Pancreas-preserving management in reinterventions for severe pancreatic fistula after pancreatoduodenectomy: a systematic review

Abstract

Pancreas-preserving surgical management of the PR after LTPOPF can be performed with acceptable mortality and morbidity. These data suggest that CP should have a more precisely specified role in the management algorithm and should not be performed systematically.

An Alternative Surgery for an Atypical Kind of Grade C Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy

“…Non-operative management can be initially attempted but, soon, concomitant bleeding, pancreatitis, peritonitis, sepsis, clinical deterioration up to hemodynamic instability affect nearly all patients making redo surgery imperative and the only salvage treatment (1)(2)(3)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). In this regard, so many surgical alternatives are available today that surgeons are often spoiled for choice; however, it is important to say that no procedure has met with unanimous consensus thus far (1)(2)(3)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Completion pancreatectomy has been long advocated as the operation of choice because it decreases the erosion exerted by pancreatic juice; however, its use has been progressively retrenched because of the demanding accomplishment, significant mortality rate (38-64%) and severe related consequences (both exocrine and endocrine pancreatic insufficiency, including a complex diabetic condition named "brittle" diabetes, with a mortality rate of 3.5%) (5-7).…”

“…The conservative techniques, which preserve the viable pancreatic remnant, such as pancreatogastrostomy, prompt or delayed re-pancreaticojejunostomy, internal or external wirsungostomy, although enthralling and quite successful, appear somewhat venturesome to accomplish as salvage procedures in precipitated situations (1, 3, 5, 8-10). On the other hand, other types of interventions, such as surgical drainage of the anastomotic region or disconnection of the pancreatico-jejunal anastomosis with closure and conservation of the pancreatic stump, although easier to conduct, are associated with a high risk of persistent POPF and elevated mortality rate (3,5,8,11).…”

“…Considering this knowledge, removal of the pancreas remnant in the context of a grade-C fistula can be considered an unnecessarily highrisk overtreatment" (12). However, although this and other succeeding papers surrounding this particular subject have described a profusion of surgical techniques, so far no one has been mentioning of including intestinal resection to the operative management of pancreatic stump (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). Interestingly, this omission seems to be flanked with another important anatomopathologic aspect overlooked by nearly all authors: the condition of the Rough-limb anastomozed to the pancreas.…”

“…On the other hand, in 0.2-to 8.9% of circumstances, it can dramatically go downhill complicating with hemorrhage, pancreatitis, peritonitis or sepsis; such a life-threatening event is known as grade C POPF (2). This sort of fistula is associated with mortality rates of up to 40% and immediate surgical correction represents the only possible remedy (1)(2)(3). Of interest, in light of our experience, failure of PA could not be the only anatomophysiologic basis responsible for the development of grade C POPF.…”

Symptomatik, Diagnostik, Therapie und Klassifikation von 22 Patienten mit Postpankreatektomie-Hämorrhagien (PPH) in einer Serie von 400 konsekutiven Pankreaskopfresektionen und Pankreatektomien

“…In beiden gesondert dargestellten Fällen war eine Restpankreatektomie erfolgt. Die Indikation zur komplettierenden Pankreatektomie muss auch in der Blutungssituation genau überprüft werden, da verschiedene pankreaserhaltende Rekonstruktionstechniken etabliert sind [21]. In der Zusammenfassung aller Ergebnisse und der Literatur ergibt sich unseres Erachtens der folgende Entscheidungsbaum (l " Abb.…”