Incidence of Pancreatic Fistula after Distal Pancreatectomy and Efficacy of Endoscopic Therapy for Its Management: Results from a Tertiary Care Center

Abstract

Pancreatic fistula is a known complication of distal pancreatectomy. Endotherapy with pancreatic duct stent placement and pancreatic sphincterotomy has been shown to be effective in its management; however, experience of endotherapy in the management of this complication has not been extensively reported from the United States. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement has also been proposed to prevent this complication after distal pancreatectomy. In our cohort of 59 patients who underwent distal pancreatectomy, 13 (22%) developed a pancreatic fistula in the immediate postoperative period, of whom 8 (14%) patients (5 female, mean age 52 years) were referred for an ERCP because of ongoing symptoms related to the pancreatic fistula. The pancreatic fistula resolved in all patients after a median duration of 62 days from the index ERCP. The median number of ERCPs required to document resolution of the pancreatic fistula was 2. Although a sizeable percentage of patients develop a pancreatic fistula after distal pancreatectomy, only a small percentage of patients require ERCP for management of this complication. Given the high success rate of endotherapy in resolving pancreatic fistula and the fact that the majority of patients who undergo distal pancreatectomy never require an ERCP, performing ERCP for prophylactic pancreatic duct stent prior to distal pancreatectomy might not be necessary.

Endoscopic main duct stenting in refractory postoperative pancreatic fistula after distal pancreatectomy – a friend or a foe?

“…Watanabe et al [ 25 ] demonstrated a similar hospital stay with or without ET (40 days) and the mean healing time after ET was 46 days in 11 patients. Reddymasu et al [ 28 ] reported healing in eight patients 44–379 days after ET. Goasguen et al [ 26 ] evaluated ten patients (including two enucleations) who underwent ET, experiencing a POPF resolution after 1–12 days.…”

“…Thus, the placement of a stent in the MPD could facilitate fistula resolving. However, this treatment adjunct has only been scarcely evaluated, and so far, without any promising results [ 25 – 28 ].…”

Practice patterns of VTE chemoprophylaxis after discharge following hepatic and pancreatic resections for cancer: A survey of hepatopancreatobiliary surgeons

“…Several studies have established that a pancreatic leak or fistula postoperatively constitutes a risk factor for a delayed hemorrhage, presumably because the leak can lead to abscess formation and weaken the surrounding tissue and blood vessels, thereby increasing the potential for hemorrhage [26–28]. The rate of pancreatic fistula after pancreaticoduodenectomy and distal pancreatectomy has been reported to be has high as 28% [29, 30]. As such, if a patient were to develop a VTE and need to be placed on therapeutic anticoagulation, they may be at increased risk for bleeding in the setting of a leak [31].…”

Diagnosis and management of postoperative pancreatic fistula

“…Furthermore, radiologically guided external drainage may cause localized skin irritation and infections, prolongs the duration of treatment (especially in collections associated with distal pancreatectomy and enucleation), delays oral re-feeding, and implies a longer hospital stay [29]. The use of endoscopic ultrasound (EUS)-guided transmural drainage, initially applied for management of pseudocysts secondary to acute pancreatitis, has grown in frequency to drain collections associated with POPF, after both PD and distal pancreatectomy [30,31]. Briefly, an FNA needle is used to puncture through the gastric wall into the fluid collection.…”