Abstract
Pancreatic resections are the treatment of choice for periampullary neoplasms. Although improvements in the surgical techniques and perioperative management have reduced the mortality to less than 5% (Bassi et al. (2005) Surgery 138:8–13), the postoperative morbidity still remains high. Morbidity is largely related to the development of postoperative pancreatic fistula (POPF) that mostly influences the postoperative outcome. The International Study Group for Pancreatic Fistula (ISGPF) established the drainage of abdominal fluid rich in amylase as diagnostic evidence of POPF (Bassi et al. (2005). Surgery 138:8–13). Since the POPF clinical impact is wide variable, ISGPF provided three different grades of severity, ranged from the harmless grade A to the grade C characterized by life-threatening conditions. Although several risk factors have been identified, POPF still remains not avoidable. However according to the risk, certain surgical mitigation strategies may be adopted in order to prevent the C grade fistula. When POPF occurs, its treatment requires a multidisciplinary approach. In most cases the fistula healing is reached putting the exocrine pancreatic function at rest. The patient is fasting and supported with enteral or parental nutrition. Somatostatin may be administered, and when signs of infection of the fistula are present, antibiotics may be required. When abdominal collections developed, interventional procedures may be needed. Due to a high mortality rate, surgical treatment is reserved to selected critically ill patients in whom minimally invasive approaches fail to control the POPF course. The surgical approach is depending on the impaired intra-abdominal condition. Rescue completion pancreatectomy resolves the POPF but is not always technically feasible, and it is related to high morbidity. Pancreas-preserving approaches are technically easier, but further surgical operations may be required to control the POPF.
In conclusion POPF is a complex, multivariable phenomenon with uncertain outcome even at high-volume centers, which continues to challenge pancreatic surgeons.
Keywords
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138:8–13.
Pratt WB, Callery MP, Vollmer CM. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg. 2008;32:419–28.
Bassi C, Butturini G, Molinari E, Mascetta G, Salvia R, Falconi M, Gumbs A, Pederzoli P. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg. 2004;21:54–9.
McMillan MT, Vollmer CM, Asbun HJ, et al. The characterization and prediction of ISGPF Grade C fistulas following pancreatoduodenectomy. J Gastrointest Surg. 2015; doi:10.1007/s11605-015-2884-2.
Butturini G, Daskalaki D, Molinari E, Scopelliti F, Casarotto A, Bassi C. Pancreatic fistula: definition and current problems. J Hepato-Biliary-Pancreat Surg. 2008;15:247–51.
Pratt WB, Callery MP, Vollmer CM. The latent presentation of pancreatic fistulas. Br J Surg. 2009;96:641–9.
Vallance AE, Young AL, Macutkiewicz C, Roberts KJ, Smith AM. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. HPB. 2015;17:1040–8.
Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013;216:1–14.
Roberts KJ, Hodson J, Mehrzad H, Marudanayagam R, Sutcliffe RP, Muiesan P, Isaac J, Bramhall SR, Mirza DF. A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy. HPB (Oxford). 2014;16:620–8.
Roberts KJ, Sutcliffe RP, Marudanayagam R, et al. Scoring system to predict pancreatic fistula after pancreaticoduodenectomy: a UK multicenter study. Ann Surg. 2015;261:1191–7.
Wellner UF, Kayser G, Lapshyn H, Sick O, Makowiec F, Höppner J, Hopt UT, Keck T. A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively. HPB (Oxford). 2010;12:696–702.
Yamamoto Y, Sakamoto Y, Nara S, Esaki M, Shimada K, Kosuge T. A preoperative predictive scoring system for postoperative pancreatic fistula after pancreaticoduodenectomy. World J Surg. 2011;35:2747–55.
Miller BC, Christein JD, Behrman SW, Callery MP, Drebin J a, Kent TS, Pratt WB, Lewis RS, Vollmer CM. Assessing the impact of a fistula after a pancreaticoduodenectomy using the post-operative morbidity index. HPB (Oxford). 2013;15:781–8.
McMillan MT, Fisher WE, Van Buren G, et al. The value of drains as a fistula mitigation strategy for pancreatoduodenectomy: something for everyone? Results of a randomized prospective multi-institutional study. J Gastrointest Surg. 2015;19:21–31.
Topal B, Fieuws S, Aerts R, Weerts J, Feryn T, Roeyen G, Bertrand C, Hubert C, Janssens M, Closset J. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial. Lancet Oncol. 2013;14:655–62.
Motoi F, Egawa S, Rikiyama T, Katayose Y, Unno M. Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. Br J Surg. 2012;99:524–31.
Scaife CL, Hewitt KC, Mone MC, Hansen HJ, Nelson ET, Mulvihill SJ. Comparison of intraoperative versus delayed enteral feeding tube placement in patients undergoing a Whipple procedure. HPB (Oxford). 2014;16:62–9.
