Secretin Infusion to Prevent Pancreatic Leaks Following Pancreatic Resection
Study Details
Study Description
Brief Summary
Pancreatic leaks complicate pancreatic resection in approximately 20% of cases. The pancreatic anastomosis or repair has been referred to as the Achilles heel of pancreatic surgery. Unfortunately, despite recognition of this problem and multiple operative techniques proposed to prevent this complication, leaks continue to represent a major cause of morbidity for patients undergoing pancreatic surgery. Treatment of leaks often requires nutritional support with total parenteral nutrition to diminish the leak in addition to invasive interventions to contain the leak with drains, stents or in severe cases, reoperation. Experiential data suggest that intra-operative infusions of secretin, a naturally occurring hormone that stimulates bicarbonate release from the pancreas, following resection but just prior to abdomen closure, may identify a leak if present. If secretin can demonstrate evidence of leaking intra-operatively, the pancreatic duct leak may be able to be fixed prior to abdominal closure. The investigators aim to determine if giving an intra-operative infusion of secretin will allow for identification and treatment of leaks after pancreatic reconstruction and prior to abdominal closure, leading to a reduction in the rate of pancreatic anastomotic leaks requiring intervention. The investigators will perform a double-blind, randomized pilot study of 176 patients undergoing pancreatic resection (pancreaticoduodenectomy and distal pancreatectomy) at Dartmouth-Hitchcock Medical Center. 88 of those patients will receive an intra-operative secretin infusion prior to abdominal closure and 88 will receive a saline placebo. Our primary outcome of interest will be the rate of pancreas duct leaks in each group as measured by the concentration of amylase present in the surgical drains 3 days following surgery.
Condition or Disease | Intervention/Treatment | Phase |
---|---|---|
|
Phase 2/Phase 3 |
Detailed Description
We hypothesize that intra-operative, intravenous secretin administration will decrease the rate of pancreatic leaks in patients undergoing pancreatic resection. Our primary objective is to determine if intravenous secretin administration will decrease the amount of pancreatic leaks as measured by the 2016 ISGPS definition of pancreatic leaks. Our 1) secondary objectives are to determine if intra-operative intravenous secretin administration changes the management of the pancreatic resection margin intra-operatively and 2) Length of hospital stay.
Use a level of detail similar to what would be used when submitting an article for publication in a peer reviewed journal. Explain the study procedures, data collection, and analysis process. Please define terms and explain concepts which might be confusing to reviewers who are not expert in the area of the study. If a formal protocol for the study exists, page references to the protocol are acceptable.
This study design is a prospective, double-blind, randomized-controlled trial. We will enroll patients in our institution undergoing pancreatic resection to receive either 1) one dose weight-based Secretin to be given once the closure of the pancreatic resection margin is complete 2) saline placebo.
Consent and basic demographics will be garnered by the physician in an office visit once the surgery has been scheduled and consent for the surgery is being obtained. The consent will be validated by the treating surgeon in the pre-procedure area on the day of the surgery.
The patient will undergo the scheduled surgery. Once the pancreatic anastomosis has been deemed acceptable by the attending physician, but prior to abdominal closure, the patient will be randomized to receive either Secretin (0.2 mcg/kg) or saline placebo. The attending surgeon will be blinded to this assignment.
10 minutes after receiving the Secretin or placebo, the attending surgeon will examine the anastomosis or repaired cut edge of the pancreas to determine if leakage of pancreatic fluid is noted, leak location(s), type (side branch/main duct) and whether any further intervention was performed in an effort to close the leak. Specifics of operative intervention will be documented. The patient will then undergo standard surgical closure of the abdomen.
As is standard of care at DHMC, surgical drains will be placed adjacent to the anastomosis and drain amylase output will be checked on POD #1, POD#3 and POD#5. Pancreatic leak is defined according to the International Study Group of Pancreatic Fistula (ISGPF) definition as amylase drainage of greater than a 3-fold elevation above the upper limit of normal in serum through the surgically placed drains on POD #3. Randomization assignments will be revealed once the patient has been discharged from the hospital following their initial surgical intervention. A follow-up visit with the patient two weeks following discharge, will evaluate for any evidence of ongoing pancreatic duct leak.
The primary outcome of interest will be the presence of pancreatic leaks based on the drain amylase on POD#3. Secondary outcomes will include the technical interventions intra-operatively directed to leak closure or manipulation of the anastomosis following Secretin or placebo stimulation and the length of hospitalization.
