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Pathologic Assessment of Pancreatic Fibrosis for Objective Prediction of Pancreatic Fistula and Management of Prophylactic Drain Removal After Pancreaticoduodenectomy

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Abstract

Background

Soft pancreatic texture is a commonly accepted risk factor associated with pancreatic fistula (PF) after pancreaticoduodenectomy (PD). However, its evaluation is subjective and its predictive value is limited. The present study was performed to establish intraoperative PF prediction parameter: the pathological assessment of pancreatic fibrosis, which was an objective evaluation that was strongly related to pancreatic consistency.

Methods

Based on the results of a retrospective investigation on grades of pancreatic fibrosis and PF occurrence in 51 consecutive patients, an algorithm for intraoperative selection of early prophylactic drain removal was established. Prophylactic drains of patients with pancreatic fibrosis ≥30 % in the frozen section of pancreatic stump were removed on postoperative day (POD) 4. As CRP ≥10 mg/dL on POD 4 was a strong risk factor for PF in patients with fibrosis <30 %, the drains of these patients were maintained.

Results

The algorithm was applied to 26 consecutive patients. Prophylactic drains were removed in 14 patients and retained in 12 patients on POD 4. No PF was observed in patients with pancreatic fibrosis ≥30 % (n = 8). Among six patients with fibrosis <30 %, CRP <10 mg/dL, and without infection in the drain fluid, only two developed grade A PF. All nine patients with pancreatic fibrosis <30 % and CRP ≥10 mg/dL developed grade B PF. No grade C PF was observed in any group.

Conclusions

The pathological evaluation of pancreatic fibrosis could objectively predict PF occurrence. Intraoperative assessment of pancreatic fibrosis could be applied to tailor postoperative drain management after PD.

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Abbreviations

BMI:

Body mass index

CRP:

C-reactive protein

H&E:

Hematoxylin and eosin

IPMN:

Intraductal papillary mucinous neoplasm

PD:

Pancreaticoduodenectomy

PF:

Pancreatic fistula

SSPPD:

Subtotal stomach preserving pancreaticoduodenectomy

POD:

Postoperative day

WBC:

White blood cell

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Acknowledgments

The authors would like to thank Enago for the English language review.

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Authors and Affiliations

  1. Department of Surgery, Uwajima City Hospital, #1-1, Goten-machi, Uwajima, Ehime, 798-8510, Japan

    Hidenori Kiyochi, Taro Nakamura, Naoki Ishida & Shinsuke Kajiwara

  2. Department of Pathology, Uwajima City Hospital, #1-1, Goten-machi, Uwajima, Ehime, 798-8510, Japan

    Shouichi Matsukage

  3. Department of Hepato-Biliary-Pancreatic Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan

    Yasutsugu Takada

Authors
  1. Hidenori Kiyochi
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  2. Shouichi Matsukage
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  3. Taro Nakamura
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  4. Naoki Ishida
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  5. Yasutsugu Takada
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  6. Shinsuke Kajiwara
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Correspondence to Hidenori Kiyochi.

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Kiyochi, H., Matsukage, S., Nakamura, T. et al. Pathologic Assessment of Pancreatic Fibrosis for Objective Prediction of Pancreatic Fistula and Management of Prophylactic Drain Removal After Pancreaticoduodenectomy. World J Surg 39, 2967–2974 (2015). https://doi.org/10.1007/s00268-015-3211-5

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  • DOI: https://doi.org/10.1007/s00268-015-3211-5

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