000 /uL)\], have residual intra-abdominal fluid collection (largest diameter \> 4cm) despite tube drainage on CT scan (with or without contrast, performed when the patient meet inclusion criteria). * Current or history of severe heart, lung, kidney, or liver failure * Karnofsky Performance Score \<60 * Pregnant or lactating * Have received somatostatin or its analogue in the index admission * Decline to participate
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Days to fistula closure | The date of fistula closure is the date on which the drain is removed after an output of ≦ 10 mL during 48 hours, without recurrence of fistula within the next 3 months | Days from the randomly allocated treatment to fistula closure |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Hospital costs after the assigned treatment | From treatment to discharge from the index admission, an average of 2 weeks | Costs from the assigned treatment to discharge |
| Rate of fistula-related complications | From occurrence of fistula to 3 months after drain removal | Proportion of patients who develop fever/infection, ileus, postpancreatectomy hemorrhage from the assigned treatment to end of follow-up. |
| Rate of persistent or recurrent POPF after initial drain removal | From drain removal to 3 months after drain removal or recurrence of fistula, whichever occurs first | Proportion of patients with fluid collection on follow-up CT, which is to be performed at 3 months after removal of drain or when recurrence of fistula is suspected clinically. |
| Length of hospital stay after the assigned treatment | From treatment to discharge from the index admission, an average of 2 weeks | Days from the assigned treatment to discharge |
| 30-day fistula closure rate | From enrollment to 4 months after fistula occurrence | Proportion of patients in whom the drain can be removed by 30 days after occurrence of fistula, without recurrence within the next 3 months |
Other
| Measure | Time frame | Description |
|---|---|---|
| Incidence of Treatment-Emergent Adverse Events | From treatment to discharge from the index admission, an average of 2 weeks | Fever/infection or pain that develops within 48 hours after the allocated treatment, or any adverse events judged to be related to the treatment |
Countries
Taiwan
Outcome results
None listed