Patient demographics, risk factors, operative technique, randomization assignment and outcome data will be recorded on standard case report forms - See Case Report Forms in Appendix. Data will be stored in an encrypted hard-drive by a single agent (Gardner) who is the only researcher who has access to the randomization data.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
---|---|
Active Comparator: Secretin Stimulate pancreatic secretion |
Drug: Secretin
Drug to stimulate pancreatic secretion
|
Placebo Comparator: Saline Placebo should not stimulate the pancreas to release its fluids |
Drug: Placebo
|
Outcome Measures
Primary Outcome Measures
- Number of Participants With Biochemical Leak/Grade B Fistula/Grade C Fistula [3 days]
Outcome based on revised ISGPS Guidelines which require a three day drain amylase concentration greater than 3x the normal serum amylase concentration. Biochemical leaks are the mildest for of fistula which have no clinical consequence. Grade B fistula are more severe requiring usually percutaneous drainage placement. Grade C fistula are most severe resulting in significant morbidity and/or death.
Secondary Outcome Measures
- Number of Participants With Intra-operative Intervention, Subsequent Biochemical Leak or B/C Fistula After Drug Administration [Through completion of intra-operative intervention and subsequent biochemical leak, B/C Fistula up to 30 days post-operatively]
Following the administration of Secretin or Placebo intraoperatively, the surgeon will have the opportunity to evaluate the anastomosis to determine if there is ongoing leak. If there is ongoing leak, then the surgeon will be able to treat the leak intra-operatively prior to operative closure. In those patients in whom an intervention was performed, they were subsequently evaluated to determine if they developed a biochemical leak or grade B/C fistula.
- Length of Hospitalization [Duration of study - average 30 days]
Surrogate marker for operative success
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Scheduled for pancreatic surgery requiring pancreatic resection at DHMC
-
Age greater than 18 years old
-
Ability to provide written informed consent
Exclusion Criteria:
-
Inability to provide written informed consent
-
Current ongoing acute pancreatitis
-
Pregnant or nursing mothers
-
Any medical condition which in the judgment of the Investigator renders participation in this study medically inadvisable.
-
Participation in an investigational clinical study for a drug or medical device within 30 days prior to Visit 1.
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
---|---|---|---|---|---|
1 | Dartmouth-Hitchcock Medical Center | Lebanon | New Hampshire | United States | 03756 |
Sponsors and Collaborators
- Dartmouth-Hitchcock Medical Center
Investigators
None specified.Study Documents (Full-Text)
More Information
Publications
None provided.- D13208 TBG-01
Study Results
Participant Flow
Recruitment Details | |
---|---|
Pre-assignment Detail |
Arm/Group Title | Secretin | Saline |
---|---|---|
Arm/Group Description | Stimulate pancreatic secretion Secretin: Drug to stimulate pancreatic secretion | Placebo should not stimulate the pancreas to release its fluids Placebo |
Period Title: Overall Study | ||
STARTED | 87 | 83 |
COMPLETED | 87 | 83 |
NOT COMPLETED | 0 | 0 |
Baseline Characteristics
Arm/Group Title | Secretin | Saline | Total |
---|---|---|---|
Arm/Group Description | Stimulate pancreatic secretion Secretin: Drug to stimulate pancreatic secretion | Placebo should not stimulate the pancreas to release its fluids Placebo | Total of all reporting groups |
Overall Participants | 87 | 83 | 170 |
Age (years) [Mean (Standard Deviation) ] | |||
Mean (Standard Deviation) [years] |
63.4
(12.3)
|
63.5
(12.1)
|
63.45
(12.15)
|
Sex: Female, Male (Count of Participants) | |||
Female |
43
49.4%
|
33
39.8%
|
76
44.7%
|
Male |
44
50.6%
|
50
60.2%
|
94
55.3%
|
Race and Ethnicity Not Collected (Count of Participants) | |||
Count of Participants [Participants] |
0
0%
|
||
Body Mass Index (kg/m^2) [Mean (Standard Deviation) ] | |||
Mean (Standard Deviation) [kg/m^2] |
26.6
(5.0)
|
26.7
(6.3)
|
26.65
(5.8)
|
Outcome Measures
Title | Number of Participants With Biochemical Leak/Grade B Fistula/Grade C Fistula |
---|---|
Description | Outcome based on revised ISGPS Guidelines which require a three day drain amylase concentration greater than 3x the normal serum amylase concentration. Biochemical leaks are the mildest for of fistula which have no clinical consequence. Grade B fistula are more severe requiring usually percutaneous drainage placement. Grade C fistula are most severe resulting in significant morbidity and/or death. |