Harris a G. Somatostatin and somatostatin analogues: pharmacokinetics and pharmacodynamic effects. Gut. 1994;35:S1–4.
Allen PJ, Gönen M, Brennan MF, et al. Pasireotide for postoperative pancreatic fistula. N Engl J Med. 2014;370:2014–22.
McMillan MT, Christein JD, Callery MP, Behrman SW, Drebin J a, Kent TS, Miller BC, Lewis RS, Vollmer CM. Prophylactic octreotide for pancreatoduodenectomy: more harm than good? HPB (Oxford). 2014;16:954–62.
Gurusamy KS, Koti R, Fusai G, Davidson BR. Somatostatin analogues for pancreatic surgery. Cochrane Database Syst Rev. 2013;4:CD008370.
Kurumboor P, Palaniswami KN, Pramil K, George D, Ponnambathayil S, Varma D, Aikot S. Octreotide does not prevent pancreatic fistula following pancreatoduodenectomy in patients with soft pancreas and non-dilated duct: a prospective randomized controlled trial. J Gastrointest Surg. 2015;19:2038–44.
Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, Kellum JM, Welling RE, Moore EE. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg. 1992;216:172–83.
Bassi C, Malleo G. Pancreas: Postoperative pancreatic fistula: use of enteral nutrition. Nat Rev Gastroenterol Hepatol. 2011;8:427–8.
O’Keefe SJD. Physiological response of the human pancreas to enteral and parenteral feeding. Curr Opin Clin Nutr Metab Care. 2006;9:622–8.
Xiong JJ, Altaf K, Mukherjee R, Huang W, Hu WM, Li a, Ke NW, Liu XB. Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy. Br J Surg. 2012;99:1050–61.
Klek S, Sierzega M, Turczynowski L, Szybinski P, Szczepanek K, Kulig J. Enteral and parenteral nutrition in the conservative treatment of pancreatic fistula: a randomized clinical trial. Gastroenterology. 2011;141:157–63. 163.e1
Gianotti L, Braga M, Gentilini O, Balzano G, Zerbi A, Di Carlo V. Artificial nutrition after pancreaticoduodenectomy. Pancreas. 2000;21:344–51.
Vu MK, van der Veek PP, Frölich M, Souverijn JH, Biemond I, Lamers CB, Masclee AA. Does jejunal feeding activate exocrine pancreatic secretion? Eur J Clin Investig. 1999;29:1053–9.
Meier R, Ockenga J, Pertkiewicz M, Pap a, Milinic N, Macfie J, Löser C, Keim V. ESPEN guidelines on enteral nutrition: pancreas. Clin Nutr. 2006;25:275–84.
Weimann A, Braga M, Harsanyi L, et al. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25:224–44.
ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26:1SA–138SA.
Fong ZV, Correa-Gallego C, Ferrone CR, Veillette GR, Warshaw AL, Lillemoe KD, Fernández-Del Castillo C. Early drain removal-the middle ground between the drain versus no drain debate in patients undergoing pancreaticoduodenectomy: a prospective validation study. Ann Surg. 2015;262:378–83.
Dou C, Liu Z, Jia Y, Zheng X, Tu K, Yao Y, Liu Q. Systematic review and meta-analysis of prophylactic abdominal drainage after pancreatic resection. World J Gastroenterol. 2015;21:5719–34.
Tilara A, Gerdes H, Allen P, Jarnagin W, Kingham P, Fong Y, DeMatteo R, D’Angelica M, Schattner M. Endoscopic ultrasound-guided transmural drainage of postoperative pancreatic collections. J Am Coll Surg. 2014;218:33–40.
Zink SI, Soloff EV, White RR, Clary BM, Tyler DS, Pappas TN, Paulson EK. Pancreaticoduodenectomy: frequency and outcome of post-operative imaging-guided percutaneous drainage. Abdom Imaging. 2009;34:767–71.
Cronin CG, Gervais DA, Fernandez-Del Castillo C, Mueller PR, Arellano RS. Interventional radiology in the management of abdominal collections after distal pancreatectomy: a retrospective review. Am J Roentgenol. 2011;197:241–6.
Mcmillan MT, Malleo G, Bassi C, Butturini G, Salvia R, Roses RE, Lee MK, Fraker DL, Drebin JA, Vollmer CM. Drain management after pancreatoduodenectomy: reappraisal of a prospective randomized trial using risk stratification. J Am Coll Surg. 2015;221:798–809.
Hackert T, Hinz U, Pausch T, Fesenbeck I, Strobel O, Schneider L, Fritz S, Büchler MW. Postoperative pancreatic fistula: we need to redefine grades B and C. Surgery. 2015;159:1–6.
