Pancreatic Fistula after Pancreatectomy: Definitions, Risk Factors, Preventive Measures, and Management—Review

Abstract

Resection of pancreas, in particular pancreaticoduodenectomy, is a complex procedure, commonly performed in appropriately selected patients with benign and malignant disease of the pancreas and periampullary region. Despite significant improvements in the safety and efficacy of pancreatic surgery, pancreaticoenteric anastomosis continues to be the “Achilles heel” of pancreaticoduodenectomy, due to its association with a measurable risk of leakage or failure of healing, leading to pancreatic fistula. The morbidity rate after pancreaticoduodenectomy remains high in the range of 30% to 65%, although the mortality has significantly dropped to below 5%. Most of these complications are related to pancreatic fistula, with serious complications of intra-abdominal abscess, postoperative bleeding, and multiorgan failure. Several pharmacological and technical interventions have been suggested to decrease the pancreatic fistula rate, but the results have been controversial. This paper considers definition and classification of pancreatic fistula, risk factors, and preventive approach and offers management strategy when they do occur.

Total Pancreatectomy for Pancreatic Pathology: Contraindication or Privileged Indication?

“…In addition to this, surgeons have carried out TP to treat or avoid perioperative complications, arising from pancreatic anastomotic insufficiency with or without bleeding, following pancreaticoduodenectomy or distal pancreatectomy [3,4]. These complications may occur increasingly, while dealing with a soft pancreas during primary surgery, which may prompt some surgeons to opt for TP [4,7]. However the concern has been, about the management of these patients in a pancreatic state, with its attendant total endocrine and exocrine insufficiency [1][2][3][4][5].…”

“…However the Achilles heel of this operation is the pancreatic anastomosis with an incidence of pancreatic leak ranging from 2-29% [7]. While most of these cases can be managed successfully by non-surgical approach, some 15% of them would require an emergency surgical intervention and are categorized into "trouble group" requiring TP [4,7].…”

“…While most of these cases can be managed successfully by non-surgical approach, some 15% of them would require an emergency surgical intervention and are categorized into "trouble group" requiring TP [4,7]. These patients would develop pancreatic anastomosis insufficiency complicated by acute bleeding, necrosis of pancreatic remnant followed by severe sepsis [7]. They are critically ill and would usually be in American Association of Anaesthesiologists group 111 or 1V [4].…”

“…This group is characterized by high morbidity (73%) and mortality (47%). To compound matters, their reoperation is demanding, in view of their poor general condition, adhesions, altered anatomy, oedematous friable tissues, significant intraoperative bleeding and need for transfusion [4,7]. Such patients who are considered near surgical disaster, are not ideal for any reconstructive surgery and may need and emergency salvage TP [4,7].…”

“…As the reported risk of leak in these patients is significant and the consequence of some of these with secondary haemorrhage is fatal, some surgeons would consider the option of TP in these cases [3,4,7]. However the major issue is in deciding what constitutes a soft pancreas that would warrant a TP [4].…”