Time Frame | 3 days |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title | Secretin | Saline |
---|---|---|
Arm/Group Description | Stimulate pancreatic secretion Secretin: Drug to stimulate pancreatic secretion | Placebo should not stimulate the pancreas to release its fluids Placebo |
Measure Participants | 87 | 83 |
Biochemical Leak |
25
28.7%
|
16
19.3%
|
Grade B Fistula |
3
3.4%
|
5
6%
|
Grade C Fistula |
0
0%
|
0
0%
|
Title | Number of Participants With Intra-operative Intervention, Subsequent Biochemical Leak or B/C Fistula After Drug Administration |
---|---|
Description | Following the administration of Secretin or Placebo intraoperatively, the surgeon will have the opportunity to evaluate the anastomosis to determine if there is ongoing leak. If there is ongoing leak, then the surgeon will be able to treat the leak intra-operatively prior to operative closure. In those patients in whom an intervention was performed, they were subsequently evaluated to determine if they developed a biochemical leak or grade B/C fistula. |
Time Frame | Through completion of intra-operative intervention and subsequent biochemical leak, B/C Fistula up to 30 days post-operatively |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title | Secretin | Saline |
---|---|---|
Arm/Group Description | Stimulate pancreatic secretion Secretin: Drug to stimulate pancreatic secretion | Placebo should not stimulate the pancreas to release its fluids Placebo |
Measure Participants | 87 | 83 |
Intervention |
8
9.2%
|
3
3.6%
|
Subsequent Biochemical Leak |
8
9.2%
|
2
2.4%
|
Subsequent B/C Fistula |
0
0%
|
1
1.2%
|
Title | Length of Hospitalization |
---|---|
Description | Surrogate marker for operative success |
Time Frame | Duration of study - average 30 days |
Outcome Measure Data
Analysis Population Description |
---|
[Not Specified] |
Arm/Group Title | Secretin | Saline |
---|---|---|
Arm/Group Description | Stimulate pancreatic secretion Secretin: Drug to stimulate pancreatic secretion | Placebo should not stimulate the pancreas to release its fluids Placebo |
Measure Participants | 87 | 83 |
Mean (Standard Deviation) [Days] |
10.3
(6.5)
|
10.2
(5.5)
|
Adverse Events
Time Frame | Study enrollment until 30 days post-hospital discharge, an average of 45 days | |||
---|---|---|---|---|
Adverse Event Reporting Description | ||||
Arm/Group Title | Secretin | Saline | ||
Arm/Group Description | Stimulate pancreatic secretion Secretin: Drug to stimulate pancreatic secretion | Placebo should not stimulate the pancreas to release its fluids Placebo | ||
All Cause Mortality |
||||
Secretin | Saline | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 0/87 (0%) | 1/83 (1.2%) | ||
Serious Adverse Events |
||||
Secretin | Saline | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 15/87 (17.2%) | 32/83 (38.6%) | ||
Cardiac disorders | ||||
Hypotension | 0/87 (0%) | 2/83 (2.4%) | ||
Gastrointestinal disorders | ||||
Gastroparesis | 0/87 (0%) | 1/83 (1.2%) | ||
Pancreatitis | 0/87 (0%) | 2/83 (2.4%) | ||
Hepatobiliary disorders | ||||
Bile Leak | 1/87 (1.1%) | 3/83 (3.6%) | ||
Infections and infestations | ||||
Infection - other | 1/87 (1.1%) | 2/83 (2.4%) | ||
Superficial surgical site infection | 1/87 (1.1%) | 6/83 (7.2%) | ||
Surgical and medical procedures | ||||
Deep Surgical Site Infection | 3/87 (3.4%) | 3/83 (3.6%) | ||
Hemorrhage | 6/87 (6.9%) | 10/83 (12%) | ||
Hernia | 0/87 (0%) | 1/83 (1.2%) | ||
Other | 3/87 (3.4%) | 2/83 (2.4%) | ||
Other (Not Including Serious) Adverse Events |
||||
Secretin | Saline | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 36/87 (41.4%) | 23/83 (27.7%) | ||
Cardiac disorders | ||||
Hypertension | 7/87 (8%) | 2/83 (2.4%) | ||
Hypotension | 10/87 (11.5%) | 5/83 (6%) | ||
Gastrointestinal disorders | ||||
Gastroparesis | 2/87 (2.3%) | 1/83 (1.2%) | ||
Hepatobiliary disorders | ||||
Chyle Leak | 3/87 (3.4%) | 1/83 (1.2%) | ||
Infections and infestations | ||||
Infection - other | 1/87 (1.1%) | 3/83 (3.6%) | ||
Surgical and medical procedures | ||||
Deep Surgical Site Infection | 1/87 (1.1%) | 0/83 (0%) | ||
Hemorrhage | 3/87 (3.4%) | 5/83 (6%) | ||
Hernia | 0/87 (0%) | 1/83 (1.2%) | ||
Superficial Surgical Site Infection | 6/87 (6.9%) | 4/83 (4.8%) | ||
Other | 3/87 (3.4%) | 1/83 (1.2%) |
Limitations/Caveats
More Information
Certain Agreements
Principal Investigators are NOT employed by the organization sponsoring the study.
There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.
Results Point of Contact
Name/Title | Timothy B. Gardner MD MS |
---|---|
Organization | Dartmouth-Hitchcock Medical Center |
Phone | 603-650-6472 |
timothy.b.gardner@hitchcock.org |
- D13208 TBG-01