Azeem N, Baron TH, Topazian MD, Zhong N, Fleming CJ, Kendrick ML. Outcomes of endoscopic and percutaneous drainage of pancreatic fluid collections arising after pancreatic tail resection. J Am Coll Surg. 2012;215:177–85.
Kwon YM, Gerdes H, Schattner MA, et al. Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage. Surg Endosc. 2013;27:2422–7.
Varadarajulu S, Trevino JM, Christein JD. EUS for the management of peripancreatic fluid collections after distal pancreatectomy. Gastrointest Endosc. 2009;70:1260–5.
Onodera M, Kawakami H, Kuwatani M, et al. Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery. Surg Endosc Other Interv Tech. 2012;26:1710–7.
Grobmyer SR, Hunt DL, Forsmark CE, Draganov PV, Behrns KE, Hochwald SN. Pancreatic stent placement is associated with resolution of refractory grade C pancreatic fistula after left-sided pancreatectomy. Am Surg. 2009;75:654–7. discussion 657–8
Reddymasu SC, Pakseresht K, Moloney B, Alsop B, Oropezia-Vail M, Olyaee M. Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center. Case Rep Gastroenterol. 2013;7:332–9.
Maire F, Ponsot P, Debove C, Dokmak S, Ruszniewski P, Sauvanet A. Endoscopic management of pancreatic fistula after enucleation of pancreatic tumors. Surg Endosc. 2014;29:3112–6.
Farley DR, Schwall G, Trede M. Completion pancreatectomy for surgical complications after pancreaticoduodenectomy. Br J Surg. 1996;83:176–9.
Paye F, Lupinacci RM, Kraemer A, Lescot T, Chafaï N, Tiret E, Balladur P. Surgical treatment of severe pancreatic fistula after pancreaticoduodenectomy by wirsungostomy and repeat pancreatico-jejunal anastomosis. Am J Surg. 2013;206:194–201.
Van Berge Henegouwen MI, De Wit LT, Van Gulik TM, Obertop H, Gouma DJ. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg. 1997;185:18–24.
Balzano G, Pecorelli N, Piemonti L, Ariotti R, Carvello M, Nano R, Braga M, Staudacher C. Relaparotomy for a pancreatic fistula after a pancreaticoduodenectomy: a comparison of different surgical strategies. HPB (Oxford). 2014;16:40–5.
Nentwich MF, El Gammal AT, Lemcke T, et al. Salvage completion pancreatectomies as damage control for post-pancreatic surgery complications: a single-center retrospective analysis. World J Surg. 2015;39:1550–6.
Büchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z’graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg. 2003;138:1310–4. discussion 1315
Pessaux P, Sauvanet A, Mariette C, Paye F, Muscari F, Cunha AS, Sastre B, Arnaud J-P. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg. 2011;253:879–85.
Kent TS, Callery MP, Vollmer CM. The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence. HPB (Oxford). 2010;12:577–82.
Standop J, Glowka T, Schmitz V, Schäfer N, Overhaus M, Hirner A, Kalff JC. Operative re-intervention following pancreatic head resection: indications and outcome. J Gastrointest Surg. 2009;13:1503–9.
Bachellier P, Oussoultzoglou E, Rosso E, Scurtu R, Lucescu I, Oshita A, Jaeck D. Pancreaticogastrostomy as a salvage procedure to treat severe postoperative pancreatic fistula after pancreatoduodenectomy. Arch Surg. 2008;143:966–70. discussion 971
Denost Q, Pontallier A, Rault A, Ewald JA, Collet D, Masson B, Sa-Cunha A. Wirsungostomy as a salvage procedure after pancreaticoduodenectomy. HPB. 2012;14:82–6.
De Castro SMM, Busch ORC, Van Gulik TM, Obertop H, Gouma DJ. Incidence and management of pancreatic leakage after pancreatoduodenectomy. Br J Surg. 2005;92:1117–23.
Bassi C, Butturini G, Salvia R, Contro C, Valerio A, Falconi M, Pederzoli P. A single-institution experience with fistulojejunostomy for external pancreatic fistulas. Am J Surg. 2000;179:203–6.
Nair RR, Lowy AM, McIntyre B, Sussman JJ, Matthews JB, Ahmad SA. Fistulojejunostomy for the management of refractory pancreatic fistula. Surgery. 2007;142:636–42.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 Springer-Verlag Berlin Heidelberg
About this chapter
Cite this chapter
Pulvirenti, A., Marchegiani, G., Pea, A., Salvia, R., Bassi, C. (2017). Pancreatic Fistula. In: Kim, SW., Yamaue, H. (eds) Pancreatic Cancer. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-47181-4_30
Download citation
DOI: https://doi.org/10.1007/978-3-662-47181-4_30
Published:
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-662-47180-7
Online ISBN: 978-3-662-47181-4
eBook Packages: MedicineMedicine (R0)